Anti-reflux mucosectomy (ARMS) for refractory GERD and initial clinical experience

Background and Aim: PPI therapy is the mainstay for gastroesophageal reflux disease (GERD), however laparoscopic fundoplication is recommended in refractory patients. Various endoscopic methods have been attempted with variable success. Anti-reflux mucosectomy (ARMS) is a recently introduced endoscopic therapy for refractory GERD. Here we present our initial clinical experience of ARMS. Methods: Twelve patients with refractory GERD (GERD symptoms > =1 year, daily PPI usage > = 6 months) and absence of hiatus hernia > 3cm on EGD underwent ARMS using a cap EMR technique from March to September 2016. Pre-ARMS evaluation included EGD, esophageal manometry and 24-hour ambulatory esophageal pH studies. Follow up was at 4 to 6 weeks post procedure. Prospective data included pre- and post-ARMS symptom scoring using GERD-HRQL questionnaire and Deemester scores, Hill's grading of gastroesophageal valve on EGD, PPI requirement and procedure related adverse events (AE). Results: Mean GERD-HRQL score improved significantly after ARMS from 40 to 12. Mean Deemester score (pre) = 28; post=9. Mean Hill's valve grade (pre) =2.6; post=1.6. Two AE's - both muscle injury, treated by endoclips. No dysphagia. At 4 weeks follow up, 9/12 patients (75%) had discontinued PPI, 2/12 (16.7%) had 50% reduction in PPI dosage. Conclusions: The current study shows impressive short-term results for ARMS. Symptom resolution and acid exposure reduction occurred in all patients; 11/12 patients could discontinue or reduce PPI usage. AE's were minor. Larger randomized studies with longer term follow up are recommended.