Anti-Reflux Mucosectomy Intervention and the SECS Criteria

Abstract

In this Digestive Endoscopy issue, Yamamoto et al. present an article entitled “Efficacy and Safety of Closure-Focused Anti-Reflux Mucoplasty Compared With Conventional ARMS: A Propensity Score-Matched Study” [1]. ARMS and ARMA, which were developed as endoscopic procedures for managing gastro-esophageal reflux disease (GERD) since 12 years and pioneered by Inoue H, were compared to the so-called ARMP and ARMP-V [1, 2]. Before starting any commentaries in this Editorial, we have not to forget that ESGE guidelines about Endoscopic management of motility disorders, stated in 2020 “ESGE recommends against the use of Anti Reflux Mucosectomy (ARMS) in routine clinical practice in the treatment of GERD” [3]. However these ESGE guidelines were provided 6 years ago and it could be postulated that any endoscopic treatment for GERD should be analyzed according to the following criteria: Is it a procedure Simple, Efficient, Cost-effective and Safe, namely SECS criteria?

Yamamoto et al. included 251 patients in a retrospective study with propensity-score matching. These new techniques or improvement changed the concept of mucosectomy previously performed with EMR, ESD or plasma argon to mucoplasty [1]. With ARMP, a mucosal resection on the gastric side of the lesser curve with complete closure with either prong clips or suturing (which was more demanding) was done. The goal was to eliminate the so-called “dead space” below the esogastric junction. A “derivated procedure” was ARM-V where the authors were adding an uvula-like valve after mucosal resection by ESD to anchor a flap.

We can easily imagine that these improved techniques are clearly more demanding. This is confirmed by an increase of the procedure time from 49.3 mn to 74.6 mn. Moreover, by pooling the ARMS/ARMA results versus ARMP/ARMV results, they found similar postoperative quality of life (QOL) and no significant difference regarding the acid exposure-time (AET 35.1% vs. 45.7%). However, the ARMP/ARMV clearly decreased the rate of adverse events from 25.5% to 5.3%. One could say that the AEs rate in the group of ARMS/ARMA is very high compared to the rate in recent meta-analyses about 13%; the main symptom being dysphagia ranging from 5% to 16% [4-6].

Despite the authors not finding any difference regarding the efficacy of ARMP/ARMV, they highlight the interest of mini-invasive procedures for managing GERD [1]. GERD is a frequent GI disease with about 40% of patients that are only partial responders to PPI [4, 5, 7]. Therefore, patients with refractory GERD or PPI dependency with side-effects or contraindications could be candidates for these noninvasive procedures that we could call ARMI for anti-reflux mucosal interventions. We could say that regarding endoscopic management of functional disease, the procedures should be in adequacy with the SECS criteria: Simple/Efficient/Cost-effective/Safe. Because GERD is a frequent disease with clear alteration of the quality of life, ARMI should be (1) easy to practice for having a good diffusion among endoscopists; (2) efficient because of the quality-of-life-impact; (3) cost-effective to decrease the cost-impact on National Health Insurance; (3) safe because it is a benign disease. ARMI seems already to respond to the SECS criteria.

Nevertheless, ARMIs procedures still have to face with practical and technical issues. One of the technical issue related to ARMI, is the duration time of the procedure. In previous-meta-analyses, there were for ARM-BL (ARMS with band ligation) 12.3 mn ± 3.2 mn; ARMS was ranging from 35 to 54.7 mn (the procedure time being 2 times longer with ESD than with EMR) and ARMA 29–35.6 mn [4, 5, 8]. Summarizing the ARMI procedure times, we could consider that it is always < 1 h. In the paper of Yamamoto et al. the closure-focused group was much longer than ARMS and ARMI (74.65 ± 25.8 mn vs. 49.3 ± 23.5 mn). This is not in favor for fulfilling the SECS criteria, looking to the “Simple” criteria. In addition, the problem of hospital stay is crucial for a so widely diffused disease, looking to the cost-efficacy of this technique. The mean time for hospital stay with ARMS/ARMA and ARMP was ranging from 4.5 to 5.2 days in this paper. This is an essential point since some series performed ARMI procedures in daily patients, which is of course much more cost-effective [9]. In most of the recent meta-analyses, the mean hospital day was 4.4 days. Probably when excluding the ESD procedures, ARMI could be performed in daily patients because most of the complications are delayed or not severe, despite AGREE classification is not available in the previously published studies [4, 5, 7, 8].

The way to assess ARMI efficiency is probably the most challenging part for the clinical outcome of the patients. Not all the studies are evaluating at the same time clinical efficacy, acid exposure, and quality of life. In one meta-analysis comparing ARMS and ARMA, the clinical efficacy of ARMS and ARMA was, respectively, 76% and 87% with significant improvement of the De Meester score and acid exposure time at 6 months [6]. In other studies comparing ARMI, Strtta, Laparoscopic Nissen and including a large number of studies, ARMI procedures showed a decrease in PPI intake with a mean rate of 37% and a significant decrease of acid exposure time, De Meester score, and QOL scores [4]. Moreover, they found that these results were stable with time, up to 36 months in some of the studies. In addition, these results were comparable to Stretta procedures and laparoscopic Nissen but with lower AEs compared to the latter [4].

Finally, if Yamamoto's study showed a technical improvement of the ARMP and ARM-V modified procedures, the clinical efficacy was similar whereas the procedure time was much longer [1]. Considering the SECS evaluating process, we could say that ARMIs procedures seem simple endoluminal procedures; efficient for clinical efficacy, acid exposure time, QOL and mid-term follow-up; cost-effective mainly if the procedures are performed in daily patients; safe without severe complication, dysphagia being the main one that could be endoscopically managed. Therefore, despite GERD being a functional disease with complex evaluation, ARMIs procedures are mini-invasive management with of course some failures but without definitive sequalae, responding to the SECS criteria.

The author has nothing to report.

Marc Barthet is a consultant for Taewoong and Boston Scientific.

This article is linked with Yamamoto et al. To view this article, visit https://doi.org/10.1111/den.70201.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.