Feasibility and outcomes of anti‐reflux mucosectomy for proton pump inhibitor dependent gastroesophageal reflux disease: First Indian study (with video)

Abstract

Background Anti‐reflux mucosectomy (ARMS) is a newfangled minimally invasive technique, with successful outcomes for the management of gastroesophageal reflux (GER). We present our initial experience (success rate) and safety profile for this procedure. Methods Consecutive patients with daily dependence on proton pump inhibitor (PPI) for GER were prospectively enrolled from September 2016 to August 2019 and underwent ARMS using a cap assisted endoscopic mucosal resection. Severity was assessed by gastroesophageal reflux disease questionnaire. Gastroscopy and 24‐h pH‐metry was done pre and post procedure. Patient characteristics, PPI requirement, adverse events and follow‐up were documented. Results Sixty‐two patients [44 (71%) male] underwent successful ARMS with a mean age (SD) of 36 (9.9) years. Technical success was achieved in 100 % of patients. Intraoperative bleeding was noted in 62 (100%) patients, endoscopic hemostasis was successfully achieved. At follow‐up dysphagia was seen in 5 (8%) patients which needed a single session of endoscopic dilation. At 2 months, mean (SD) DeMeester score normalized in 45 (72.5%) patients from 76.8 (18.3) to 14.3 (6.1) (P < 0.001). PPI could be stopped in 43 (69.4%) patients. The mean (SD) GERD‐Q score reduced from 10.6 (1.9) to 3.4 (1.5) (P < 0.001). However, in 12 (19.3%) patients low dose of PPIs was continued, while 7 (11.3%) patients continued full dose. Thirty‐eight (61.3%) patients telephonically reported symptomatic improvement and were off PPIs at 12 months. Conclusions Anti‐reflux mucosectomy is safe and effective for treatment of GER. The long term outcomes are favorable, response is durable and promising at our center. Appropriate patient selection still remains primal to the overall success of ARMS.

Endoscopic treatment of proton pump inhibitor‐refractory gastroesophageal reflux disease with anti‐reflux mucosectomy: Experience of 109 cases

“…The anti‐reflux effect of ARMS was confirmed based on objective data of MII‐pH. Based on the available literature, the rate of patients with discontinued PPI use ranged from 63% to 69.4%, 18–20 with significant improvement in questionnaire scores, AET and DeMeester score 18 . Although the number of cases was slightly small and long‐term data was lacking, all were safely completed without any problems.…”

Feasibility of resection and plication “RAP” technique for management of medically refractory GERD in patients with altered gastric anatomy

“…After an average of two dilatation procedures per patient, complete resolution of dysphagia was observed, with no reoccurrence during the observation period. Dysphagia has been previously documented after ARMS and RAP technique and likely results from stricturing at LES [3,18,[27][28][29]. As demonstrated in previous studies, dysphagia is manageable endoscopically in all patients and does not appear to recur after an initial adequate dilation.…”

Early outcomes of peroral endoscopic myotomy with fundoplication for achalasia cardia – Is it here to stay?

“…Patients who have previously undergone LHM or anterior POEM are the limitations for POEM-F as there will be adhesions and fibrosis along the anterior wall of the esophagus. 24 Antireflux mucosectomy 25 might not be an appropriate choice in these patients, but transoral incisionless fundoplication appears as an alternative to POEM-F, and has been found to be useful in treating symptomatic patients failing medical therapy. 26 To conclude, POEM-F is definitely feasible but with decent technical and limited success in the short to medium term follow-up.…”