Post written by Kazuki Yamamoto, MD, PhD, from the Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.

This video case introduces the effectiveness of antireflux mucoplasty (ARM-P) with valve (ARM-P/V) for proton pump inhibitor—refractory GERD. Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) are effective treatments for proton pump inhibitor—refractory or dependent GERD, as supported by meta-analyses.

However, ARMS and ARMA involve resecting or ablating excess mucosa from the lesser curvature of the stomach, typically removing three-quarters to four-fifths of the area, requiring a 3- to 4-week healing period and increasing the risk of bleeding and strictures.

Recently, Lu et al¹ introduced antireflux mucosal valvuloplasty (ARMV), which conserves mucosa through endoscopic submucosal dissection (ESD) to create a mucosal flap valve. However, similar to ARMS, it requires an incision of approximately three-fourths of the circumference via ESD, raising concerns about an increased risk of adverse events.

To address these concerns, we have successfully integrated ARM-P and ARMV into ARM-P/V, leading to favorable clinical outcomes, as this video case demonstrates. This adaptation upholds ARMV’s principle of mucosal preservation.

In addition, prompt closure and a limited mucosal incision promote mucosal formation, reduce the risks of bleeding and stricture formation, and minimize individual outcome variations.

ARMS and ARM-P resect the mucosa using ESD or the cap-assisted EMR technique, while ARM-P/V conserves the mucosa for valve formation, which is more physiologically natural. Furthermore, although the concept of defect closure after ESD is gradually gaining acceptance, it has yet to be widely adopted in endoscopic antireflux therapy. We hope that other endoscopists will recognize the importance of defect closure in the field of endoscopic antireflux therapy.

Summary of endoscopic antireflux therapy techniques. ARMA, Antireflux mucosal ablation; ARM-P, antireflux mucoplasty; ARM-P/V, antireflux mucoplasty with valve; ARMS, antireflux mucosectomy.

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1. Lu J, Chen F, Lv X, et al. Endoscopic construction of an antireflux mucosal barrier for the treatment of GERD: a pilot study (with video). Gastrointest Endosc 2023;98:1017-22. ↩︎