Minimally invasive endoscopic techniques have been proposed in recent years for non-medical symptom control in patients with gastroesophageal reflux disease (GERD). Anti-reflux mucosal resection (ARMS) and ablation (ARMA) involve resection or ablation of the mucosa at the cardia to induce scar retraction at the esophagogastric junction (EGJ), with the aim of tightening the flap valve. Various technical variations have been described to optimize the technique. To date, their efficacy has been demonstrated in numerous reports and a few meta-analyses.

Between March 2023 and November 2025, patients on long-term proton pump inhibitor (PPI) therapy for diagnosed GERD were enrolled at our institution. The technique consists in ablation of the cardiac mucosa for 3 cm on the gastric side and along the Z-line, sparing 25% of the mucosa at the greater curvature. We chose to include the Z-line in the ablation area (ARMA-Z), hypothesizing that this approach may reduce acid sensitivity by improving mucosal integrity and restoring the impaired esophageal barrier function in GERD. Ablation was performed in the retroflex position using an Argon Plasma Coagulation probe (Forced APC, effect 2, 40W). A submucosal bleb was first created by injecting saline mixed with methylene blue along the EGJ. Clinical and endoscopic data were collected at baseline and at follow-up (3, 6, and 12 months). The primary outcome was subjective symptom improvement; secondary outcomes included changes in flap valve grade and  and rates of PPI discontinuation.

A total of 15 patients underwent ARMA-Z (8 women, mean age 57 ± 4.4 years). All had a long history of typical symptoms and 7 also reported pharyngo-laringeal symptoms. All showed positive 24-hour pH-impedance monitoring with significant symptom correlation. High-resolution manometry ruled out major motility disorders. All patients had experienced satisfactory symptom control on standard-dose PPIs but relapsed rapidly after withdrawal (PPI-dependent). One patient experienced medication-related side effects. Technical success was achieved in 100% of cases, with no immediate adverse events. Follow-up data are available for 12 patients. All patients reported symptomatic improvement at 3 months and all subsequent follow-ups, with 58% achieving complete remission. At 6 months, 8 patients (67%) discontinued PPI therapy and 1 (8%) reduced the dose; the remaining 25% continued on standard dose. Among patients who discontinued PPI, 75% remained off medication at 12 months follow-up, while 25% required short courses of therapy for occasional symptoms. Upper endoscopy confirmed improvement in flap valve morphology, with all patients achieving Hill grade 1. No transient stenosis or significant dysphagia was observed.

Our preliminary findings demonstrate promising results in GERD symptom control through mechanical strengthening of the flap valve and desensitization of the Z-line. Compared with similar techniques, ARMA-Z appears to have a safer profile, is easier to perform, and is cost-effective. If longer follow-up and objective testing in larger cohort studies confirm these results, ARMA-Z could become a game changer for GERD patients with persistent troublesome symptoms requirinbg long-term medical therapy or those experiencing adverse drug reactions.