Endoscopic Therapies for GERD: Exploring ARMA, ARMS, and GERDX

Gastroesophageal reflux disease, or GERD, is a chronic digestive disorder wherein stomach acid flows up into the esophagus causing irritation and discomfort. Lifestyle changes and medications remain the most commonly used remedies for cases of this pathology; however, they do not always bring about a long-term solution. For patients who are not responsive to drugs or those who wish to avoid long-term drug use, advanced endoscopic treatments bring new hope. Two of these promising methods, ARMA (Anti-Reflux Mucosal Ablation) and ARMS (Anti-Reflux Mucosectomy), are shown to be effective treatments for GERD. There is also new attention on the minimally invasive GERDX procedure. Below, we explore these treatments in detail.

ARMA (Anti-Reflux Mucosal Ablation) and ARMS (Anti-Reflux Mucosectomy): Advanced Endoscopic Treatments for GERD

ARMA and ARMS are the new endoscopic treatments in GERD management that involve modification of the gastroesophageal junction (GEJ), where the esophagus meets the stomach. They offer minimally invasive options to traditional anti-reflux surgeries, with less downtime and lower risks.

How Does ARMA Work?

The rationale behind Anti-Reflux Mucosal Ablation (ARMA) is to ablate a portion of the subcardial mucosa. It is the innermost lining next to the gastroesophageal junction. The result of ablation is controlled scar formation, which in turn closes this gap brought about by a weakened lower esophageal sphincter. Thereafter, it allows for strength of the esophageal barrier through scar tissue and thus minimises the opportunity of acid reflux going into the esophagus.

• Techniques Used in ARMA: ARMA is typically performed with advanced techniques like spray coagulation or argon plasma coagulation. Both are widely used in endoscopic interventions and are indeed quite effective in ablating mucosal tissue without having to undergo a more invasive surgery.

ARMS: A New Approach to GERD Treatment

ARMS differs from ARMA in the approach. ARMA involves ablation, whereas in this procedure, ARMS is performed by removing a hemi-circumferential section of mucosa at the gastroesophageal junction under an approach known as endoscopic mucosal resection, or EMR. As the treated area heals, the tissue contracts around the junction, thus making the lower sphincter firmer, and hence preventing acid reflux into the esophagus.

• Recovery After ARMS:
  In the healing phase, the contraction of the area treated will cause a tighter valve thus reducing reflux. Importantly, ARMS does not remove deep layers of the gastric tissue; thus it is a safe procedure that will not prevent patients from undergoing future laparoscopic anti-reflux surgeries if needed.

Clinical Evidence and Safety

The safety and efficacy of both ARMA and ARMS in managing GERD have been established in various studies. However, in its latest development, ARMS remains a new procedure, and investigations are continually conducted to optimise the procedure with minimal chances of complications such as postoperative dysphagia or need for esophageal dilatation.

Patient Selection: The Key to Success

Like all GERD treatments, patient selection becomes the difference between success and failure for both ARMA and ARMS. The ideal candidate is one that has not responded well to medication for controlling symptoms of GERD and whose structure is nearly or partially normal. To date, both treatments appear promising but need long-term research on effectiveness.

GERDX: An Innovative Endoscopic Solution for GERD

GERDX is the most advanced treatment option for GERD patients who are looking for a less invasive treatment as an alternative to drug therapy but who would not consider surgical intervention. Unlike ARMA and ARMS, GERDX is based on an altogether different principle of treating the disease at its pathophysiological mechanism - endoscopic full-thickness plication (eFTP) of the gastroesophageal junction, which encroaches upon the abdominal esophagus and pulls it back into the chest, thereby occluding reflux from occurring.

What is GERDX?

GERDX is a procedure designed to restore the natural flap valve function of the gastroesophageal junction. It prevents backflow of stomach acid into the esophagus. GERDX is ideal for patients who have a hiatal hernia of less than 3 cm and also for patients who do not want to be on medications for a long time or patients not fit for invasive surgery.

How GERDX is Performed?

The GERDX procedure is similar to any other standard endoscopy that is conducted under general anaesthesia or deep sedation. The steps of the procedure are as follows:

1. Preparation and Anesthesia:
After sedation, a flexible endoscope is passed through the mouth and then into the stomach. Attached with an endoscope, the Applicator performs plication.

Tissue Retraction:
The Tissue Retractor on the Applicator draws the anterior gastric wall into the open arms of the device so that enough tissue is concentrated for suturing. Throughout the procedure, the endoscope provides clear visualisation of the area so that accuracy is ensured.

Endoscopic Full-Thickness Plication (eFTP):
Once positioned appropriately, the arms of the Applicator close, creating a full thickness fold in the stomach wall. This folding tightens the gastroesophageal junction, thus restoring its function to prevent reflux. A pre-tied suture is attached by the Applicator, holding the fold in place.

Completion:
Once the suture is applied, the instrument is removed from the body of the patient, who is left under close observation for a short time of recovery before being discharged. The whole process usually takes approximately 45 minutes to complete.

Advantages of GERDX

GERDX is highly effective with an approximate success rate of 90%, much higher than the 40-45% achieved by laser-based treatments. Another advantage that GERDX has as compared to other anti-reflux surgeries, is that it is much less invasive. Most patients can return to their normal activities within short periods of time following this procedure with minimal complications and faster rehabilitation time.

The other major benefit of GERDX is that it does not limit future treatment options. In fact, it has been noticed that other relatively more invasive surgeries may make future procedures even more complicated whereas GERDX keeps the future treatment doors open in case these are required in the future.

Conclusion: Choosing the Right Endoscopic Therapy for GERD

New hopes for GERD patients have come with innovative endoscopic therapies such as ARMA, ARMS, and GERDX, for example, especially in those who opt for medications and more aggressive surgeries. These therapies modify the mucosal layers of the gastroesophageal junction to prevent reflux either by bringing tissue together or by greater dimensional restriction. GERDX actually tightens the junction physically by full-thickness plication.

While these hold much promise, it is vital to note that they are relatively new treatments and much remains to be learnt about the efficacy of these treatments over the long term. For patients in Gurgaon and the Delhi NCR region, expert care with the latest treatment options is available at the Institute of Gastroenterology and Digestive Health (IGDH) at Marengo Asia Hospitals.

If you're considering treatment options like ARMA, ARMS, or GERDX, consult with our experienced team at IGDH to determine the best approach for your specific needs.