Anti-reflux mucosectomy for gastroesophageal reflux disease: efficacy and the mechanism of action.

Previous studies suggest that anti-reflux 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 mechanism of action. METHODS:Gastroesophageal reflux (GERD) patients with insufficient symptom control despite twice daily proton pump inhibitor (PPI) underwent a piecemeal multiband mucosectomy of 50% of the circumference of the esophago-gastric-junction (EGJ), extending 2cm into the cardia. The primary endpoint was the total number of reflux episodes during 24-h pH-impedance studies. RESULTS:11 patients were treated (8 men, age 37 (32-57) years), one patient is lost to follow-up after treatment. ARMS reduced the total number of reflux episodes from 74 (50-82) to 37 (28-66) p=0.008) and total acid exposure from 8.7% (6.4-12.7) to 5.3% (3.5-6.7) (p=0.008). Treatment reduced the number of transient lower esophageal sphincter relaxations (TLESRs) (from 4 (1-8) to 2 (1-4), p=0.027) during a 90-minute postprandial period. Reflux symptoms were reduced substantially (from 3.6 (3.6-3.9) to 1.6 (0.7-2.7), p=0.007). Treatment did not increase dysphagia (Brief Esophageal Dysphagia Questionnaire)of 8.2 (±7.3) to 8.5 (±6.5) (p=0.879). Impedance planimetry showed no changes in EGJ distensibility after treatment (4.4 (±2.1) mm2/mmHg to 4.3 (±2.2) mm2/mmHg), p=0.952). One delayed post-procedural bleeding (10%, (1/10)) occurred requiring repeat endoscopy, no strictures developed. CONCLUSION:ARMS is an effective treatment option in PPI refractory GERD patients reducing acid exposure, reflux episodes and symptoms. While its working mechanism could not be explained by a difference in distensibility, a reduction in TLSERs might play a role.