Pilot study on anti-reflux mucoplasty: Advancing endoscopic anti-reflux therapy for gastroesophageal reflux disease

Abstract

Objectives: Anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) were developed as interventions for proton pump inhibitor (PPI)-refractory/-dependent gastroesophageal reflux disease (GERD). Although ARMS and ARMA are established treatments for PPI-refractory GERD, reliance on natural healing for ulcer scar formation introduces uncertainty and bleeding risk. To address these issues, we introduced a novel approach called anti-reflux mucoplasty (ARM-P), which involves immediate closure of mucosal defects following mucosectomy. This pilot study aims to evaluate the safety, feasibility, and efficacy of ARM-P.

Methods: A retrospective single-center study was conducted using prospectively collected data from October 2022 to July 2023. Patients with PPI-refractory/-dependent GERD who underwent ARM-P were included. The study evaluated technical success of ARM-P, before and after ARM-P GERD-Health Related Quality of Life Questionnaire, GerdQ, and Frequency Scale for the Symptoms of GERD scores, along with PPI discontinuation and endoscopic esophagogastric junction morphology.

Results: A total of 20 patients with a median age of 61.5 years underwent the ARM-P procedure. The procedure achieved 100% technical success without adverse events. After ARM-P, 55.0% discontinued PPI usage and 15.0% reduced PPI dose by half. Median GERD-Health Related Quality of Life Questionnaire score improved from 21 to 6 (P = 0.0026), median GerdQ score improved from 9 to 7 (P = 0.0022), and median Frequency Scale for the Symptoms of GERD score decreased from 16 to 7 (P = 0.0003). Median Hill's Classification significantly improved from grade III to grade I (P = 0.0001).

Conclusions: This study presents the first pilot report of ARM-P, demonstrating its procedural safety, technical feasibility, and short-term efficacy.

Keywords: anti‐reflux mucoplasty; anti‐reflux mucosal ablation; anti‐reflux mucosectomy; endoscopic anti‐reflux therapy; gastroesophageal reflux disease.

Figure 1

Loop‐11 closure technique, which is a line‐assisted closure method incorporating a support thread to ensure continuous traction throughout the closure. (A) Clipping is initiated at the most distal end, and the second clip is deployed adjacent to the first clip. Subsequent clips are then deployed in a zigzag fashion onto the contralateral side and continue in this manner until reaching the proximal end. (B) Continuous traction using a thread facilitates the mucosa and submucosa approximating together, allowing for complete closure, supplemented with the use of additional clips. (C) The last clip is applied to the mucosa to secure it firmly and prevent any potential loosening of the sutures.

Figure 2

The upper endoscopy revealed a Hill's flap grade III hiatal hernia.

Figure 3

A partial mucosal resection (1/3 of circumference) with endoscopic mucosal resection with cap technique was performed along the lesser curvature of the cardia.

Figure 4

The closure of the defect was achieved by the Loop‐9 closure technique, which involves an endoscopic purse‐string suturing method.

Figure 5

A subsequent endoscopy conducted 2 months after the procedure demonstrated an improved hernia tightening, along with a reshaped mucosal flap valve.

Figure 6

A study flowchart of patient population. AET, acid exposure time; GERD, gastroesophageal reflux disease; LA, Los Angeles; PPI, proton pump inhibitor; SAP, symptom association probability; SI, symptom index.

Figure 7

Median GERD‐Health Related Quality of Life Questionnaire (GERD‐HRQL) score improved from 21 to 6 (P = 0.0026), median GerdQ score improved from 9 to 7 (P = 0.0022), and median Frequency Scale for the Symptoms of GERD (FSSG) score decreased from 16 to 7 (P = 0.0003). ARM‐P, anti‐reflux mucoplasty.