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CLINICAL OUTCOMES OF ANTI-REFLUX MUCOSAL ABLATION (ARMA) FOR GASTROESOPHAGEAL REFLUX DISEASE: AN INTERNATIONAL BI-INSTITUTIONAL STUDY

Yuto Shimamura 1, Enrique Rodríguez de Santiago 2, Mayo Tanabe 1, kei ushikubo 1, Kazuki Yamamoto 1, Yoshiaki Kimoto 1, YOHEI NISHIKAWA 1, Ryohei Ando 1, Marc Julius Navarro 1, Carlos Teruel Sanchez - Vegazo 2, Sofía Parejo 2, Alba Martínez Sánchez 2, Enrique Vazquez Sequeiros 2, Manabu Onimaru 1, Agustin Albillos 2, Haruhiro Inoue 1

Affiliations

1 Showa University Koto Toyosu Hospital, Tokyo, Japan

2 Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain

Summary

AI Generated

Anti-reflux mucosal ablation (ARMA) is a novel endoscopic procedure for GERD that achieved 60% clinical success at 2-6 months and 70% at one year in a retrospective two-center study of 68 patients.

The procedure involved mucosal ablation of the gastric cardiac mucosa using thermal probe or argon plasma catheter to induce scar formation and enhance the gastroesophageal junction flap valve, with technical success in all 80 procedures performed
Patients included those with definitive GERD (64.7%) or reflux hypersensitivity (35.3%), without significant sliding hernia, who were either refractory to or unwilling to continue PPI/PCAB therapy
Median GERD-HRQL score improved significantly from 26 to 11 at 2-6 months (p<0.001), and median acid exposure time decreased from 5.3% to 0.7% (p=0.003)
Adverse events included transient stenosis requiring balloon dilatation in 12.1% of patients and delayed bleeding in 7.5%, with no immediate adverse events, blood transfusions, or procedure-related mortality
The authors conclude the procedure is technically feasible, reproducible, and safe for patients without significant sliding hernia, and suggest both PPI-refractory and PPI-responsive patients may be appropriate candidates

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Abstract

Introduction

Various minimally invasive endoscopic procedures have aimed at filling the gap between medical therapy and surgical intervention. Anti-reflux mucosal ablation (ARMA) is a novel endoscopic treatment in which mucosal ablation of the gastric cardiac mucosa with either a thermal probe or with an argon plasma catheter is performed to induce scar formation to enhance the gastroesophageal junction flap valve.

Aims & Methods

We aimed to assess the feasibility, effectiveness, and safety of ARMA. All patients who underwent ARMA between May 2018 and December 2022 were retrospectively analyzed using a prospectively collected database at two referral centers. We offered ARMA to patients if they met the following criteria:
1) Patients with chronic (> six months) GERD symptoms, including heartburn, regurgitation, and/or extraesophageal symptoms;
2) Objective GERD diagnosis based on the Lyon consensus, either on an acid exposure time in the distal esophagus > 6% (definitive GERD) or on the existence of hypersensitive esophagus;
3) No significant sliding hernia (< 3cm);
4) Symptoms refractory to Proton pump inhibitors (PPI) or potassium competitive acid blockers (PCAB) or PPI/PCAB-sensitive GERD patients unwilling to maintain long-term acid suppression drugs.
GERD questionnaires, upper endoscopy, and 24-hour pH monitoring were documented at 2-6 months and 12 months after ARMA. Clinical success was defined as a > 50% reduction in validated GERD questionnaires.

Results

A total of 80 ARMA procedures in 68 patients were analyzed. Definitive GERD was diagnosed in 44 (64.7%) patients and 24 (35.3%) with reflux hypersensitivity. The ARMA procedure had technical success in all cases, and mucosal ablation of the planned area was completed. The median procedural time was 32 (range 16-100) minutes. Clinical success at 2-6 months and one year of a first ARMA procedure was 60% (39/65, 95% CI 48%-71%) and 70% (21/30, 95% CI 52%-83%), respectively. The median GERD-HRQL score at 2-6 months improved significantly from 26 (range, 5 – 51) to 11 (range, 0-50) (p < 0.001). Fifty-one patients (71.8%) were evaluated by 24-hour pH monitoring at 2-6 months post-ARMA. The median AET significantly decreased from 5.3% to 0.7% (p=0.003). In addition, the rate of esophagitis decreased (p< 0.001). Eight patients underwent a second ARMA, and the second ARMA had a clinical success rate of 50% (4/8). All cases had no immediate adverse events, but ten (12.1%) patients with transient stenosis required balloon dilatation. Six patients (7.5%) experienced delayed bleeding after a median of 10 days (range 1-21), which was controlled with conservative treatment (n = 1) or repeated endoscopy (n = 5). No patient required a blood transfusion. Multivariate analysis performed to identify predictors of the short-term success of a first ARMA did not find any factor associated with the primary outcome.

Conclusion

Our data shows that ARMA in patients without significant sliding hernia is technically feasible, reproducible, safe, and improves GERD symptoms in approximately two out of three patients in the short term. Patients with reflux hypersensitivity and proven GERD may be the appropriate candidates regardless of their response to PPI/PCAB.

References

1. Rodríguez de Santiago E, Sanchez-Vegazo CT, Peñas B, et al. Anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) for gastroesophageal reflux disease: a systematic review and meta-analysis. Endosc Int Open 2021;9:E1740-e1751.
2. Inoue H, Tanabe M, de Santiago ER, et al. Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study. Endosc Int Open 2020;8:E133-e138.
3. Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018;67:1351-1362.

Disclosure

Enrique Rodríguez de Santiago declares Olympus (speaker fee, advisory, proctorship, and educational activities), Norgine (educational activities), and Casen (educational activities). Carlos Teruel declares Norgine (educational activities). Haruhiro Inoue declares Olympus (advisory, educational activities), Top Corporation (advisory), and Takeda Pharmaceutical Company (educational activities)

Conference

UEG Week Copenhagen 2023

Topics

Oesophagus

Submission format

Abstract

Session

Breakthroughs in GORD and functional dyspepsia (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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The role of endoscopy in diagnosis and monitoring of IBD: Present and future directions

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The role of endoscopy in diagnosis and monitoring of IBD: Present and future directions

Marietta Iacucci 1

Affiliations

1 University College Cork, Cork, Ireland

Summary

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

IBD

Session

Monitoring of disease activity in IBD

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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When is the time to call the surgeon?

Emma V. Carrington 1

Affiliations

1 University of North Carolina / NCRBSI, London, United Kingdom

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

Neurogastroenterology & Motility Surgery Primary Care Small Intestine & Nutrition

Session

Chronic constipation: How to diagnose and treat this frequent condition in clinical practice

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

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2026

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Summary is not available for this content yet.

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

IBD

Session

Monitoring of disease activity in IBD

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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FIRST MULTIDEVICE ARTIFICIAL INTELLIGENCE MODEL FOR INTRAOPERATIVE PREDICTION OF COLORECTAL ANASTOMOTIC LEAKAGE

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FIRST MULTIDEVICE ARTIFICIAL INTELLIGENCE MODEL FOR INTRAOPERATIVE PREDICTION OF COLORECTAL ANASTOMOTIC LEAKAGE

Miguel Mascarenhas-Saraiva 1, Francisco Mendes 1, André Martins dos Santos 1, Filipa Fonseca 1, Larissa Mercadante de Assis 2, Felix Bonilla 2, Gonçalo Soares 3, Daniela Cavadas 4, Miguel Martins 1, Maria Almeida 1, Joana Mota 1, Ali Murtada 5, Marley Feitosa 6, Matheus Carvalho 2, Filipe Marques 7, João Ferreira 7, Ahsan Javed 5, Shakil Ahmed 5, Maisa Vasconcellos 6, Carlos Frederico Sparapan Marques 2, Manuel Limbert 4, Guilherme Macedo 1

Affiliations

1 Centro Hospitalar São João, Porto, Portugal

2 Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil

3 Centro Hospitalar Universitário de Santo António, Porto, Portugal

4 Instituto Português de Oncologia de Lisboa, Lisboa, Portugal

5 Royal Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom

6 Hospital das Clínicas da Faculdade de Medicina da USP de Ribeirão Preto, Ribeirão Preto, Brazil

7 Faculdade de Engenharia da Universidade do Porto, Porto, Portugal

Summary

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Abstract

Introduction

Anastomotic leakage (AL) is the postoperative complication with the greatest impact on both patients and healthcare systems after colorectal surgery, carrying substantial morbidity and mortality. Current assessment remains suboptimal and relies exclusively on clinical, radiological, and analytical parameters, often leading to delayed diagnosis and worse outcomes. Artificial intelligence (AI) in digestive healthcare has enabled the development of several detection (CADe) and characterization (CADx) models, although CADex models remain scarce. This study aimed to develop a multidevice deep learning model for intraoperative risk stratification, enabling real time prediction of AL.

Aims & Methods

An AI model based on a convolutional neural network was developed to predict AL using laparoscopic video frames, with a bounding box highlighting the region contributing most to leak prediction. AL diagnosis was established according to clinical, analytical, and imaging criteria. Normal anastomosis required stoma closure and at least 6 months of clinical follow up. To prevent overfitting and selection bias, dataset splitting was performed at the case level, ensuring that frames from the same surgery were not represented in both training and testing sets. The dataset was divided into training and testing sets using an 80 percent and 20 percent split. The detection component (CADe) was evaluated with mAP50, whereas the characterization component (CADx) was evaluated with accuracy and AUC ROC.

Results

This multicenter study included 71 colorectal surgeries and 17,801 frames collected across 4 reference centers in Europe and the Americas, using seven different laparoscopy systems, including conventional and robotic platforms. Thirteen patients developed CAL during postoperative follow up, whereas the remaining patients had an uneventful recovery without CAL. The AI model detected anastomoses with an mAP50 of 0.973. Frames associated with AL were identified with 99.0 percent accuracy and an AUC ROC of 0.997.

Conclusion

This is the first multidevice, interoperable AI model for intraoperative risk stratification enabling automatic prediction of AL development through a CADe mechanism for anastomosis identification, in a cohort including patients from both Europe and the Americas. The development of prognosis driven AI models is essential to support intraoperative decision making, allowing risk reduction through targeted preventive or active measures. Ultimately, these tools may reduce the incidence of this postoperative complication, with meaningful benefit for both patients and healthcare systems.

Event

UEG Week Barcelona 2026

Topics

Endoscopy Surgery Mechanisms & Personalised Medicine Colorectal

Submission format

Abstract

Session

Lower GI disorders: A multidisciplinary approach

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Affiliations

1 University Of Sydney, Sydney, Australia

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This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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Panel discussion: Immunotherapy in digestive cancers - Where are we heading?

Summary

AI Generated

Summary is not available for this content yet.

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Abstract

Event

UEG Postgraduate Teaching Programme Berlin 2025

Topics

Digestive Oncology Immunology Mechanisms & Personalised Medicine

Session

Immunotherapy in digestive cancers: Where are we heading?

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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