Proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD) remains a therapeutic challenge, and there is an increasing demand for minimally invasive endoscopic options that provide durable symptom relief. Antireflux mucoplasty (ARM-P) is an endoscopic anti-reflux procedure in which mucosal resection is performed at the gastric cardia, followed by immediate endoscopic closure, thereby reshaping the esophagogastric junction. Antireflux mucoplasty with valve (ARM-PV) further incorporates a valvuloplasty concept by creating a mucosal flap and fixing it to the underlying muscle layer with clips before closing the defect, enabling the construction of an antireflux valve. However, in conventional ARM-PV, mucosal flap fixation clips may be embedded and potentially interfere with subsequent endoscopic suturing. Clinical data on ARM-P and ARM-PV, as well as strategies to overcome these clip-related issues, are still limited. We therefore aimed to evaluate the clinical outcomes of ARM-P and ARM-PV for PPI refractory GERD and to assess the feasibility of a modified ARM-PV approach developed to reduce problems related to flap fixation clips.

To address these clip-related issues, we developed a modified ARM-PV technique that omits clip fixation of the mucosal flap to the muscle layer. This modification was designed to simplify the procedure while preserving the antireflux valve mechanism. We retrospectively reviewed consecutive patients with PPI-refractory GERD who underwent ARM-P or ARM-PV at a single tertiary center. Clinical outcomes, including technical success, adverse events, changes in GERD-related symptoms, and use of acid-suppressive medication, were analyzed. Symptom severity was assessed before treatment and at 1 month using the GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) and the Frequency Scale for the Symptoms of GERD (FSSG).

Thirteen consecutive patients with PPI-refractory GERD were treated, including 6 who underwent ARM-P and 7 who underwent ARM-PV, of whom 6 received the modified ARM-PV technique. All procedures were completed successfully without major adverse events (bleeding, perforation, or stricture). In the overall cohort, GERD-HRQL improved from a median of 23 at baseline to 5 at 1 month, and FSSG improved from 29 to 13, all of which were statistically significant. In the subgroup treated with the modified ARM-PV approach, GERD-HRQL improved from 27.5 to 6.5 and FSSG from 31 to 12, also showing statistically significant symptom relief comparable to that observed in the full cohort. Regarding acid-suppressive therapy, all 13 patients were receiving full-dose PPI or P-CAB at baseline. At 1 month, 4 patients (31%) remained on full dose, 3 patients (23%) were maintained on half dose, and 6 patients (46%) were able to discontinue or switch to on-demand use, with a similar pattern seen in the modified ARM-PV subgroup.

In this single-center retrospective series, ARM-P and ARM-PV provided significant improvement in GERD-related symptoms and allowed reduction of acid-suppressive medication in patients with PPI-refractory GERD, without major adverse events such as bleeding, perforation, or stricture. The modified ARM-PV technique, which omits mucosal flap clip fixation to the muscle layer, appeared to be a feasible and safe endoscopic innovation that maintained clinical efficacy while potentially mitigating clip-related issues. Larger prospective studies with longer follow-up are warranted to confirm the durability of these outcomes and to further define the role of the modified ARM-PV approach among endoscopic treatments for refractory GERD.