Abstract
Introduction: Incompetent gastroesophageal junction (GEJ) is the cause for GERD in most patients. The lower esophageal sphincter (LES), crus of diaphragm, GEJ flap valve and angle of His maintain the competency of GEJ. Anti-reflux interventions aim at reestablishing GEJ flap valve and gastropaxy. Persistent high abdominal pressure leads to failure of the intervention overtime. Re-do of surgical procedures is a high-risk surgery. Therefore, non-surgical antireflux interventions as a primary or a savage modality to reestablish GEJ competency are needed. This is further more important as adverse outcomes with long term PPIs use are being increasingly recognized. Haruhiro Inouea described mucosal resection of gastric cardia to re-establish GEJ flap valve with promising anti-reflux effect. Here, I report first anti-reflux mucosectomy (ARM) after failed fundoplication demonstrating its effectiveness and feasibility. Case description: A 65-year-old Caucasian female, BMI 36, underwent Nissen fundoplication for GERD. This was taken down and Toupe partial fundoplication performed 3 years ago due to progressive dysphagia. She had good response for 1 year but symptoms of GERD reoccurred. She was back on twice daily PPIs. She also had dysphagia to solids and regurgitation in middle of eating. Esophageal pH monitoring off PPIs had DeMeester score of 39 and symptoms of heartburn and regurgitation were related with acid reflux. Esophageal impedance manometery showed good deglutitive relaxation of LES with intact peristalsis but median DCI was 648 with 30% incomplete bolus clearance. Endoscopy showed loose GEJ with 2 cm hiatal hernia, Hill grade 4. Piecemeal mucosal resection after submucosal lift was performed covering 2/3rdcircumference in the gastric cardia along the lesser curvature, starting at the z line as described in the video, in endoscopy suite under general anesthesia. Patient was instructed to take twice a day PPIs for 1 week and then decrease to once a day. At three-week follow-up, patient was on once a day PPI, had no acid reflux but had persistent regurgitation while eating. Endoscopy showed tight GEJ flap valve and scar was still healing. Patient was instructed to continue once PPIs for 2 more weeks and eat slow which improved her regurgitation. Discussion: ARM is feasible and effective anti-reflux intervention even in presence of hiatal hernia and failed fundoplication. Durability of response is unknown.