Clinical feasibility of a new antireflux ablation therapy on gastroesophageal reflux disease (with video)

Published:April 25, 2020DOI:

      Backgrounds and Aims

      New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia.


      Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT.


      One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARAT time was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, and GERD-HRQL score had decreased from 18.8% to 2.8% (P = .001), 42.5 to 9.1 (P = .001), and 36.5 to 10 (P = .02), respectively, and these values were maintained up to 36 months. Success (AET <4%) was achieved in 89% and 72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill type II (odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P = .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P = .042), and AET <4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P = .021).


      ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.)

      Graphical abstract


      AET (acid exposure time), ARAT (antireflux ablation therapy), ARMS (antireflux mucosectomy), CI (confidence interval), DM (DeMeester), EGJ (esophagogastric junction), ESD (endoscopic submucosa dissection), GERD-HRQL (Gastroesophageal Reflux Disease-Health-Related Quality of Life), H-APC (hybrid argon plasma coagulation), MLRM (multiple logistic regression model), OR (odds ratio), PPI (proton pump inhibitors), UE (upper endoscopy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • El-Serag H.B.
        • Sweet S.
        • Winchester C.C.
        • et al.
        Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.
        Gut. 2014; 63: 871-880
        • Johansson J.
        • Håkansson H.O.
        • Mellblom L.
        • et al.
        Prevalence of precancerous and other metaplasia in the distal oesophagus and gastro-oesophageal junction.
        Scand J Gastroenterol. 2005; 40: 893-902
        • Gyawali C.P.
        • Kahrilas P.
        • Savarino E.
        • et al.
        Modern diagnosis of GERD: the Lyon Concensus.
        Gut. 2018; 67: 1351-1362
        • Scarpellini E.
        • Ang D.
        • Pauwels A.
        • et al.
        Management of refractory typical GERD symptoms.
        Nat Rev Gastroenterol Hepatol. 2016; 13: 281-294
        • Makunts T.
        • Cohen I.V.
        • Awdishu L.
        • et al.
        Analysis of postmarketing safety data for proton-pump inhibitors reveals increased propensity for renal injury, electrolyte abnormalities, and nephrolithiasis.
        Sci Rep. 2019; 9: 2282
        • Kurlander J.E.
        • Kennedy J.K.
        • Rubenstein J.H.
        • et al.
        Patients’ perceptions of proton pump inhibitor risks and attempts at discontinuation: a national survey.
        Am J Gastroenterol. 2019; 114: 244-249
        • Yadlapati R.
        • Hungness E.S.
        • Pantolfino J.E.
        Complications of antireflux surgery.
        Am J Gastroenterol. 2018; 113: 1137-1147
        • Ritcher J.E.
        Gastroesophageal reflux disease treatment: side effects and complications of fundoplication.
        Clin Gastroenterol Hepatol. 2013; 11: 465-471
        • Sobrino-Cossio S.
        • Soto-Perez J.C.
        • Coss-Adame E.
        • et al.
        Post-fundoplication symptoms and complications: diagnostic approach and treatment.
        Rev Gastroenterol Mex. 2017; 82: 234-247
        • Carlson M.A.
        • Frantzides C.T.
        Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases.
        J Am Coll Surg. 2001; 193: 428-439
        • Rantanen T.K.
        • Salo J.A.
        • Sipponen J.T.
        Fatal and life-threatening complications in antireflux surgery and recurrence of gastroesophageal reflux.
        JAMA. 2017; 318: 939-946
        • Nabi Z.
        • Reddy D.N.
        Endoscopic management of gastroesophageal reflux disease: revisited.
        Clin Endosc. 2016; 49: 408-416
        • Triadafilopoulos G.
        Stretta: a valuable endoscopic treatment modality for gastroesophageal reflux disease.
        World J Gastroenterol. 2014; 20: 7730-7738
        • Fass R.
        • Cahn F.
        • Scotti D.J.
        • et al.
        Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease.
        Surg Endosc. 2017; 31: 4865-4882
        • McCarty T.R.
        • Itidiare M.
        • Njei B.
        • et al.
        Efficacy of transoral incisionless fundoplication for refractory gastroesophageal reflux disease: a systematic review and meta-analysis.
        Endoscopy. 2018; 50: 708-725
        • Witteman B.P.
        • Conchillo J.M.
        • Rinsma N.F.
        • et al.
        Randomized controlled trial of transoral incisionless fundoplication vs proton pump inhibitors for treatment of gastroesophageal reflux disease.
        Am J Gastroenterol. 2015; 110: 531-542
        • Ritcher J.E.
        • Kumar A.
        • Lipka S.
        • et al.
        Efficacy of laparoscopic Nissen fundoplication vs transoral incisionless fundoplication or proton pump inhibitors in patients with gastroesophageal reflux disease: a systematic review and network meta-analysis.
        Gastroenterology. 2018; 154: 1298-1308
        • Weitzendorfer M.
        • Spaun G.O.
        • Antoniou S.A.
        • et al.
        Clinical feasibility of a new full-thickness endoscopic plication device (GERDxTM) for patients with GERD: results of a prospective trial.
        Surg Endosc. 2018; 32: 2541-2549
        • Kim H.J.
        • Kwon C.I.
        • Kessler W.R.
        • et al.
        Long-term follow-up results of endoscopic treatment of gastroesophageal reflux disease with the MUSETM endoscopic stapling device.
        Surg Endosc. 2016; 30: 3402-3408
        • Ganz R.A.
        A review of new surgical and endoscopic therapies for gastroesophageal reflux disease.
        Gastroenterol Hepatol (N Y). 2016; 12: 424-431
        • Nabi Z.
        • Reddy D.N.
        Update on endoscopic approaches for the management of gastroesophageal reflux disease.
        Gastroenterol Hepatol (N Y). 2019; 15: 369-376
        • Muthusamy V.R.
        • Lightdale J.R.
        • Acosta R.D.
        • et al.
        The role of endoscopy in the management of GERD.
        Gastrointest Endosc. 2015; 81: 1305-1310
        • Satodate H.
        • Inoue H.
        • Yoshida T.
        • et al.
        Circumferential EMR of carcinoma arising in Barrett’s esophagus: case report.
        Gastrointest Endosc. 2003; 58: 288-292
        • 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
        • Bapaye A.
        • Gangireddy R.
        • Mahadik M.
        • et al.
        Anti-reflux mucosectomy (ARMS) for refractory GERD and initial clinical experience.
        Gastrointest Endosc. 2017; 85 ([abstract]): AB120
        • Inoue H.
        • Sumi K.
        • Tatsuta T.
        • et al.
        Clinical results of antireflux mucosectomy (ARMS) for refractory GERD.
        Gastrointest Endosc. 2017; 85 ([abstract]): AB120
        • Patil G.
        • Dalai A.
        • Maydeo A.
        Feasibility and outcomes of anti-reflux mucosectomy (ARMS) for proton pump inhibitor dependent gastroesophageal reflux disease: first Indian study (with video).
        Dig Endosc. 2019 Dec 13;
        • Ota K.
        • Takeuchi T.
        • Harada S.
        • et al.
        A novel endoscopic submucosal dissection technique for proton pump inhibitor-refractory gastroesophageal reflux disease.
        Scand J Gastroenterol. 2014; 49: 1409-1413
        • Hedberg H.M.
        • Kuchta K.
        • Ujiki M.B.
        First experience with banded anti-reflux mucosectomy (ARMS) for GERD: feasibility, safety, and technique (with video).
        J Gastrointest Surg. 2019; 23: 1274-1278
        • Saleem W.M.
        • Hanafy A.S.
        • Mohamed S.I.
        Endoscopic management of refractory gastroesophageal reflux disease.
        Scand J Gastroenterol. 2018; 53: 390-397
        • Benias P.C.
        • D’Souza L.
        • Lan G.
        • et al.
        Initial experience with a novel resection and plication (RAP) method for acid reflux: a pilot study.
        Endosc Int Open. 2018; 6: E443-E449
        • Tanabe M.
        • Inoue H.
        • Ueno A.
        • et al.
        A novel endoscopic fundoplication for gastroesophageal reflux disease; anti-reflux mucosal ablation (ARMA).
        Gastrointest Endosc. 2019; 89 ([abstract]): AB190
        • Yoo I.K.
        • Ko W.J.
        • 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
        • Roman S.
        • Gyawali C.P.
        • Savarino E.
        • et al.
        Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group.
        Neurogastroenterol Motil. 2017; 29: 1-15
        • Velanovich V.
        The development of the GERD-HRQL symptom severity instrument.
        Dis Esophagus. 2007; 20: 130-134
        • Hill L.D.
        • Kozarek R.A.
        • Kraemer S.J.
        • et al.
        The gastroesophageal flap valve: in vitro and in vivo observations.
        Gastrointest Endosc. 1996; 44: 541-547
        • Lundell L.R.
        • Dent J.
        • Bennett J.R.
        • et al.
        Endoscopic assessment of esophagitis: clinical and functional correlates and further validation of the Los Angeles classification.
        Gut. 1999; 45: 172-180
        • Dakkak M.
        • Bennett J.R.
        A new dysphagia score with objective validation.
        J Clin Gastroenterol. 1992; 14: 99-100
        • Gyawali C.P.
        • Fass R.
        Management of gastroesophageal reflux disease.
        Gastroenterology. 2018; 154: 302-318
        • Kothari T.H.
        • Kothari S.
        • Kaul V.
        Hybrid argon plasma coagulation: a new modality for treatment of a diffuse foregut anastomotic dysplastic lesion.
        VideoGIE. 2019; 4: 209-210
        • Pech O.
        Hybrid argon plasma coagulation in patients with Barrett esophagus.
        Gastroenterol Hepatol (N Y). 2017; 13: 610-612
        • Friedel D.
        Potential role of new technological innovations in nonvariceal hemorrhage.
        World J Gastrointest Endosc. 2019; 16: 443-453
        • Gong E.J.
        • Ahn J.Y.
        • Jung H.Y.
        • et al.
        Effects of argon plasma coagulation on human stomach tissue: an ex vivo study.
        J Gastroenterol Hepatol. 2017; 32: 1040-1045
        • Patel A.
        • Sayuk G.S.
        • Gyawali C.P.
        Parameters of esophageal pH-impedance monitoring that predict outcomes of patients with gastroesophageal reflux disease.
        Clin Gastroenterol Hepatol. 2015; 13: 884-891

      Linked Article

      • Endotherapy for gastroesophageal reflux disease: Another chance of success?
        Gastrointestinal EndoscopyVol. 92Issue 6
        • Preview
          Endotherapy for GERD has been a topic of interest over the past 25 years, with successive waves of enthusiasm and disappointment. However, until now, it has not really entered routine clinical practice. The first techniques to be investigated included injection of bulking agents (Enteryx, Boston Scientific, Marlborouth, Mass, USA), submucosal implants (Gatekeeper, Medtronic, Minneapolis, Minn, USA), suturing techniques (Endocinch, Bard and Plicator, NDO), injection of collagen, and radiofrequency of the muscle layer around the lower esophageal sphincter.
        • Full-Text
        • PDF