Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study

Abstract

Background: In our previous case report of circumferential mucosal resection for short-segment Barrett's esophagus with high-grade dysplasia, symptoms of gastro-esophageal reflux disease (GERD) were significantly improved. This observation suggests that anti-reflux mucosectomy (ARMS) could represent an effective anti-reflux procedure, with the advantage that no artificial devices or prostheses would be left in situ.

Methods: In this pilot study, 10 patients with treatment-refractory GERD received ARMS, 2 of whom circumferential, and the remaining 8 crescentic.

Results: Key symptoms of GERD improved significantly after ARMS. In the DeMeester score, mean heartburn score decreased from 2.7 to 0.3 (P=0.0011), regurgitation score from 2.5 to 0.3 (P=0.0022), and total score from 5.2 to 0.67 (P=0.0011). At endoscopic examination, the flap valve grade decreased from 3.2 to 1.2 (P=0.0152). In 24-h esophageal pH monitoring the fraction of time at pH <4 improved from 29.1% to 3.1% (P=0.1). Fraction time absorbance more than >0.14 of bile reflux was controlled from 52% to 4% (P=0.05). In 2 cases of total circumferential resection, repeat balloon dilation was necessary to control stenosis. In all cases, proton pump inhibitor prescription could be discontinued with no ill effects.

Conclusion: This initial case series demonstrated the potential anti-reflux effect of ARMS, with a crescentic mucosal resection appearing adequate. Further longitudinal study of patients without sliding hiatus hernia will be required to establish ARMS as an effective technique to control GERD in this setting.

Keywords: Gastroesophageal reflux disease; anti-reflux mucosectomy; endoscopic treatment.

Figure 1

DeMeester score before and after anti-reflux mucosectomy (ARMS). The upper and lower bars show the standard deviation. The square indicates mean value. The DeMeester scores significantly improved after cardiac mucosal reduction (heartburn, P=0.0011; regurgitation, P=0.0011; total, P=0.0011)

Figure 2

Flap valve grade before and after anti-reflux mucosectomy (ARMS). The flap valve grade score significantly improved after cardiac mucosal reduction (P=0.0065)

Figure 3

Endoscopic follow up of circumferential anti-reflux mucosectomy (ARMS) (retroflexed views). (A) Immediately after circumferential ARMS. Approximately 2 cm-wide gastric cardia mucosa was circumferentially resected by cap-endoscopic mucosal resection method [18]. (B) Appearance at 3 years. A tight gastro-esophageal junction. Convergence of three gastric folds was observed along the lesser curve of the stomach. (C) More than 10 years after circumferential ARMS. Appearance is similar to Fig. 3B. (D) More than 10 years after circumferential ARMS (forward view). Chromoendoscopy with Lugol’s solution demonstrated well-stained squamous epithelium with neither recurrence of esophagitis nor Barrett’s esophagus

Figure 4

Endoscopic follow up of crescentic anti-reflux mucosectomy (ARMS). (A) Before ARMS. Endoscopy in retroflexion demonstrated significant hiatal hernia (Flap valve score 3) but no sliding component. Chest pain and regurgitation were prominent in this case (DeMeester score 5) and symptoms were not controlled by double dose proton pump inhibitor. (B) Immediately after procedure. Endoscopy in retroflexion showed two-thirds circumferential artificial ulcer. ARMS was centered at lesser curve and the mucosal flap valve at greater curve was preserved. (C) Appearance at 2 months. Mucosal valve was re-shaped and well-defined (Mucosal flap valve Grade 1). (D) Alternative endoscopic view at 2 months. Mucosal valve as appeared as though “stitched” at the lesser curve of gastric cardia

Figure 5

Changes of acid reflux after anti-reflux mucosectomy (ARMS). The fraction of time at pH <4 was improved from 29.1% to 3.1% (P=0.05)

Figure 6

Changes of bile reflux after anti-reflux mucosectomy (ARMS). Fraction time absorbance (>0.14) was controlled from 52% to 4% in Bilitec (P=0.05)