Introduction

Medical treatment with acid suppressive medications is effective in managing gastroesophageal reflux disease (GERD) symptoms, but some experience persistent symptoms. To address this, we have developed minimally invasive endoscopic intervention: anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA). In ARMS and ARMA, we artificially create an ulcer at the level of the gastric cardia by resecting or ablating the mucosa and achieve cardioplasty through the scarring process. Previous studies have shown favorable outcomes. However, some challenges of ARMS and ARMA remains including the slow onset of therapeutic effect and the risk of delayed bleeding in patients who are taking antithrombotic medications. Thus, we developed ARM-P (anti-reflux mucoplasty), in which the mucosal defect is closed immediately after resection with the expectation of faster treatment efficacy and reduced risk of postoperative bleeding. The closure of the mucosal defect was achieved with traction using endoclips and support threads.

Aims & Methods

A retrospective case series was conducted at the single tertiary referral center from October 2022 to March 2023. We included all consecutive patients who underwent ARM-P. Inclusion criteria were the presence of at least one typical reflux symptom more than two times a week despite double-dose PPI treatment for at least 6 months, or pathologic esophageal acid exposure defined by acid exposure time > 6.0%. Frequency Scale for the Symptoms of GERD (FSSG) and Gerd Q questionnaire at baseline and at 2 months post-ARM-P were evaluated.

Results

Ten patients (6 males, median age 56.5 years, range 33-76 years) who underwent ARM-P during the study period; one patient had a history of Toupet fundoplication, but no other previous surgery. The median procedure time was 95 minutes (range: 45-205), and all patients had no adverse events such as bleeding or perforation. The median hospital stay was 5 days (range: 5-9 days). Of the 9 patients followed up 2 months after ARM-P, all showed improvement in Hill's flap grade from a median of 2 (range: 1-3) to 1 (range: 1-1). 6 patients were able to discontinue acid suppression drugs, and their symptom scores improved significantly: FSSG from 186 to 121 (p=0.05) and GERDQ from 56 to 46 (p=0.01).

Conclusion

Technical and clinical results, including improvements in cardia morphology and patient symptoms, were evaluated. The results confirmed that it is technically feasible, that the cardia morphology was modified, and that the patient's symptoms improved.

References

-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: 346-51.
-Sumi K, Inoue H, Kobayashi Y, et al. Endoscopic treatment of proton pump inhibitor-refractory gastroesophageal reflux disease with anti-reflux mucosectomy: Experience of 109 cases. Dig Endosc. 2021; 33: 347-54.
-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-E8.
-Rodriguez de Santiago E, Sanchez-Vegazo CT, Penas B, et al. Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) for gastroesophageal reflux disease: a systematic review and meta-analysis. Endosc Int Open. 2021; 9: E1740-E51.
-Inoue H, Takeshita K, Hori H, Muraoka Y, Yoneshima H, Endo M. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc. 1993; 39: 58-62.
-Inoue H, Shimamura Y, Fukuda M, Ando R, Kato H, Tanabe M, Julius Navarro M. Loop-10” line-assisted clip closure method: closure of perforation in re-do peroral endoscopic myotomy VideoGIE. 2023.

Disclosure

H Inoue declares: Olympus (advisory, educational activities), Top Corporation (advisory), Takeda Pharmaceutical Company (educational activities).

Introduction

Gastric emptying scintigraphy (GES) is an accepted standard for gastroduodenal function (GDF) testing, while various other investigations are available for the assessment of dyspeptic symptoms. However, in the absence of guidelines, it remains uncertain which test one should favour.

Aims & Methods

This study examined variation in GDF testing between centres to establish the status of current practice. A web-based questionnaire assessing availability, standard operating procedures and interpretation of 15 different GDF testing techniques was distributed among specialist practitioners via professional organizations. Availability, indication, meal-related characteristics and standard operating procedures (SOP) were compared.

Results

Fifty-nine complete responses (57 clinical practice, 86% tertiary care) were included from 28 countries. Eleven (19%) respondents referred more than 10 patients for further testing monthly. Accessibility for clinical practice were as follows: 100% gastroscopy, 91% measurement of gastric emptying (79% by GES; 19% gastric emptying breath testing (GEBT); 5% SPECT), 39% intragastric pressure measurements (IGP), 33% pyloric Endoflip (PE), 30% gastric MRI, 19% nutrient drinking challenge (NDC), 18% gastric ultrasound (US), 18% motility capsule (MC) and 16% antroduodenal manometry (AM). Other techniques were available to less than 15% of the respondents. In clinical practice, meal-related dyspeptic symptoms and chronic unexplained nausea and vomiting (CUNV) represented the main indications for GE studies as compared to epigastric pain, burning or discomfort (GES: 70% and 94% vs. 20%, p<.00001; GEBT: 100% and 100% vs. 0%, p<.001), Similar results were present for PE (73% and 93% vs. 33%, p=.002), NDC (100 and 82 vs. 27%, p=.0006). MC (33% and 67% vs. 0%, p=.05), AM (28% and 75% vs. 25%, p=.11), MRI (75% and 88% vs. 38%, p=.09) and IGP (33% and 33% vs. 0%, p=.15) By contrast, US was indiscriminately performed (57% and 71% vs. 57%, p=.82).There was a large heterogeneity in the type of meal and meal quantity used for each test as well as between tests. Symptoms were recorded by only half the respondents during GES and MRI, with higher percentages for other testing modalities. Variation in the specific symptoms included in questionnaires was present.

Conclusion

GES is widely available in clinical practice. Meal-related symptoms and CUNV represent the main indications for GDF testing in clinical practice. A large variation in the availability of GDF testing and SOPs exists between centres. This hampers clinical interpretation, data transfer between centres and research collaboration. These findings emphasise the need for an international co-operation effort at standardisation.