Antireflux Mucosectomy and Antireflux Mucosal Ablation: Techniques and Outcomes

Abstract

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal problems worldwide. Proton pump inhibitors (PPIs) are effective in achieving symptom control and preventing complications; however, studies show that approximately 30–40% of patients with GERD fail to respond to aggressive acid-suppressive therapy. While surgical intervention with laparoscopic Nissen fundoplication remains the gold standard, minimally invasive endoscopic antireflux therapies are gaining popularity for the management of PPI-dependent and PPI-refractory GERD. In 2003, we reported that the scarring process post-circumferential mucosal resection around the cardia for Barrett’s esophagus with high-grade dysplasia showed an antireflux effect to PPI-refractory GERD patient (Satodate H, Inoue H, Yoshida T, Usui S, Iwashita M, Fukami N, Shiokawa A, Kudo SE, Gastrointest Endosc 58:288–92, 2003). GER was improved by causing fibrosis at the gastric cardia resulting in the reformation of the cardiac opening. From this experience, we reported antireflux mucosectomy (ARMS) in 2014. The principle of ARMS is that creating a mucosal defect leads to healing by scar formation, which induces narrowing of the gastric cardia opening. We have utilized the cap-assisted endoscopic mucosal resection (EMR-C) technique to perform the mucosectomy. Moreover, antireflux mucosal ablation (ARMA) is a modified antireflux procedure that arises from our experience with ARMS. Mucosal ablation shows scar formation at the gastric cardia similar to the scarring seen with resection and results in narrowing of the cardiac opening. Compared to ARMS, ARMA may be advantageous as it is simpler and can be repeated regardless of the existence of a previous scar. Both ARMS and ARMA may represent effective antireflux procedures with the added advantage of requiring no additional costly devices and leaving no artificial prostheses in situ. In this chapter, we provide an overview of the indications, techniques, and outcomes of ARMS and ARMA.