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Objectives: Anti‐reflux mucosectomy (ARMS) and anti‐reflux mucosal ablation (ARMA) were developed as interventions for proton pump inhibitor (PPI)‐refractory/‐dependent gastroesophageal reflux disease (GERD). Although ARMS and ARMA are established treatments for PPI‐refractory GERD, reliance on natural healing for ulcer scar formation introduces uncertainty and bleeding risk. To address these issues, we introduced a novel approach called anti‐reflux mucoplasty (ARM‐P), which involves immediate closure of mucosal defects following mucosectomy. This pilot study aims to evaluate the safety, feasibility, and efficacy of ARM‐P. Methods: A retrospective single‐center study was conducted using prospectively collected data from October 2022 to July 2023. Patients with PPI‐refractory/‐dependent GERD who underwent ARM‐P were included. The study evaluated technical success of ARM‐P, before and after ARM‐P GERD‐Health Related Quality of Life Questionnaire, GerdQ, and Frequency Scale for the Symptoms of GERD scores, along with PPI discontinuation and endoscopic esophagogastric junction morphology. Results: A total of 20 patients with a median age of 61.5 years underwent the ARM‐P procedure. The procedure achieved 100% technical success without adverse events. After ARM‐P, 55.0% discontinued PPI usage and 15.0% reduced PPI dose by half. Median GERD‐Health Related Quality of Life Questionnaire score improved from 21 to 6 (P = 0.0026), median GerdQ score improved from 9 to 7 (P = 0.0022), and median Frequency Scale for the Symptoms of GERD score decreased from 16 to 7 (P = 0.0003). Median Hill's Classification significantly improved from grade III to grade I (P = 0.0001). Conclusions: This study presents the first pilot report of ARM‐P, demonstrating its procedural safety, technical feasibility, and short‐term efficacy. [ABSTRACT FROM AUTHOR]

Objectives: Minimally invasive treatments have been applied for gastroesophageal reflux disease (GERD), but the long‐term results are controversial. Antireflux mucosectomy (ARMS) is a simple endoscopic procedure that does not require the insertion of a foreign body. We provide the first report on the long‐term results of ARMS. Methods: This was a single‐center, single‐arm trial, prospective study of 88 patients with proton pump inhibitor (PPI)‐refractory GERD who underwent ARMS between June 2012 and June 2017. Primary outcomes were the rates of long‐term effectiveness and PPI discontinuation. Secondary outcomes were to compare patients' preoperative background characteristics, questionnaire, and multichannel intraluminal impedance and pH monitoring data to examine the predictive factors of ARMS. The clinical course was reviewed, including the need for additional treatment after ARMS. Results: Antireflux mucosectomy produced a long‐term effect in 68.3% of the patients, and PPI could be discontinued in 42% of patients. There were significant differences in age, intensity of preoperative symptoms, and acid‐related indicators. Forty‐five percent (27/60) had reflux hypersensitivity and ARMS provided long‐term effectiveness in 81% of these patients. There was no significant difference in subjective symptom assessment between those with short‐term and long‐term efficacy. Additional treatment was administered in 23% (14/60) and scheduled at 1–2 years' follow‐up. Conclusions: Antireflux mucosectomy showed long‐term efficacy, and many of the cases with short‐term effects were able to maintain them. In addition, ARMS is also effective in patients with reflux hypersensitivity, and provides a treatment option that bridges the gap between surgical and medical treatment. [ABSTRACT FROM AUTHOR]

Background: Functional endoscopy signifies a significant advancement in gastrointestinal examination, integrating motor function assessments alongside routine endoscopy findings. Traditional gastrointestinal endoscopy primarily focuses on the detection of early-stage cancer by identifying morphological changes within the gastrointestinal tract. These alterations include modifications in lumen structure, color tone, and surface patterns, which can be diagnosed using endoscopic images that assess these morphological changes. In contrast, functional endoscopy aims to dynamically evaluate the peristaltic movements of the digestive tract and the presence or movement of reflux of digestive fluids during the endoscopic procedure. It also seeks to identify morphological changes such as hiatal hernias, as observed in conventional endoscopy. Consequently, relying solely on endoscopic images proves inadequate for diagnosis, necessitating continuous observation of these dynamic movements. Summary: The endoscopic pressure study integrated system (EPSIS) serves as an exemplar of functional endoscopy. It incorporates a stress test to assess the functionality of the lower esophageal sphincter (LES) through intragastric insufflation. A crucial element of EPSIS evaluation is the identification of the scope holding sign (SHS), which signifies LES contraction. EPSIS also encompasses the observation of esophageal peristaltic waves and the auditory detection of burping, providing a comprehensive diagnostic approach while observing the sphincter from a retroflex view on the stomach side. By integrating these dynamic findings, functional endoscopy offers an efficient method for diagnosing functional gastrointestinal diseases, such as gastroesophageal reflux disease (GERD). Key Messages: Functional endoscopy combines motor function assessments with traditional endoscopy, enhancing the diagnostic capabilities of gastrointestinal examinations. Traditional endoscopy focuses on identifying morphological changes, while functional endoscopy evaluates dynamic movements, reflux, and sphincter functionality. EPSIS exemplifies functional endoscopy, featuring a stress test and the SHS for LES contraction assessment. EPSIS provides a comprehensive approach to diagnose GERD by integrating dynamic observations. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been an important challenge since the early days of POEM implementation. The esophagogastric junction anti-reflux barrier consists of internal lower esophageal sphincter (LES) (i.e., intrinsic muscles of distal esophagus with sling fibers) and external LES (crural diaphragm and phrenoesophageal ligament anchors the distal esophagus to the crural diaphragm). During conventional POEM, the entire internal LES is unintentionally dissected. Preservation of the sling fiber may reduce post-POEM GERD, but its safety and effectiveness have been unclear. In this study, we investigated the safety and effectiveness of sling fiber preservation POEM (SP-POEM) for reducing severe post-procedural erosive esophagitis. Methods: We analyzed data of 236 patients who underwent POEM; of these, 203 patients underwent posterior myotomy without (Group 1) or with attempted (Group 2) sling fiber preservation. Group 1 (N = 79; sling fiber excision, N = 68) and Group 2 (N = 90; sling fiber preservation, N = 81) were compared. Post-procedural erosive esophagitis (Los Angeles classification) were assessed and the area (direction and length) of mucosal break was also investigated. The gastroesophageal flap valve was evaluated by Hill's classification. Results: Severe erosive esophagitis exceeding grade C (Los Angeles classification) occurred in 44.1% of patients (30/68) in Group 1 and in 18.5% of patients (15/81) in Group 2. In mapping of erosive esophagitis, mucosal breaks appeared widely in all directions in Group 1; they tended to be limited in Group 2 (especially in the 2 o'clock direction). Assessment using the Hill's classification showed that the gastroesophageal flap valve was preserved after SP-POEM. Conclusion: SP-POEM is safe and effective, with a success rate of 90%. The rate of severe erosive esophagitis can be decreased by preserving sling fibers. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool for gastroesophageal reflux disease (GERD). EPSIS has been developed to evaluate lower esophageal sphincter function by monitoring the intragastric pressure (IGP) while insufflating the stomach during gastroscopy. Based on previous data, EPSIS could diagnose GERD with good accuracy by assessing IGP waveform pattern. This study aimed to further characterize the waveform to improve the diagnostic yield of EPSIS. Methods: We conducted a retrospective analysis of patients with typical GERD symptoms who underwent both EPSIS and 24‐h impedance‐pH monitoring (MII‐pH) at a single tertiary referral center from October 2018 to May 2020. EPSIS was performed by using a through‐the‐scope catheter connected to the pressure measuring system (TR‐W550, TR‐TeH08, AP‐C35; Keyence, Osaka, Japan) to monitor IGP. Abnormal acid reflux was defined as acid exposure time (AET) over 6.0%. Pressure waveform was characterized as follows: (i) Basal IGP, (ii) Maximum IGP, (iii) Pressure difference, (iv) Gradient of the waveform. Results: A total of 57 patients with GERD symptoms were analyzed. Twenty‐one patients presented abnormal AET on MII‐pH. Among EPSIS parameters, pressure difference during insufflation correlated with AET (ρ = −0.66, P < 0.01) and showed the best diagnostic accuracy for AET with the cutoff value of 4.7 mmHg (area under the curve [AUC], 0.87). The gradient of EPSIS waveform also revealed good diagnostic accuracy for abnormal AET with the cutoff value of 0.07 mmHg/s (AUC, 0.81). Conclusions: Endoscopic pressure study integrated system waveform parameters, especially pressure difference, presented high diagnostic accuracy for the presence of abnormal acid reflux. [ABSTRACT FROM AUTHOR]

Objectives Methods Results Conclusions The endoscopic pressure study integrated system (EPSIS) represents an innovative approach for evaluating lower esophageal sphincter function by monitoring intragastric pressure using diagnostic gastroscopes. This study aimed to assess the feasibility and validity of employing ultrathin gastroscopes for EPSIS.A retrospective analysis was conducted on a database of consecutive patients who underwent EPSIS using both ultrathin and regular gastroscopes between September 2021 and October 2023. The study compared EPSIS parameters between the two gastroscope types to evaluate the correlation of key metrics.Thirty patients underwent EPSIS with both ultrathin and regular gastroscopes. Significant positive correlations were observed in the pressure waveform: maximum intragastric pressure (mmHg) (ρ = 0.82, P < 0.001) and intragastric pressure gradient (mmHg/s) (ρ = 0.80, P < 0.001) when comparing the two gastroscopes. Maximum intragastric pressure (15.5 [5.3–20.3] vs. 18.5 [3.4–21.6], P < 0.001) and pressure gradient (0.16 [0.013–0.41] vs. 0.24 [0.0039–1.13], P < 0.001), (median [range]) were significantly lower with ultrathin gastroscopes.This study establishes that EPSIS parameters obtained with an ultrathin gastroscope exhibit a significant correlation with those obtained using a regular gastroscope, with each EPSIS parameter consistently lower. These findings support the viability of EPSIS for ultrathin gastroscopy and highlight its potential as a diagnostic tool for assessing lower esophageal sphincter function. [ABSTRACT FROM AUTHOR]

Objectives: Patients with esophageal motility disorders (EMDs) including achalasia after gastric surgery have not been thoroughly characterized. Furthermore, the efficacy of peroral endoscopic myotomy (POEM) in this population should be clarified. Methods: In this retrospective multicenter study of 3707 patients with EMDs, 31 patients (0.8%) had a history of gastric surgery. Patient characteristics and POEM efficacy were compared between patients with and without previous gastric surgery. Results: In patients with EMD after gastric surgery, age at EMD diagnosis was higher (72.0 years), male sex was predominant (90.3%), and the American Society of Anesthesiologists physical status score was higher (≥II, 48.4%). High‐resolution manometry (HRM) findings did not reveal significant differences. In patients who underwent gastric surgery, atrophic gastritis was common (80.6%), and gastric cancer was the primary surgical indication (32.3%). Distal gastrectomy was performed in 28 patients (90.3%). POEM was effective (3.3% adverse events; 100% treatment success). The incidence rates of reflux esophagitis (RE) and symptomatic gastroesophageal reflux disease (GERD) were 60.0% and 16.7%, respectively, without significant intergroup differences, and severe RE was not observed in the long‐term follow‐up. Extended gastric myotomy was a risk factor for RE. Conclusion: Patients with gastric surgery often present severe disease manifestations; the surgical indication is mainly gastric cancer. HRM findings can be similarly used for diagnosis in patients with and without gastric surgery. POEM maintains safety and efficacy with acceptable RE and symptomatic GERD rates. To prevent RE, extended myotomy should be avoided. [ABSTRACT FROM AUTHOR]