Download PDF
CC BY 4.0 · Endoscopy 2024; 56(12): 897-905
DOI: 10.1055/a-2333-5232
Original article

Antireflux mucosectomy for gastroesophageal reflux disease: efficacy and the mechanism of action

Thijs Kuipers 
1   Gastroenterology and Hepatology, Amsterdam UMC Location AMC, Amsterdam, Netherlands (Ringgold ID: RIN26066)
2   Gastroenterology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands (Ringgold ID: RIN571165)
,
Renske A.B. Oude Nijhuis
1   Gastroenterology and Hepatology, Amsterdam UMC Location AMC, Amsterdam, Netherlands (Ringgold ID: RIN26066)
2   Gastroenterology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands (Ringgold ID: RIN571165)
,
Roos E. Pouw
1   Gastroenterology and Hepatology, Amsterdam UMC Location AMC, Amsterdam, Netherlands (Ringgold ID: RIN26066)
2   Gastroenterology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands (Ringgold ID: RIN571165)
,
Albert J. Bredenoord
1   Gastroenterology and Hepatology, Amsterdam UMC Location AMC, Amsterdam, Netherlands (Ringgold ID: RIN26066)
2   Gastroenterology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands (Ringgold ID: RIN571165)
› Author Affiliations Clinical Trial: Registration number (trial ID): NL8246, Trial registry: Netherlands National Trial Register (http://www.trialregister.nl), Type of Study: Interventional
› Further Information
Also available at
   Permissions and Reprints


Abstract

Background Previous studies suggested that antireflux mucosectomy (ARMS) is effective in reducing reflux symptoms and total acid exposure, although the mechanism is unknown. Our objective was to investigate the effect of ARMS on reflux parameters and its mechanism of action.

Methods Gastroesophageal reflux disease (GERD) patients with insufficient symptom control despite a twice-daily proton pump inhibitor (PPI) underwent a piecemeal multiband mucosectomy of 50% of the circumference of the esophagogastric junction (EGJ), extending 2 cm into the cardia. The primary end point was the total number of reflux episodes during 24-hour pH-impedance studies.

Results 11 patients (8 men; median age 37 [interquartile range (IQR) 32–57] years) were treated, with one patient subsequently lost to follow-up. ARMS reduced the median (IQR) number of total reflux episodes (74 [60–82] vs. 37 [28–66]; P = 0.008) and total acid exposure time (8.7% [6.4%–12.7%] vs. 5.3% [3.5%–6.7%]; P = 0.03). Treatment reduced the median (IQR) number of transient lower esophageal sphincter relaxations (TLESRs) during a 90-minute postprandial period (4 [1–8] vs. 2 [1–4]; P = 0.03) and reflux symptom scores (3.6 [3.6–3.9] vs. 1.6 [0.7–2.7]; P = 0.005). Treatment did not increase the mean (SD) dysphagia scores (8.2 [7.3] vs. 8.5 [6.5]) or change the EGJ distensibility on impedance planimetry (4.4 [2.1] vs. 4.3 [2.2] mm2/mmHg). One delayed post-procedural bleed requiring repeat endoscopy occurred (10%); no strictures developed.

Conclusion ARMS is an effective treatment option in PPI-refractory GERD, reducing acid exposure, reflux episodes, and symptoms. While its working mechanism could not be explained by a difference in distensibility, a reduction in TLESRs might play a role.

Supplementary Material



Publication History

Received: 14 December 2023

Accepted after revision: 23 May 2024

Accepted Manuscript online:
27 May 2024

Article published online:
09 July 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013; 108: 308-329
    CrossrefPubMedSearch in Google Scholar
  • 2 Dent J, Dodds WJ, Friedman RH. et al. Mechanism of gastroesophageal reflux in recumbent asymptomatic human subjects. J Clin Invest 1980; 65: 256-267
    CrossrefPubMedSearch in Google Scholar
  • 3 Dodds WJ, Dent J, Hogan WJ. et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. NEJM 1982; 307: 1547-1552
    CrossrefPubMedSearch in Google Scholar
  • 4 Eherer AJ, Netolitzky F, Högenauer C. et al. Positive effect of abdominal breathing exercise on gastroesophageal reflux disease: a randomized, controlled study. Am J Gastroenterol 2012; 107: 372-378
    CrossrefPubMedSearch in Google Scholar
  • 5 Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther 2014; 5: 105-112
    CrossrefPubMedSearch in Google Scholar
  • 6 Garg SK, Gurusamy KS. Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev 2015; 2015: CD003243
    CrossrefPubMedSearch in Google Scholar
  • 7 Corley DA, Katz P, Wo JM. et al. Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial. Gastroenterology 2003; 125: 668-676
    CrossrefPubMedSearch in Google Scholar
  • 8 Repici A, Fumagalli U, Malesci A. et al. Endoluminal fundoplication (ELF) for GERD using EsophyX: a 12-month follow-up in a single-center experience. J Gastrointest Surg 2010; 14: 1-6
    CrossrefPubMedSearch in Google Scholar
  • 9 Schwartz MP, Wellink H, Gooszen HG. et al. Endoscopic gastroplication for the treatment of gastro-oesophageal reflux disease: a randomised, sham-controlled trial. Gut 2007; 56: 20-28
    CrossrefPubMedSearch in Google Scholar
  • 10 Inoue H, Ito H, Ikeda H. et al. Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study. Ann Gastroenterol 2014; 27: 346-351
    PubMedSearch in Google Scholar
  • 11 Yoo IK, Cho JY, Hong S-P. 528 Anti-reflux endoscopic surgery: endoscopic cardioplasty using endoscopic mucosal resection may effectively treat refractory gastroesophageal reflux disease. Gastrointest Endosc 2018; 87: AB89
    CrossrefPubMedSearch in Google Scholar
  • 12 Inoue H, Sumi K, Tatsuta T. et al. 998 Clinical results of antireflux mucosectomy (ARMS) for refractory GERD. Gastrointest Endosc 2017; 85: AB120
    CrossrefPubMedSearch in Google Scholar
  • 13 Sumi K, Inoue H, Ando R. et al. Long-term efficacy of antireflux mucosectomy in patients with refractory gastroesophageal reflux disease. Dig Endosc 2024; 36: 305-313
    CrossrefPubMedSearch in Google Scholar
  • 14 Roman S, Holloway R, Keller J. et al. Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry. Neurogastroenterol Motil 2017; 29: e12920
    CrossrefPubMedSearch in Google Scholar
  • 15 Gyawali CP, Kahrilas PJ, Savarino E. et al. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67: 1351-1362
    CrossrefPubMedSearch in Google Scholar
  • 16 Chen JW, Rubenstein JH. Esophagogastric junction distensibility assessed using the functional lumen imaging probe. World J Gastroenterol 2017; 23: 1289-1297
    CrossrefPubMedSearch in Google Scholar
  • 17 Bredenoord AJ, Rancati F, Lin H. et al. Normative values for esophageal functional lumen imaging probe measurements: A meta-analysis. Neurogastroenterol Motil 2022; 34: e14419
    CrossrefPubMedSearch in Google Scholar
  • 18 Bredenoord AJ, Weusten BL, Timmer R. et al. Characteristics of gastroesophageal reflux in symptomatic patients with and without excessive esophageal acid exposure. Am J Gastroenterol 2006; 101: 2470-2475
    CrossrefPubMedSearch in Google Scholar
  • 19 Kessler WR, McNulty G, Lehman GA. 51 A prospective, randomized study on the effect of band ligation with or without mucosectomy as a treatment for GERD: Pilot study, 12 month experience. Gastrointest Endosc 2013; 77: AB120
    CrossrefPubMedSearch in Google Scholar
  • 20 Sumi K, Inoue H, Kobayashi Y. et al. Endoscopic treatment of proton pump inhibitor-refractory gastroesophageal reflux disease with anti-reflux mucosectomy: Experience of 109 cases. Dig Endosc 2021; 33: 347-354
    CrossrefPubMedSearch in Google Scholar
  • 21 Yoo IK, Ko WJ, Kim HS. et al. Anti-reflux mucosectomy using a cap-assisted endoscopic mucosal resection method for refractory gastroesophageal disease: a prospective feasibility study. Surg Endosc 2020; 34: 1124-1131
    CrossrefPubMedSearch in Google Scholar
  • 22 Garg R, Mohammed A, Singh A. et al. Anti-reflux mucosectomy for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Endosc Int Open 2022; 10: E854-E864
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Hillman L, Yadlapati R, Whitsett M. et al. Review of antireflux procedures for proton pump inhibitor nonresponsive gastroesophageal reflux disease. Dis Esophagus 2017; 30: 1-14
    CrossrefPubMedSearch in Google Scholar
  • 24 Kessing BF, Broeders JA, Vinke N. et al. Gas-related symptoms after antireflux surgery. Surg Endosc 2013; 27: 3739-3747
    CrossrefPubMedSearch in Google Scholar
  • 25 Broeders JA, Mauritz FA, Ahmed Ali U. et al. Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease. Br J Surg 2010; 97: 1318-1330
    CrossrefPubMedSearch in Google Scholar
  • 26 Yeh JH, Lee CT, Hsu MH. et al. Antireflux mucosal intervention (ARMI) procedures for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Therap Adv Gastroenterol 2022; 15
    CrossrefPubMedSearch in Google Scholar
  • 27 Pandolfino JE, Zhang QG, Ghosh SK. et al. Transient lower esophageal sphincter relaxations and reflux: mechanistic analysis using concurrent fluoroscopy and high-resolution manometry. Gastroenterology 2006; 131: 1725-1733
    CrossrefPubMedSearch in Google Scholar
  • 28 Kim HI, Hong SJ, Han JP. et al. Specific movement of esophagus during transient lower esophageal sphincter relaxation in gastroesophageal reflux disease. J Neurogastroenterol Motil 2013; 19: 332-337
    CrossrefPubMedSearch in Google Scholar
  • 29 Franzi SJ, Martin CJ, Cox MR. et al. Response of canine lower esophageal sphincter to gastric distension. Am J Physiol 1990; 259: G380-G385
    CrossrefPubMedSearch in Google Scholar
  • 30 Kessing BF, Conchillo JM, Bredenoord AJ. et al. Review article: the clinical relevance of transient lower oesophageal sphincter relaxations in gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2011; 33: 650-661
    CrossrefPubMedSearch in Google Scholar
  • 31 Tomizawa Y, Iyer PG, Wong Kee Song LM. et al. Safety of endoscopic mucosal resection for Barrett's esophagus. Am J Gastroenterol 2013; 108: 1440-1448
    CrossrefPubMedSearch in Google Scholar
  • 32 Abou Ali E, Belle A, Hallit R. et al. Management of esophageal strictures after endoscopic resection for early neoplasia. Therap Adv Gastroenterol 2021; 14: 1756284820985298
    CrossrefPubMedSearch in Google Scholar