Antireflux mucosectomy for refractory gastroesophageal reflux disease following peroral endoscopic myotomy

Hideomi Tomida; Kazuhiro Tange; Yoshiou Ikeda; Yoichi Hiasa

doi:10.5946/ce.2024.344

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Image of Issue Antireflux mucosectomy for refractory gastroesophageal reflux disease following peroral endoscopic myotomy: Hideomi Tomida^1,, Kazuhiro Tange², Yoshiou Ikeda¹, Yoichi Hiasa³; DOI: https://doi.org/10.5946/ce.2024.344
Published online: March 13, 2025

¹Endoscopy Center, Ehime University Hospital, Toon, Japan

²Department of Inflammatory Bowel Diseases and Therapeutics, Ehime University Graduate School of Medicine, Toon, Japan

³Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan

Correspondence: Hideomi Tomida Endoscopy Center, Ehime University Hospital, 454 Shitsukawa, Toon, Ehime 791-0295, Japan E-mail: hideomi.tomida.epch@hotmail.com

• Received: December 20, 2024 • Revised: December 26, 2024 • Accepted: December 27, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Peroral endoscopic myotomy (POEM) is a minimally invasive and effective procedure for treating esophageal achalasia, and it is widely performed worldwide. One of the complications associated with POEM is the development of gastroesophageal reflux disease (GERD).¹ The efficacy of anti-reflux mucosectomy (ARMS) for acid-suppressant-refractory GERD has been reported²^,³; however, it remains unclear whether ARMS is effective for severe GERD following POEM. Here, we report a case in which ARMS was effective in successfully treating severe GERD after POEM.

A 57-year-old man underwent POEM for esophageal achalasia at another hospital. Two years after POEM, he developed vonoprazan-refractory GERD, which prevented him from sleeping in the supine position. He was subsequently admitted to our institution. Esophagogastroduodenoscopy (EGD) revealed mucosal injury with ulceration at the esophagogastric junction (Fig. 1A, inset), and the cardia was opened to approximately twice the diameter of the endoscope. A post-POEM scar was noted on the posterior wall of the cardia (Fig. 1A, arrow). The 24-hour pH monitoring revealed significant acid reflux, with an acid exposure time of 18.0% (pH<4) (Fig. 1B).

The patient was treated with ARMS using the endoscopic submucosal dissection technique. The mucosa was resected in a fan shape, approximately 90° centered on the POEM scar (Fig. 2A, B). Severe fibrosis was observed in the submucosa; however, the mucosa was carefully dissected (Fig. 2C). The circular muscle was absent due to the POEM exposure of the longitudinal muscle (Fig. 2D). After 2 months of treatment, the reflux symptoms resolved, and anti-acid therapy was discontinued. Follow-up EGD showed no evidence of reflux esophagitis, and the cardiac size had decreased (Fig. 3A). Additionally, 24-hour pH monitoring demonstrated a decrease in acid exposure time to 1.3% (Fig. 3B). In conclusion, ARMS is a viable treatment option for severe GERD after POEM.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Acknowledgments

Informed consent was obtained from the patient for publication of his related information and imaging.

Author Contributions

Conceptualization: HT; Data curation: HT, KT; Investigation: HT, KT; Supervision: HT, YI; Writing–original draft: HT; Writing–review & editing: all authors.

Fig. 1.

Pre-anti-reflux mucosectomy endoscopy revealed an ulceration at the esophagogastric junction (inset) and the cardia was dilated at the postoperative scar (arrow). The 24-hour pH monitoring revealed an acid exposure time (pH<4) of 18.0%.

Fig. 2.

(A, B) Anti-reflux mucosectomy (ARMS) was performed to resect the mucosa around the post-peroral endoscopic myotomy (POEM) scar. (C) Severe fibrosis was found in the submucosa at the site of previous POEM. (D) In post-ARMS ulcers, the scarred area of the POEM showed a loss of the circular muscle, exposing the longitudinal muscle.

Fig. 3.

Post-anti-reflux mucosectomy (ARMS) endoscopy revealed that the cardia had contracted due to ulcer healing, and the inflammation at the esophagogastric junction had resolved. The 24-hour pH monitoring after ARMS showed no significant acid reflux.

REFERENCES

1. Han SY, Youn YH. Role of endoscopy in patients with achalasia. Clin Endosc 2023;56:537–545.Article PubMed PMC PDF
2. Sumi K, Inoue H, Ando R, et al. Long-term efficacy of antireflux mucosectomy in patients with refractory gastroesophageal reflux disease. Dig Endosc 2024;36:305–313.Article PubMed
3. Rodríguez de Santiago E, Sanchez-Vegazo CT, Peñas 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–E1751.Article PubMed PMC

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Antireflux mucosectomy for refractory gastroesophageal reflux disease following peroral endoscopic myotomy

DOI: https://doi.org/10.5946/ce.2024.344

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Figure

Antireflux mucosectomy for refractory gastroesophageal reflux disease following peroral endoscopic myotomy

Fig. 1. Pre-anti-reflux mucosectomy endoscopy revealed an ulceration at the esophagogastric junction (inset) and the cardia was dilated at the postoperative scar (arrow). The 24-hour pH monitoring revealed an acid exposure time (pH<4) of 18.0%.

Fig. 2. (A, B) Anti-reflux mucosectomy (ARMS) was performed to resect the mucosa around the post-peroral endoscopic myotomy (POEM) scar. (C) Severe fibrosis was found in the submucosa at the site of previous POEM. (D) In post-ARMS ulcers, the scarred area of the POEM showed a loss of the circular muscle, exposing the longitudinal muscle.

Fig. 3. Post-anti-reflux mucosectomy (ARMS) endoscopy revealed that the cardia had contracted due to ulcer healing, and the inflammation at the esophagogastric junction had resolved. The 24-hour pH monitoring after ARMS showed no significant acid reflux.

Fig. 1.

Fig. 2.

Fig. 3.

Antireflux mucosectomy for refractory gastroesophageal reflux disease following peroral endoscopic myotomy