Application status of endoscopic anti-reflux mucosal interventions in the treatment of gastroesophageal reflux disease

Table 1 Anti-reflux mucosectomy treatment for gastroesophageal reflux disease has shown favorable outcomes, %

Ref.	Year	Intervention1	Cases	Effective rate	PPI usage
					Discontinuation	Reduction
Inoue et al[6]	2014	ARMS	10	100	100	0
He et al[8]	2022	L-ARMS	69	85.5	55.1	30.4
Gao et al[9]	2023	ARMS	36	75	25	50
Sumi et al[10]	2021	ARMS	88	69.3	40-50	NA
Wong et al[11]	2020	ARMS	33	90.9	90.9	NA
Sui et al[12]	2022	ARMS	39	89.7	71.8	17.9
Sumi et al[14]	2024	ARMS	88	68.3	42	NA
Lee et al[15]	2024	ARMS-C	115	86	37.5	NA
Yoo et al[16]	2020	ARMS-C	33	93.9	63.6	30.3
Yang et al[17]	2021	ARMS	39	85.7	66.7	19
Hedberg et al[18]	2019	ARMS	19	68.4	68.4	NA
Chou et al[22]	2022	ARMS	11	73.9	56.5	NA
Klimczak and Strzelczyk[24]	2023	ARMS	20	86.7	73.33	NA
Monino et al[32]	2020	ARMS-b	21	76.2	57.1	19.0
Patil et al[33]	2020	ARMS	62	88.7	69.4	19.4
Laquière et al[37]	2022	ARMS	13	91	91	NA
Hu et al[38]	2023	ARMS	12	75	50	25
Average				82.60	63.65	23.44

¹Intervention: Nomenclature of the intervention is based on the designation published by the authors rather than the specific surgical approach.

ARMS: Anti-reflux mucosectomy; L-ARMS: Ligation-assisted anti-reflux mucosectomy; ARMS-C: Anti-reflux mucosectomy with cap-assisted; ARMS-b: Anti-reflux mucosectomy using band ligation; PPI: Proton pump inhibitor; NA: Not available.

Table 2 Anti-reflux mucosal ablation or peroral endoscopic cardial constriction treatment for gastroesophageal reflux disease has shown favorable outcomes, %

Ref.	Year	Intervention	Cases	Effective rate	PPI usage
					Discontinuation	Reduction
Inoue et al[19]	2020	ARMA	8	100	62.5	37.5
Hernández Mondragón et al[20]	2020	ARAT	108	94.3	78.6	15.7
Chou et al[22]	2023	ARMA	12	73.9	56.5	NA
Shimamura et al[23]	2024	ARMA	68	70	43.4	NA
Klimczak et al[24]	2023	ARMA	10	86.7	73.3	NA
Average				84.98	62.86	26.60
Li et al[25]	2017	PECC	47	73.7	NA	NA
Liu et al[26]	2020	C-BLART	60	43	43	NA
Seleem et al[27]	2018	EBL	75	65	65	NA
Li et al[28]	2021	PECC-b	68	77.9	77.9	NA
Jiang et al[29]	2022	PECC-b	16	62.5	NA	NA
Deshmukh et al[30]	2022	ARBM	4	100	100	NA
Hu et al[34]	2018	PECC	13	69	NA	NA
Wang et al[39]	2020	PECC	15	100	93.3	6.7
Average				73.89	75.84	6.70

ARMA: Anti-reflux mucosal ablation; ARAT: Anti-reflux ablation therapy; PECC: Peroral endoscopic cardial constriction; EBL: Endoscopic band ligation; C-BLART: Clip band ligation anti-reflux therapy; PECC-b: Peroral endoscopic cardial constriction with band ligation; ARBM: Anti-reflux band mucosectomy; PPI: Proton pump inhibitor; NA: Not available.

Table 3 Concise inclusion criteria for anti-reflux mucosectomy in gastroesophageal reflux disease patients

Ref.	Year	Intervention	Inclusion criteria1
			GERD diagnosis	Hiatal hernia	Hill score	Los Angeles’s grade	Barrett’s esophagus
Inoue et al[6]	2014	ARMS	Refractory GERD	Without	NA	NA	Included
Inoue et al[6]	2014	ARMS-C	Refractory GERD	≤ 3 cm	NA	NA	Included
He et al[8]	2022	ARMS	Refractory GERD	≤ 3 cm	NA	NA	NA
Sumi et al[10]	2021	ARMS	Refractory/PPI-depended GERD	≤ 2 cm	2-4	NA	NA
Wong et al[11]	2020	ARMS	Refractory GERD	≤ 2 cm	NA	A-B	NA
Sui et al[12]	2022	ARMS	PPI-depended GERD	≤ 2 cm	NA	A-B	Excluded
Sumi et al[14]	2024	ARMS-C	Refractory/PPI-depended GERD	≤ 3 cm	NA	NA	NA
Yang et al[17]	2021	L-ARMS	Refractory/PPI-depended GERD	≤ 2 cm	NA	A-C	NA
Chou et al[22]	2022	ARMS	GERD	3-5 cm	NA	NA	NA
Monino et al[32]	2020	ARMS-b	Refractory GERD	≤ 2 cm	≤ 2	A-B	Included
Monino et al[32]	2020	ARMS	Refractory GERD	≤ 2 cm	≤ 3	A-C	NA
Patil et al[33]	2020	ARMS	Refractory GERD	≤ 3 cm	NA	NA	NA
Patil et al[33]	2020	ARMS	Refractory/PPI-depended GERD	≤ 3 cm	≤ 3	A-C	Included
Hedberg et al[35]	2019	ARMS	GERD	≤ 2 cm	NA	NA	NA
Hedberg et al[35]	2019	ARMS	GERD	≤ 2 cm	NA	NA	NA
Laquière et al[37]	2022	ARMS	PPI-depended GERD	≤ 3 cm	NA	NA	NA
Hu et al[38]	2023	ARMS	Refractory GERD	NA	NA	NA	NA

¹Inclusion criteria: The patient inclusion criteria as defined in the study.

ARMS: Anti-reflux mucosectomy; ARMS-C: Anti-reflux mucosectomy with cap-assisted; L-ARMS: Ligation-assisted anti-reflux mucosectomy; ARMS-b: Anti-reflux mucosectomy using band ligation; GERD: Gastroesophageal reflux disease; PPI: Proton pump inhibitor; NA: Not available.

Table 4 Concise inclusion criteria for anti-reflux mucosal ablation and peroral endoscopic cardial constriction in gastroesophageal reflux disease patients

Ref.	Year	Intervention	Inclusion criteria
			GERD diagnosis	Hiatal hernia	Hill score	Los Angeles’s grade	Barrett’s esophagus
Inoue et al[19]	2020	ARMA	Refractory GERD	≤ 3 cm	≤ 3	NA	NA
Hernández Mondragón et al[20]	2020	ARAT	Refractory GERD	Without	≤ 3	NA	Excluded
Chou et al[22]	2023	ARMA	PPI-depended GERD	≤ 3 cm	2-3	NA	NA
Shimamura et al[23]	2024	ARMA	Refractory/PPI-depended GERD	≤ 3 cm	NA	NA	NA
Klimczak et al[24]	2023	ARMA	Refractory GERD	NA	NA	NA	NA
Li et al[25]	2017	PECC	GERD	NA	NA	NA	NA
Liu et al[26]	2020	C-BLART	Refractory GERD	≤ 2 cm	NA	A-C	Excluded
Seleem et al[27]	2018	EBL	Refractory GERD	≤ 2 cm	NA	A-B	NA
Li et al[28]	2021	PECC-b	GERD	≤ 2 cm	NA	NA	NA
Jiang et al[29]	2022	PECC-b	Refractory/PPI-depended GERD	≤ 2 cm	NA	NA	Excluded
Deshmukh et al[30]	2022	ARBM	Refractory GERD	≤ 2 cm	NA	NA	NA
Hu et al[34]	2018	PECC	GERD	≤ 3 cm	NA	NA	Excluded
Wang et al[39]	2020	PECC	Refractory/PPI-depended GERD	≤ 3 cm	NA	NA	Excluded

ARMA: Anti-reflux mucosal ablation; ARAT: Anti-reflux ablation therapy; PECC: Peroral endoscopic cardial constriction; EBL: Endoscopic band ligation; C-BLART: Clip band ligation anti-reflux therapy; PECC-b: Peroral endoscopic cardial constriction with band ligation; ARBM: Anti-reflux band mucosectomy; GERD: Gastroesophageal reflux disease; PPI: Proton pump inhibitor; NA: Not available.

Table 5 Technical specifications and subtypes of anti-reflux mucosectomy

Ref.	Year	Intervention	Excision range1
			Circumferential degree	Lesser curvature	Greater curvature	Esophagus	Stomach
Inoue et al[6]	2014	ARMS	240°-360°	Resected	Remained	1 cm	2 cm
He et al[8]	2022	L-ARMS	240°	Resected + ligated	Remained	Resected	Resected
Gao et al[9]	2023	ARMS	240°-270°	Resected	Remained	1 cm	1 cm
Sumi et al[10]	2021	ARMS	240°-290°	Remained	Remained	0	Resected
Wong et al[11]	2020	ARMS	240°-270°	Remained	Remained	0	Resected
Sui et al[12]	2022	ARMS	240°-270°	Resected	Remained	1 cm	2 cm
Sumi et al[14]	2024	ARMS	240°-290°	Resected	Remained	0	Resected
Lee et al[15]	2024	ARMS-C	210°-290°	Resected	Remained	0	Resected
Yang et al[17]	2021	ARMS	180°-270°	Resected	Remained	1 cm	2 cm
Chou et al[22]	2022	ARMS	240°-290°	Remained	Remained	0	Resected
Klimczak and Strzelczyk[24]	2023	ARMS	2-3 cm remained	Remained/resected	Remained	0	1 cm
Monino et al[32]	2020	ARMS-b	270°	Resected	Remained	1 cm	2 cm
Patil et al[33]	2020	ARMS-C	210°-290°	Resected	Remained	0	Resected
Patil et al[33]	2020	ARMS	240°	Resected	Remained	1 cm	2 cm
Hedberg et al[35]	2019	ARMS	240°-270°	Resected	Remained	0	3 cm
Laquière et al[37]	2022	ARMS	Esophagus 180°; stomach 240°	Resected	Remained	1 cm	2 cm
Hu et al[38]	2023	ARMS	240°-290°	Resected	Remained	1 cm	2 cm

¹Excision range: The surgical scope as described in the study.

ARMS: Anti-reflux mucosectomy; ARMS-b: Anti-reflux mucosectomy using band ligation; ARMS-C: Anti-reflux mucosectomy with cap-assisted; L-ARMS: Ligation-assisted anti-reflux mucosectomy.

Table 6 Technical specifications and subtypes of anti-reflux mucosal ablation and peroral endoscopic cardial constriction

Ref.	Year	Intervention	Excision range
			Circumferential degree	Lesser curvature	Greater curvature	Esophagus	Stomach
Inoue et al[19]	2020	ARMA	2-3 cm remained	Remained	Remained	0	2 cm
Hernández Mondragón et al[20]	2020	ARAT	270°-320°	Remained	Remained	0	3 cm
Chou et al[22]	2023	ARMA	2-3 cm remained	Remained	Remained	0	2 cm
Shimamura et al[23]	2024	ARMA	2-3 cm remained	Remained/ablated	Remained	0	2 cm
Klimczak et al[24]	2023	ARMA	2-3 cm remained	Remained	Remained	0	> 1 cm
Li et al[25]	2017	PECC	2	Ligation	Ligation	1 cm	0
Liu et al[26]	2020	C-BLART	2	The anterior wall of the cardia	The posterior walls of the cardia	Ligated	0
Seleem et al[27]	2018	EBL	3-4	Ligation	Ligation	Ligated	0
Li et al[28]	2021	PECC-b	Esophagus 1-3; stomach 4-10	Ligation	Stomach remained Esophagus ligated	1 cm	3 cm
Jiang et al[29]	2022	PECC-b	240°	Ligation	Remained	1 cm	2 cm
Deshmukh et al[30]	2022	ARBM	4	Ligation	Remained	0	Ligated
Hu et al[34]	2018	PECC	2	Ligation	Ligation	1 cm	0
Wang et al[39]	2020	PECC	3	Ligated (trisection)	Ligated (trisection)	Ligated	0

ARMA: Anti-reflux mucosal ablation; ARAT: Anti-reflux ablation therapy; PECC: Peroral endoscopic cardial constriction; EBL: Endoscopic band ligation; C-BLART: Clip band ligation anti-reflux therapy; PECC-b: Peroral endoscopic cardial constriction with band ligation; ARBM: Anti-reflux band mucosectomy.

Table 7 Incidence of postoperative dysphagia and related complications following anti-reflux mucosal ablation

Ref.	Year	Intervention	Cases	Incidence of adverse events (%)
				Stenosis or dysphagia	Relief after dilatation	Bleeding	Perforation
Inoue et al[6]	2014	ARMS	10	20.0	Yes	0.0	0.0
He et al[8]	2022	L-ARMS	69	65.2	No	0.0	0.0
Gao et al[9]	2023	ARMS	20	0.0	NA	0.0	0.0
Sumi et al[10]	2021	ARMS	88	15.9	Yes	2.3	1.1
Wong et al[11]	2020	ARMS	33	9.1	Yes	3.0	0.0
Sui et al[12]	2022	ARMS	39	2.6	Yes	0.0	0.0
Sumi et al[14]	2024	ARMS	36	22.2	Yes	0.0	0.0
Yang et al[17]	2021	ARMS	39	23.1	Yes	2.6	0.0
Chou et al[22]	2022	ARMS	11	0.0	NA	0.0	0.0
Klimczak and Strzelczyk[24]	2023	ARMS-C	115	0.0	NA	0.0	0.0
Monino et al[32]	2020	ARMS-b	21	14.3	Yes	4.8	0.0
Patil et al[33]	2020	ARMS-C	33	6.1	Yes	0.0	0.0
Patil et al[33]	2020	ARMS	62	8.1	Yes	0.0	3.2
Hedberg et al[35]	2019	ARMS-b	19	15.8	Yes	5.3	0.0
Laquière et al[37]	2022	ARMS	13	7.7	Yes	15.4	0.0
Hu et al[38]	2023	ARMS	12	25.0	No	0.0	0.0
Average				14.69		2.09	0.27

ARMS: Anti-reflux mucosectomy; L-ARMS: Ligation-assisted anti-reflux mucosectomy; ARMS-b: Anti-reflux mucosectomy using band ligation; ARMS-C: Anti-reflux mucosectomy with cap-assisted; NA: Not available.

Table 8 Incidence of postoperative dysphagia and related complications following anti-reflux ablation therapy and peroral endoscopic cardial constriction

Ref.	Year	Intervention	Cases	Incidence of adverse events (%)
				Stenosis or dysphagia	Relief after dilatation	Bleeding	Perforation
Inoue et al[19]	2020	ARMA	8	12.5	Yes	0.0	0.0
Hernández Mondragón et al[20]	2020	ARAT	108	13.0	Yes	0.0	0.0
Chou et al[22]	2023	ARMA	12	8.3	Yes	8.3	0.0
Shimamura et al[23]	2024	ARMA	68	13.2	Yes	8.8	0.0
Klimczak et al[24]	2023	ARMA	10	0.0	NA	0.0	0.0
Average				9.40		3.42	0.0
Li et al[25]	2017	PECC	47	4.3	No	4.3	0.0
Liu et al[26]	2020	C-BLART	60	5.0	No	0.0	0.0
Seleem et al[27]	2018	EBL	75	25.3	No	0.0	0.0
Li et al[28]	2021	PECC-b	68	41.2	No	2.9	0.0
Jiang et al[29]	2022	PECC-b	16	12.5	No	12.5	0.0
Deshmukh et al[30]	2022	ARBM	4	0.0	NA	0.0	0.0
Hu et al[34]	2018	PECC	13	0.0	NA	0.0	0.0
Wang et al[39]	2020	PECC	15	40.0	No	0.0	0.0
Average				16.04		2.46	0.0

ARMA: Anti-reflux mucosal ablation; ARAT: Anti-reflux ablation therapy; PECC: Peroral endoscopic cardial constriction; EBL: Endoscopic band ligation; C-BLART: Clip band ligation anti-reflux therapy; PECC-b: Peroral endoscopic cardial constriction with band ligation; ARBM: Anti-reflux band mucosectomy; NA: Not available.

Table 9 Advantages and limitations of anti-reflux mucosal intervention in clinical practice (anti-reflux mucosectomy, anti-reflux mucosal ablation, and peroral endoscopic cardial constriction)

Intervention		Advantages	Limitations
ARMS	ARMS-horseshoe	(1) No artificial device implantation required; (2) Short procedure time, hospital stay, and fast recovery than surgery; (3) Does not preclude future laparoscopic surgery; (4) Low bleeding rate; and (5) Available tissue specimens for pathology	Relative higher stenosis rate than ARMA
	ARMS-butterfly	(1) The same as ARMS-horseshoe; and (2) Reduced stenosis rate	Relative higher stenosis rate than ARMA
ARMA	ARMA-horseshoe	(1) No artificial device implantation required; (2) Short procedure time, hospital stay, and fast recovery than surgery; (3) Does not preclude future laparoscopic surgery; (4) Lower stenosis rate than ARMS; (5) Low perforation rate; (6) Adjunctive therapy for post-ARMS; and (7) Can be safely re-administered	(1) Tissue specimens for pathological analysis unavailable; and (2) Relative higher bleeding rate than ARMS
	ARMA-butterfly	(1) The same as ARMA-horseshoe; and (2) Further reduced stenosis rate	(1) Tissue specimens for pathological analysis unavailable; and (2) Higher bleeding rate than ARMS
PECC	PECC-esophagus	(1) Does not preclude future laparoscopic surgery; (2) Short hospital stays, and fast recovery; (3) Easier to conduct than ARMS; (4) Shorter procedure time; (5) Simpler instrumentation required; (6) Lower dysphagia rate than ARMS; and (7) Improves extra-esophageal symptoms	(1) Slight lower therapeutic effective rate; (2) Tissue specimens for pathological analysis unavailable; and (3) Risk of esophageal lesion aggravation
	PECC-stomach	The same as PECC-esophagus	(1) The same as PECC-esophagus; and (2) May exacerbate dysphagia and bloating
	PECC-esophagus & stomach	The same as PECC-esophagus	The same as PECC-stomach

ARMS: Anti-reflux mucosectomy; ARMA: Anti-reflux mucosal ablation; PECC: Peroral endoscopic cardial constriction; NA: Not available.

Table 10 Options of anti-reflux mucosal intervention for refractory gastroesophageal reflux disease patients with different comorbidities

Patient population			Intervention options
			ARMS	ARMA	PECC
Hiatal hernia	No	NA	Recommended	Recommended	Recommended
	Yes	≤ 2 cm	Recommended	Recommended	Recommended
		2-3 cm	Recommended	Recommended	Optional
		3-5 cm	Optional	Not recommended	Not recommended
Hill grade	I-II	NA	Recommended	Recommended	Recommended
	III	NA	Recommended	Recommended	Not recommended
	IV	NA	Recommended	Not recommended	Not recommended
Barrett’s esophagus	No	NA	Recommended	Recommended	Recommended
	Yes	Short BE	Recommended	Not recommended	Not recommended
		Long BE	Not recommended	Not recommended	Not recommended
Esophagitis (Los Angeles’s grade)	LA-A - LA-B	NA	Recommended	Recommended	Recommended
	LA-C	NA	Optional	Not recommended	Optional
	LA-D	NA	Not recommended	Not recommended	Not recommended
Age	Young (refusal of surgical procedures)	NA	Recommended	Recommended	Recommended
	Old (inability to tolerate surgical procedures)	NA	Recommended	Recommended	Recommended
Previous history of upper gastrointestinal surgery1	No	NA	Recommended	Recommended	Recommended
	Yes	NA	Recommended	Optional	Optional
Presence of mucosal abnormalities2	No	NA	Recommended	Recommended	Recommended
	Yes	NA	Recommended	Not recommended	Not recommended

¹Previous history of upper gastrointestinal surgery: Any prior upper gastrointestinal operation involving the lower esophagus, gastric cardia, or stomach, which may compromise surgical access and complicate surgical anti-reflux procedures.

²Presence of mucosal abnormalities: Confirmed or suspected mucosal abnormalities (e.g., Barrett’s esophagus) in the esophagogastric junction region requiring histopathological confirmation.

BE: Barrett’s esophagus; ARMS: Anti-reflux mucosectomy; ARMA: Anti-reflux mucosal ablation; PECC: Peroral endoscopic cardial constriction; NA: Not available.