Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study

Abstract

Background The incidence of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) has been increasing. While surgical intervention with Laparoscopic Nissen Fundoplication remains the gold standard, less invasive anti-reflux interventions are desired. We have developed a minimally invasive anti-reflux mucosal ablation (ARMA) treatment. Herein, we report its technical details and describe its feasibility, safety, and efficacy in PPI-refractory GERD. Methods We conducted a prospective single-center single-arm interventional trial evaluating the outcome of ARMA in 12 patients with PPI-refractory GERD. GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) evaluation, Frequency Scale for the Symptoms of GERD (FSSG) assessment, and impedance-pH monitoring were performed at baseline and at 2 months post-ARMA. Results A total of 12 patients underwent ARMA with a median follow-up duration of 9 months (range: 6 – 14 months). Median GERD-HRQL score significantly improved from 30.5 to 12 (P = 0.002); median FSSG score significantly improved from 25 to 10.5 (P = 0.002), and median DeMeester score decreased from 33.5 to 2.8 (P = 0.049) at 2 months follow-up. No immediate complications were observed. Conclusion Our pilot study has shown that ARMA, a new endoscopic treatment for PPI-refractory GERD, is simple, safe, and improves GERD-related symptoms and objective acid reflux parameters.

Endoscopic pressure study integrated system reflects gastroesophageal junction competence in patients with erosive esophagitis and Barrett´s esophagus

“…For instance, we could consider performing EPSIS on patients who are refractory to current therapies, such as PPI‐refractory GERD or radiofrequency ablation‐resistant BE patients. If the results of EPSIS show poor LES competences (i.e., a flat pattern and low IGP‐max), it could favour anti‐reflux treatments, such as laparoscopic anti‐reflux surgery or anti‐reflux mucosal ablation 22. Another potential application of EPSIS could be evaluating the effect of anti‐reflux surgery by performing EPSIS before and after treatment.…”

The Value of Esophageal Function Testing in Antireflux Surgery

“…ARMS is an endoscopic procedure that does not address significantly disrupted EGJ anatomy, as defined by sliding hiatal hernia >3 cm or endoscopic Hill grade IV. 38 Given the resulting scarring at the EGJ with risk of postoperative dysphagia, ARMS is also contraindicated in the presence of esophageal dysmotility. 39,40 For patients with normal motility who don't qualify for ARMS and MSA, or prefer a time-tested laparoscopic approach, the decision between Toupet and Nissen can be guided by impedance planimetry in the operating room.…”

Endoscopic treatments for GERD

“…A pilot study of 12 patients recently published demonstrated a significant improvement in GERD-HRQL scores and a reduction in DeMeester scores. 16 Concerns about severe complications, including refractory stricture, dysphagia, and chest pain, as well as rare esophageal perforation, have prevented ARMS from being fully adopted by the surgical and endoscopic community. Further studies are needed to evaluate whether ARMA is a safer alternative with less significant potential side effects.…”

“…The Inoue group has since modified their ARMS technique to a simplified version, the antireflux mucosal ablation (ARMA). A pilot study of 12 patients recently published demonstrated a significant improvement in GERD‐HRQL scores and a reduction in DeMeester scores 16 . Concerns about severe complications, including refractory stricture, dysphagia, and chest pain, as well as rare esophageal perforation, have prevented ARMS from being fully adopted by the surgical and endoscopic community.…”