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45
ab
Fig. 3.4 (a) Endoscopic image during PMMA injection. (b) Endoscopic image after PMMA
injection
3.4.3 Botulinum Toxin A
One cause of the refractory gastric reux is gastroparesis, which occurs in more
than 20% of patients [60]. Gastroparesis belongs to gastric motility disorders with
delayed gastric emptying caused by non-mechanical obstruction. The pathophysiol-
ogy of gastroparesis is complicated, including hypodynamic, impaired gastric prox-
imal tension, anterior duodenal nerve disorder, excessive pyloric contraction
(pyloric spasm), and intestinal feedback mechanism disorder. The increased volume
of gastroduodenal contents caused by gastroparesis may be one of the gastroesopha-
geal reux pathogenesis. Botulinum toxin A has a certain efcacy for refractory
gastroparesis [61, 62].
Endoscopic radiofrequency therapy alleviated the symptoms of refractory GERD
with gastroparesis by reinforcing the gastroesophageal reux barrier [63]. Therefore,
some scholars considered whether botulinum toxin injection therapy has a certain
effect on refractory GERD with gastroparesis [64]. Eleven GERD patients with
gastroparesis received botulinum toxin injection. The authors rstly developed a
scoring system to assess the severity and frequency of symptoms associated with
reux and gastroparesis. Then the efcacy of endoscopic botox injection into the
pylorus in alleviating both symptoms was tested. The injection method: Dissolved
200units of botox (Dysport, Ipsen Biopharm, UK) in 4mL physiological saline.
Then, injected 50units of botox A into each of the four quadrants of the pyloric
sphincter with a 25-gauge sclerotherapy needle. Stimulant drugs are not permitted
before or after treatment. Results: Botulinum toxin A injection signicantly
3 Endoscopic Injection Therapy forGERD
46
improved gastroparesis and reux-related symptoms in most patients, but the remis-
sion time is relatively short. The total reux symptom score (before injection) of
those who responded to treatment was signicantly higher than that of those who
did not. The efcacy of this procedure, particularly applied to GERD patients with
gastroparesis, is short-lived and lacks more experimental evidence.
For more than 30years, many scholars have tried to treat GERD by endoscopic
injection of a variety of substances, but they have not found a truly safe and effective
procedure that can be widely used in clinical practice. Since the clinical discontinu-
ation of Enteryx and Gatekeeper, trials of new substances such as Durasphere and
PMMA have provided new ideas for endoscopic injection of GERD.The key to
endoscopic injection therapy is to nd the appropriate injection substance and per-
fect the operation method, to improve the efcacy and reduce the adverse reactions.
Endoscopic injection therapy may be one of the future directions for the treatment
of GERD.
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3 Endoscopic Injection Therapy forGERD
51© Shanghai Scientic and Technical Publishers 2026
L. Li et al. (eds.), Endoscopic Therapy for Gastroesophageal Reux Disease,
https://doi.org/10.1007/978-981-95-5389-1_4
Chapter 4
Anti-reux Mucosal Resection (ARMS)
LianyongLi, QiangCai, andRongQin
4.1 Background
Gastroesophageal reux disease is prone to recurring attacks. Acid-suppressing
drugs are the rst choice for treatment, but about 30% demonstrates poor effects,
which are called the refractory GERD (rGERD). Surgery, especially laparoscopic
fundoplication, is widely applied for GERD patients with hiatal hernia. The effect is
clear, but the trauma and the cost are high. In recent years, minimally invasive endo-
scopic treatments have been applied to treat rGERD, such as intracavitary folding
and suture, radiofrequency ablation, lling injection, and implantation. But there
are still some problems, such as the requirement of costly proprietary devices or
foreign objects left in the body. In 2003, Professor Inoue [1] and others from Japan
underwent endoscopic peri-mucosal resection of esophagus on a refractory GERD
patient with high-grade dysplasia arising from Barrett’s esophagus. They found the
symptoms of GERD were improved after the operation, due to brosis at the gastric
cardia. Based on this, Professor Inoue [2] used this method to treat ten patients with
refractory GERD successfully in 2014, and for the rst time proposed the concept
of anti-reux mucosal resection (ARMS). Relevant research carried out since then
conrms that ARMS is a safe, effective, and promising endoscopic treatment tech-
nique for refractory GERD.
L. Li
Department of Gastroenterology, The Ninth Medical Center of Chinese
PLA General Hospital, Beijing, China
Q. Cai
Gastroenterology Associates, Ochsner LSU Health Shreveport, Shreveport, LA, USA
R. Qin (
*)
Department of Comprehensive Oncology, National Cancer Center/Cancer Hospital,
Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
52
4.2 What Is Anti-reux Mucosectomy (ARMS)
4.2.1 Denition
Anti-reux mucosectomy (ARMS) refers to the crescent shape resection of the
mucosa in about 3cm above and below the dentate line (1cm on the esophagus side
and 2cm on the stomach side). Scarring process can result in benign stenosis, which
can effectively control reux and improves the symptoms of gastroesophageal
reux disease.
4.2.2 Principle
Endoscopic mucosal resection (EMR) and endoscopic mucosal dissection (ESD)
are effective endoscopic treatments for precancerous lesions and early cancers of
the digestive tract. After EMR/ESD, wound healing can lead to the formation of
scar tissue. For esophageal diseases, if the EMR/ESD resection range is greater than
2/3 of the circumference, the postoperative scar tissue shrinks and esophageal ste-
nosis is easily formed (Fig.4.1).
Based on the above principle, ARMS can improve the symptoms of gastroesoph-
ageal reux disease due to benign stenosis of the gastric cardiac. The procedures
Fig. 4.1 The procedure of ESD
L. Li et al.
53
refer to the crescent mucosal resection of 2/3–3/4 circle in about 3cm above and
below the dentate line by EMR or ESD.The postoperative scar tissue shrinks to
produce benign stenosis and remodel the structure of gastroesophageal valve ap,
thereby reducing reux. Circumferential resection may lead to excessive stenosis
and difculty swallowing, which should be avoided as much as possible.
4.2.3 Surgical Indications
It can be applied to patients with refractory GERD (GERD-related symptoms per-
sisted despite normalized PPI therapy for 8weeks) without obvious hiatal hernia
(hiatal hernia <3cm; patients with an endoscopic Hill classication of II or III, not
IV [3]).
4.2.4 Surgical Contraindications
1. Hiatal hernia >3cm and/or esophageal motility disorder, such as achalasia or
incomplete relaxation of the lower esophageal sphincter [3].
2. Patients with contraindications for ordinary gastroscopy.
3. Patients with GERD which can be effectively controlled by drug treatment (PPI).
4. Patients who had undergone surgery (such as fundoplication), because the nor-
mal anatomy was changed.
5. Patients with GERD due to psychological problems [3].
4.3 Endoscopic Procedure
4.3.1 Examinations Before ARMS
1. Medical history collection, physical examination, and general examinations to
assess the patient’s general physical condition (especially cardiopulmonary
function), and exclude surgical contraindications.
2. Assessment for GERD:
1. GerdQ score and DeMeester score to assess the severity of GERD.
2. Gastroscopy to evaluate the size/grade of hiatal hernia (grade of gastroesoph-
ageal valve ap), grade of esophagitis, and conrm Barrett’s esophagus with
severe dysplasia.
3. Esophageal function test: esophageal pressure measurement, 24h PH moni-
toring, and impedance monitoring.
4 Anti-reux Mucosal Resection (ARMS)
54
4.3.2 Procedures ofARMS
1. Before surgery, fast for 6–8hours and water-free for 2hours. During intravenous
anesthesia, blood pressure, heart rate, breathing, blood oxygen saturation, and
other vital signs are monitored.
2. Main Steps:
1. Marking: Mark scheduled reduction area on the mucosa of at least 3 cm
length (1cm in the esophagus and 2cm in the stomach). Mark the cardia
bend side, front wall, and back wall after turning the gastroscopy. The length
of the retained mucosa on the greater curvature of the cardia is about twice
the diameter of the endoscope to prevent postoperative stenosis.
2. Submucosal injection: Inject a mixture of saline, epinephrine (diluted
1:10,000) and indigo carmine into the submucosa along the outside of the
marked point until the mucosa is fully lifted.
3. Mucosal resection:
3.1. EMR: The snare covers the base of the raised mucosa, and the mucosa
is removed by electrical resection. Repeat the above steps until the
raised mucosa is completely removed.
3.2. ESD: Use an IT knife or a Dual knife to cut the mucosa circularly out-
side the marked point, and gradually peel off the submucosa until the
mucosa is removed for 2/3–3/4 circle (Fig.4.2).
1a 1b 1c 1d
2a 2b 2c 2d
Fig. 4.2 (1a) Snare the mucosa; (1b) remove the mucosa; (1c) hot biopsy forceps to stop bleeding;
(1d) remove the 2/3 circumferential mucosa; (2a) submucosal injection; (2b) snare removal of the
mucosa; (2c) repeat the above steps; (2d) removal of the 3/4 circumferential mucosa
L. Li et al.
55
4.3.3 Management andFollow-Up After ARMS
Fasting for 24–48hours, and gradually diet recovery; PPI for 3days, antibiotics for
1day and nutritional support treatment; pay attention to the complications (such as
bleeding and perforation).
PPI and mucosal protective agents need to be taken orally for 2months after
operation; GerdQ score, gastroscopy, and esophagus 24h pH monitoring and/or
impedance monitoring need to be rechecked after 3months to 6months.
4.4 Complications
1. Bleeding: A small number of patients may experience bleeding during or after
surgery. Local injections, argon gas, titanium clamps, and other methods can be
used to prevent and treat bleeding. A very small number of patients need blood
transfusion and surgical hemostasis.
2. Perforation: Very few patients may experience gastrointestinal perforation dur-
ing or after surgery, and complications such as abdominal infection and peritoni-
tis may occur, which can even be severely life-threatening and require surgery if
necessary.
3. Stenosis: A few patients have excessive scar formation after surgery. Cardia ste-
nosis may occur, causing difculty in swallowing. The symptoms of stenosis can
be improved by endoscopic balloon dilation.
4.5 Advantages ofARMS
1. EMR/ESD has been commonly used for endoscopic treatment, which is feasible,
mature, and easy to extend.
2. It is safe and effective, with shorter operation time, lower risk, fewer complica-
tions, and relatively lower cost.
3. The normal anatomical structure will not be changed.
4. No need for costly proprietary devices or special equipment.
5. No foreign bodies left in the body.
6. If the effect is not up to expectations after AMRS, ARMS or other surgical treat-
ments can still be chosen.
4 Anti-reux Mucosal Resection (ARMS)