Redefining endoscopic management of refractory gastroesophageal reflux disease: the role of Stretta radiofrequency therapy and antireflux mucosectomy

Article information

Clin Endosc. 2025;58(3):398-400

Publication date (electronic) : 2025 May 8

doi : https://doi.org/10.5946/ce.2025.099

Yuto Shimamura

Department of Gastroenterology and Hepatology, Austin Health, University of Melbourne, Melbourne, VIC, Australia

Correspondence: Yuto Shimamura Department of Gastroenterology and Hepatology, Austin Health, University of Melbourne, Level 8, Harold Stokes Building, 145 Studley Road, Heidelberg, PO Box 5555, VIC 3084, Australia E-mail: yutoshimamura1219@gmail.com

Received 2025 April 1; Revised 2025 April 6; Accepted 2025 April 7.

Gastroesophageal reflux disease (GERD) is a common condition that significantly affects patient quality of life. Although proton pump inhibitors (PPIs) are widely used, a subset of patients develop refractory GERD requiring alternative therapeutic strategies. Several emerging endoscopic interventions have been introduced, including antireflux mucosectomy (ARMS),1 antireflux mucosal ablation,2,3 transoral incisionless fundoplication,4 and Stretta radiofrequency therapy (SRF).5 However, none of these endoscopic interventions have been established as standard treatments, and optimizing the outcomes remains a subject of ongoing debate.

Lee et al.6 presented a single-center retrospective study in Korea that provided valuable insights into the comparative efficacy of SRF and ARMS. The study evaluated 140 patients with refractory GERD who initially responded to PPIs but later required further intervention with either SRF or ARMS. Both procedures achieved high technical success and significant improvements in gastroesophageal reflux disease questionnaire scores. However, key differences emerged in the endoscopic findings and complication profiles. ARMS demonstrated superior efficacy in improving erosive esophagitis and gastroesophageal flap valve (GEFV) grade, with 61.1% of patients with ARMS showing esophagitis improvement compared to 35.4% in the SRF group (p=0.008). Additionally, the GEFV grade improved in 75.0% of patients with ARMS compared to 16.7% of patients with SRF (p<0.001), suggesting that ARMS provides a more robust anatomical modification, potentially reducing recurrence rates and the risk of Barrett’s esophagus-related diseases. Despite these differences, SRF achieved a comparable symptom improvement (95.8% in SRF vs. 94.4% in ARMS, p=0.73) and a similar PPI discontinuation rate (59.4% in SRF vs. 61.1% in ARMS; p=0.45), supporting its role in symptom management in selected patients. These findings align with those of recent systematic reviews and meta-analyses, which suggest that both treatments are effective and their clinical efficacies are similar.7 Additionally, they corroborated the results of Sui et al.,8 who reported no significant differences in PPI withdrawal rates between SRF and ARMS in patients with GEFV grades II and III, whereas ARMS demonstrated significantly higher PPI withdrawal rates in patients with GEFV grade IV.

Although there is growing evidence supporting the efficacy of endoscopic procedures, their indications and clinical implications remain controversial. Treatment selection should be based on patient-specific characteristics rather than a direct comparison of procedural superiority. The baseline characteristics differed significantly between the groups in this study, with patients with ARMS exhibiting more severe reflux esophagitis and higher Hill’s flap valve grades. Additionally, patients with SRF had baseline acid exposure times and DeMeester composite scores within the normal range, suggesting that acid reflux may not have been the primary issue and that esophageal hypersensitivity may have played a role. These findings highlight the importance of diagnoses based on endoscopic and functional assessments for guiding optimal therapy selection.

Each endoscopic therapy has distinct strengths and limitations that require surgeons to select the most appropriate treatment. Understanding the pathophysiology of GERD and the precise therapeutic targets of each intervention is crucial. The antireflux mechanism involves internal components, such as clasp fibers, sling fibers, and lower esophageal sphincter (LES), as well as external components, including the phrenoesophageal ligament and diaphragm. Although surgical interventions primarily address external components, most novel endoscopic therapies target the internal components. As demonstrated in this study, SRF applies radiofrequency to the muscle layer of the LES, thereby enhancing tissue compliance and reducing transient LES relaxation. In contrast, ARMS reinforces the mucosal flap valve mechanism and reduces hiatal hernia, providing anatomical reinforcement by targeting structures such as the clasp and sling fibers of the gastroesophageal junction. Understanding these distinct mechanisms is crucial for selecting the most appropriate therapeutic strategies.

Therefore, safety remains a critical consideration in the management of GERD. This study reported favorable safety profiles for SRF and ARMS, with minimal adverse events. ARMS was associated with a slightly higher incidence of bleeding and stricture; however, the differences were not statistically significant. These findings are consistent with those of previous studies, suggesting that mucosal resection techniques may carry a slightly increased risk of post-procedural complications.7 However, technological advancements continue to evolve. Novel radiofrequency-based therapies with more targeted energy delivery could improve SRF efficacy while minimizing tissue damage. Similarly, hybrid approaches combining ARMS with closure techniques such as endoscopic clipping or suturing may enhance safety by reducing post-procedural risks. Inoue et al.9 recently introduced antireflux mucoplasty (ARM-P), a novel approach involving endoscopic resection of approximately one-third of the lesser curvature mucosa, followed by closure using dead-space elimination techniques. In this study of 20 patients, no adverse events such as bleeding or stricture were reported. Additionally, recent advancements in ARM-P-incorporating valve techniques appear promising, demonstrating the ongoing refinement of endoscopic GERD therapies.10

Although compelling evidence supports endoscopic treatment for GERD, several questions remain unanswered. Long-term follow-up is essential to assess the durability, recurrence rates, and need for repeat interventions. Additionally, randomized controlled trials are needed to further clarify the relative efficacy of the different procedures. Cost-effectiveness analyses are crucial to determine their feasibility, particularly in resource-limited healthcare settings. The availability of certain devices, such as SRF, remains limited, which may impact clinical adoption.

Ongoing research and innovation are crucial for refining endoscopic GERD treatment and improving patient outcomes. Future studies should involve a personalized, minimally invasive approach that balances efficacy, safety, and long-term durability. Optimizing these strategies will advance patient care and facilitate more effective and less invasive treatment options.