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56
4.6 The Clinical Application ofARMS
In 2014, Japanese scholars Inoue etal. [2] rst reported ARMS, which referred to
treat 10 PPI-refractory patients without hiatal hernia by ESD.The results showed
that after ARMS treatment, the patient’s symptoms were signicantly improved,
and the average scores of heartburn and reux decreased from 2.7 and 2.5 to 0.3 and
0.3. The result of 24h pH monitoring showed that the percentage of time with
pH<4 decreased from 29.1% to 3.1%. All patients achieved complete discontinua-
tion of PPI after surgery. Two patients who underwent circumferential ARMS had
stenosis after the operation, which were improved by endoscopic balloon dilation.
Ota etal. [4] also conrmed the therapeutic signicance of ARMS for GERD.The
study performed traditional ESD on 13 patients with PPI-refractory GERD.Following
up 6months after the operation, it was found that 12 patients (92.3%) had GERD
symptoms relieved, and 5 patients (7.7%) had endoscopic esophagitis improved, 3
patients (23.1%) achieved complete discontinuation of PPI preparations, and 3
patients (23%) achieved PPI reduction. Bapaye A reported 15 patients with PPI-
refractory GERD.Following up 4weeks after ARMS, 11 patients (73.3%) discon-
tinued PPI and four patients (36.3%) reduced PPI dosage. Herdberg performed
ARMS on ten patients with medically refractory GERD and a hiatal hernia <2cm,
and six patients (10%) had symptoms improved signicantly and PPI discontinued.
Herdberg [5] also reported that 19 patients with GERD underwent ARMS surgery.
There are 13 patients (68%) had GERD symptoms relieved, and three patients
(16%) had dysphagia which were improved by balloon dilation. Patil etal. [6]
reported 62 cases of GERD patients who underwent ARMS.Following for 2months
after the operation, the results of 45 patients (72.5%) showed improvement in multi-
channel esophageal impedance-pH monitoring (MII-pH), 43 patients (69.4%) could
interrupt PPI treatment, and 5 patients (8%) had difculty in swallowing and under-
went endoscopic balloon dilatation. After a telephone follow-up 1year later, 38
patients (61.3%) indicated that their symptoms continued to improve, and PPI was
completely stopped. Sumi K reported 109 patients with PPI-refractory GERD who
underwent ARMS.Forty-two patients (42%) discontinued PPI after 2–6 months.
Among patients who were observed for more than 1year, the discontinuation rate
was approximately 51% (30/59), and the efcacy was maintained during this period.
Among the 21 patients who underwent Buttery method, 48% (10/21) were able to
discontinue PPI therapy. Yoo [7] performed ARMS on 33 GERD patients with path-
ological acid reux and esophageal hypersensitivity. Following up 6months after
surgery, 63% patients can interrupt PPI and 30% can reduce PPI intake. The GerDQ
score was signicantly improved, and the DeMeester score and acid exposure time
were decreased. Wong HJ compared perioperative and quality-of-life outcomes of
patients with GERD who underwent ARMS and laparoscopic Nissen fundoplica-
tion (NF). The ARMS group had shorter OR time, less estimated blood loss, shorter
hospital stays, less pain at discharge, earlier narcotic discontinuation, and earlier
return to activities of daily living compared to the NF group. The above research
show that the symptoms of about 2/3 GERD patients can be improved by ARMS
(Table4.1).
L. Li et al.
57
Table 4.1 Research results of ARMS
Author,
year Country Type of study
Pts
selection
No. of pts,
age Complete
Key
symptoms DeMeester score
GEFV by
Hill
classication Follow up
PPI
discontinued
or reduced
dosage Adverse event
Inoue,
2014
Japan Retrospective
PPI-
refractory
GERD
without
sliding
hernia
10, 56.3
(22–81)
All Signicantly
improved
after ARMS
Total 5.1–0.8; the
percentage of time
with pH<4
decreased from
29.1% to 3.1%
Signicant
decreased:
3.2–1.2
(P=0.0152)
2months 10/10
(100%)
discontinued
PPI
2 stricture
(balloon
dilation)
Ota,
2014
Japan Prospective,
single-center,
single-arm
trial
PPI-
refractory
GERD
15,
51.6±14.9
(20–65)
All 12/13
(92.3%)
symptoms
relieved; 7/13
(53.8%) the
FSSG
interview
improved
signicantly
The pH<4 holding
time ratio did not
decrease (P=0.40)
6months 3/13 (23)
discontinued
PPI, 3/13
(23%)
reduced PPI
dosage
1 stenosis
Bapaye
A, 2017
India Abstract
PPI-
refractory
GERD
15, 40.8
(22–69)
Mean
GERD-
HRQL score
improved
from
pre-
ARMS- 40.4
to
post-
ARMS- 7.6
(P<0.05)
Signicant decreased
pre- ARMS=85.8
post-ARMS = 5.9
(P<0.05).
Signicant
decreased
pre-
ARMS=2.8;
post-
ARMS=1.6
(P<0.05)
4weeks 11/15
(73.3%)
discontinued
PPI, 4/11
(36.3%)
reduced PPI
dosage
2 muscle
injury (treated
by endoclips)
1 grade I
dysphagia
(continued)
4 Anti-reux Mucosal Resection (ARMS)
58
Hedberg
HM,
2018
USA Abstract,
retrospective
Medically
refractory
GERD
and a
hiatal
hernia
<2cm
10 All 6 symptoms
improved
signicantly
1 normalized pH
testing 1year
post-procedure. 4
persistent symptoms
with reux conrmed
by pH testing
6
discontinued
PPI
1 muscle
injury
(repaired by
endoscopic
suturing with
no sequelae)
Hedberg
HM,
2019
USA Retrospective PPI-
refractory
GERD
19, 57.1
(21–88)
All 13 (68%)
symptoms
relieved
6months 13 (68%)
discontinued
PPI
3 dysphagia
(balloon
dilation)
Patil G,
2020
India Retrospective
PPI-
refractory
GERD
62,
36±9.9
All The mean
(SD)
GERD-Q
score
reduced from
10.6 (1.9) to
3.4 (1.5)
(P<0.001);
38 (61.3%)
symptoms
improved
Signicant decreased
in 45 (72.5%)
pre- ARMS=76.8
(18.3) post-
ARMS=14.3 (6.1)
(P<0.001)
2months 43 (69.4%)
discontinued
PPI, 12
(19.3%)
reduced PPI
dosage, 7
(11.3%)
continued
full dose
62 (100%)
intraoperative
bleeding
(endoscopic
hemostasis) 5
(8%)
dysphagia
(endoscopic
dilation)
Table 4.1 (continued)
Author,
year Country Type of study
Pts
selection
No. of pts,
age Complete
Key
symptoms DeMeester score
GEFV by
Hill
classication Follow up
PPI
discontinued
or reduced
dosage Adverse event
L. Li et al.
59
Sumi K,
2020
Japan Retrospective PPI-
refractory
GERD
109,
54.0±15.7
Signicant
improvement
in the
symptom
score
(P<0.01)
Signicant decreased
pre- ARMS =
64.4±75.7
post-
ARMS=24.9±36.0
(P<0.01)
Signicant
decreased
pre-
ARMS=3
(2–3)
post-
ARMS=1
(1–3),
(P=0.07).
3years 42 (42%)
discontinued
PPI after
2–6months.
51% (30/59)
discontinued
PPI after
1year. 48%
(10/21)
discontinued
PPI by
Buttery
method
Wong
HJ,
2020
USA Retrospective GERD
and a
hiatal
hernia
<2cm
33, 55±17 3weeks-2years 10 patients
(30.3%) who
underwent
ARMS
required
additional
laparoscopic
anti-reux
operations
Transient
dysphagia
Yoo IK,
2020
Korea Prospective,
single-center,
and
single-arm
trial
Medically
refractory
GERD
and a
hiatal
hernia
<3cm
33 GERD
questionnaire
scores
decreased
from 11.0 to
6.0
(P<0.001)
Signicant decreased
pre- ARMS=11.6
post-ARMS=4.0
(P<0.001)
Signicant
decreased
pre-
ARMS=3
post-
ARMS=1
(P<0.001)
6months 63%
discontinued
PPI, 30%
reduced PPI
dose
2 stricture
(balloon
dilation)
4 Anti-reux Mucosal Resection (ARMS)
60
Currently, clinical studies have conrmed that ARMS is a safe and effective
endoscopic treatment for PPI-refractory GERD.Moreover, this method can be per-
formed by endoscopic technology (EMR/ESD) which most endoscopists are famil-
iar with, without the need for new and expensive special equipment. Therefore, it
can be widely promoted for clinical applications.
ARMS is a new minimally invasive technique with broad application prospects.
But ARMS still needs to be improved, and it is necessary to continuously study the
better strategy to obtain the best clinical effect. Its long-term efcacy and safety also
need to be conrmed by further studies. For PPI-refractory GERD, further improve-
ments of ARMS surgery are expected to ll the gap between medical treatment and
surgical intervention.
References
1. Satodate H, et al. Circumferential EMR of carcinoma arising in Barrett's esophagus: case
report. Gastrointest Endosc. 2003;58:288–92.
2. Inoue H, etal. Anti-reux mucosectomy for gastroesophageal reux disease in the absence of
hiatus hernia: a pilot study. Ann Gastroenterol. 2014;27:346–51.
3. Shimamura Y, Inoue H.Anti-reux mucosectomy: can we do better? Dig Endosc. 2020. https://
doi.org/10.1111/den.13632.
4. Ota K, etal. A novel endoscopic submucosal dissection technique for proton pump inhibitor-
refractory gastroesophageal reux disease. Scand J Gastroenterol. 2014;49:1409–13.
5. Hedberg HM. First experience with banded anti-reux mucosectomy (ARMS) for GERD:
feasibility, safety, and technique (with video). Dig Endosc. 2019;23:1274–8. https://doi.
org/10.1007/s11605- 019- 04115- 1.
6. Patil G, Dalal A, Maydeo A.Feasibility and outcomes of anti-reux mucosectomy (ARMS)
for proton pump inhibitor dependent gastroesophageal reux disease: rst Indian study (with
video). Dig Endosc. 2020. https://doi.org/10.1111/den.13606.
7. Kuchta K, etal. Anti-reux mucosectomy using a cap-assisted endoscopic mucosal resection
method for refractory gastroesophageal disease: a prospective feasibility study. J Gastrointest
Surg. 2020;34:1124–31.
https://doi.org/10.1007/s00464- 019- 06859- y.
L. Li et al.
61© 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_5
Chapter 5
Stretta Radiofrequency Treatment
LianyongLi, QiangCai, andXinkeSui
5.1 Background
PPI is currently the main clinical treatment method for GERD.Although it can
relieve the symptoms of most patients, it does not address underlying pathophysio-
logic changes such as transient lower esophageal sphincter relaxation, mucosal
nerve paresthesia, cardia relaxation, and hiatal hernia; therefore, it cannot funda-
mentally solve the problem and requires long-term medication. Even so, about 20%
of refractory patients do not respond to medication, and a signicant proportion of
patients do nd it difcult to tolerate long-term use. Since 2000, foreign scholars
began to study Stretta microradiofrequency technology for the treatment of
GERD.Radiofrequency refers to the electromagnetic wave with a frequency from
300KHz to 300GHz. Tissue ablation and cutting can be carried out by utilizing the
thermal effect generated by radiofrequency. Most medical radiofrequency uses fre-
quencies from 200 to 750KHz. Stretta is currently a radiofrequency instrument
used for the treatment of GERD, with a frequency of 465 KHz. Stretta is an endo-
scopic radiofrequency technology approved by the Food and Drug Administration
(FDA) for the treatment of GERD in 2000. In recent years, Stretta trace radiofre-
quency therapy has been promoted and applied worldwide. Clinical studies have
proved that this technique is a minimally invasive, simple, safe, and effective treat-
ment [1–7].
L. Li · Q. Cai · X. Sui (*)
Department of Gastroenterology, The Ninth Medical Center of Chinese
PLA General Hospital, Beijing, China
62
5.2 What Is Stretta Radiofrequency Therapy
Stretta consists of a tube with a probe, a basket, and a balloon with four nickel-
titanium electrodes. Electrodes are radially distributed on the surface of the balloon,
which is located in the basket and connected to a catheter, which is connected to a
radiofrequency generator with temperature and resistance monitoring invitro [8]. It
consists of a four-channel radio frequency generator and catheter system. Stretta
radiofrequency treatment is under the guidance of gastroscope. For Stretta radiofre-
quency therapy, a catheter is passed through the biopsy channel of an endoscope and
advanced to the dentate line, with electrodes inserted into the muscular layer of the
lower esophagus. A built-in thermocouple automatically adjusts the output energy;
the target tissue is the muscularis propria. Radiofrequency current is used to induce
localized thermal injury to the gastroesophageal junction and the muscular layer of
the cardia, leading to muscular layer brosis. This increases the tone of the lower
esophageal sphincter, reduces tissue compliance, and thereby achieves an anti-
reux effect. In brief, a radiofrequency therapy catheter is inserted into the esopha-
gus, and the electrodes of the radiofrequency device are placed into the LES and the
muscular layer of the cardia, followed by multi-point, multi-layer cauterization of
the gastroesophageal junction.
5.2.1 Operation Principle
Its mechanism of action is to inactivate nerve endings by heat, tighten muscle layer,
activate macrophages and broblasts, and promote collagen structure reconstruc-
tion, leading to the thickening, shortening, and narrowing of the gastroesophageal
junction, making the lower esophageal sphincter relax to tighten, thereby signi-
cantly reducing acid reux and improving symptoms. The mechanisms of endo-
scopic RF are in the following two aspects:
1. The brosis on the myometrium injury leads to tissue tightness, increases the
thickness and stress of the lower esophageal sphincter (LES), and increases the
resilience on the postoperative gastric expansion.
2. The OUTCOMES on the RADIO frequency destruction of certain neurotissue
can reduce the incidence of transient lower esophageal sphincter relaxation
(TLESR).
Tam etal. [6] found that Stretta radiofrequency therapy can increase the pressure
of esophageal sphincter.
Kim etal. [9] proved in the dog experiment that this treatment can increase the
thickness of the muscle wall at the gastroesophageal junction by 50%.
Corley etal. [10] found that trace radiofrequency therapy can cause local esopha-
geal nerve injury, reduce the sensitivity of the esophagus to injury factors, and thus
shorten or relieve symptoms for a long time.
L. Li et al.
63
5.2.2 Surgical Indications
1. Acid reux, heartburn, regurgitation, abdominal distension, belching, foreign
body sensation in the pharynx, cough, chest tightness, wheezing, recurrent
laryngeal spasm, palpitation, chest pain, and other symptoms.
2. The diagnosis is conrmed by 24-h esophageal pH monitoring, esophageal pres-
sure measurement, and gastroscopy.
3. Patients who failed or could not stop taking acid-suppressing drugs and patients
who did not take acid-suppressing drugs for part of esophageal symptoms.
4. Patients who do not want surgery.
5.2.3 Contraindications toSurgery
1. Under 18
2. Pregnant women
3. Patients with undiagnosed gastroesophageal reux
4. Hiatal hernia >2cm
5. Patients with cardia or LES incomplete relaxation after swallowing
6. Patients who are too weak to tolerate treatment
5.2.4 Surgical Risks
The complication rate of RF operation was 8.6%.
Common complications include agitation, coughing, hiccups, fever, supercial
mucosal injury, chest pain, transient dysphagia, respiratory depression, and gastro-
intestinal bleeding. However, serious complications have been reported, including
esophageal perforation, aspiration pneumonia, and asphyxia.
5.2.5 Specic Operation Steps
Stretta Radiofrequency Therapy Steps:
1. Patients should take midazolam and pethidine intravenously for sedation.
2. Traditional upper gastrointestinal endoscopy was performed, and the mean value
was taken for three times to determine the dentate line distance.
3. Place the guidewire and pay attention to erosive esophagitis, hiatal hernia and
other lesions.
5 Stretta Radiofrequency Treatment
64
4. After removing the endoscope, Stretta catheter is rst introduced through the
guide wire from the mouth and connected to the RF host. When the temperature
and impedance of the needle electrode are within the normal range, treatment
can start. If the temperature or impedance is abnormal, the RF host will stop the
RF energy output. Radiofrequency energy is delivered to the lower esophageal
sphincter (LES) region via four needle electrodes during treatment to achieve a
target tissue temperature of about 85°C in the musculature.
5. By manipulating and rotating the electrode catheter, a total of 56 radiofrequency
application points across 6 levels were delivered at the distal esophagus and
gastroesophageal junction. Specically, 32 points were applied at four levels
relative to the dentate line: 1 cm above the dentate line, 0.5 cm above the dentate
line, at the dentate line, and 0.5 cm below the dentate line. For each level, radio-
frequency treatment was administered once at the initial position and once after
a 45° rotation of the catheter. Additionally, 24 points were applied at 2 levels in
the proximal stomach: at the initial position, once after a 30° left rotation, and
once after a 30° right rotation at each level. Throughout the treatment process,
continuous cold water irrigation and real-time surface temperature monitoring
were performed to ensure that the mucosal temperature remained below 45°C,
thereby preventing thermal injury to the esophageal and gastric mucosa.
After completion of treatment, exit Stretta radiofrequency electrode and use
endoscopy for examination again to ensure the safety of treatment and evaluate the
treatment (Fig.5.1).
1. Determine the position of the dentate line under the endoscope, place the guide
wire, and then push into Stretta. Start at 1cm on the dentate line, inject 25ml of
Fig. 5.1 Schematic diagram of Stretta radiofrequency treatment
L. Li et al.
65
air into the balloon, puncture it into the muscle layer, step on the pedal, and per-
form the electrocution treatment for 1min.
2. After the rst surface treatment, repeat the above treatment by moving down
5mm each time. The esophagus was treated in four planes (4 planar 8 times
for 8min).
3. Insert Stretta balloon deep into the stomach, ll the balloon with air for 25ml,
then withdraw Stretta. When there is a little resistance, let the needle out for
1min with electrocution, withdraw the needle, push it into the stomach, rotate
30°, and withdraw the needle for 1min. The needle was pulled back again,
pushed into the stomach, rotated 30° (in the same direction as the previous time),
and the needle was withdrawn for 1min.
4. The needle was collected, the balloon was inated by 22ml, and the treatment
was carried out in a slightly higher plane of the cardia, the process was the same
as above (rotation 2 times, electrication 3 times, a total of 3min).
In short, the esophagus consists of four planes, four rotations, eight treatments,
and 8min. The cardia consists of two planes, four rotations, six treatments, and
6min (Figs.5.2, 5.3, 5.4, and 5.5).
Fig. 5.2 Schematic diagram of Stretta radiofrequency treatment
5 Stretta Radiofrequency Treatment