Comments on ‘The comparative study of Stretta radiofrequency and anti-reflux mucosectomy in the management of intractable gastroesophageal reflux disease: a single-center retrospective study from Korea’

I read with great interest the study by Lee et al.1 comparing Stretta radiofrequency and anti-reflux mucosectomy (ARMS) in the management of intractable gastroesophageal reflux disease (GERD), which presented an important comparative analysis of two emerging endoscopic interventions for the treatment of proton pump inhibitor (PPI)-refractory GERD. As both clinicians and researchers are involved in therapeutic endoscopic procedures for the treatment of GERD, I believe that this study not only provides meaningful clinical data but also highlights ARMS as a procedure that deserves further attention.

ARMS is based on the concept of inducing fibrosis at the esophagogastric junction (EGJ) via targeted mucosal resection. This fibrosis results in scar contraction, thereby narrowing the EGJ and increasing the lower esophageal sphincter tone. From a mechanistic perspective, ARMS addresses two major contributors to the GERD pathophysiology—anatomical laxity at the EGJ and increased EGJ compliance—both of which predispose patients to reflux. ARMS functionally mimics surgical fundoplication by stiffening the EGJ and reducing its distensibility. These structural effects are supported by postprocedural decreases in the EndoFLIP-measured distensibility index (DI).2,3

Lee et al.1 found that while symptom improvement and PPI withdrawal rates were similar between the ARMS and Stretta groups, ARMS was associated with significantly greater improvements in endoscopic findings. Specifically, the ARMS group exhibited superior improvement in the Los Angeles grade of esophagitis, flap valve grade, and EndoFLIP DI. These objective measures, often not reported in earlier trials of GERD therapies, are crucial because they correlate with long-term disease control and risk reduction for complications such as Barrett’s esophagus (BE) and esophageal adenocarcinoma.4,5

One of the most striking findings was the significant regression of BE in the ARMS group; 16.7% of patients achieved complete resolution of BE compared to 2.1% in the Stretta group. This is particularly relevant given that chronic acid exposure is a well-established driver of intestinal metaplasia and neoplastic progression. These results align with those of previous studies suggesting that ARMS may contribute to mucosal regression in patients with short-segment BE by effectively reducing pathologic acid exposure and modifying EGJ anatomy.6

However, ARMS is a riskier procedure than Stretta radiofrequency. In a study by Lee et al.,1 25% of patients undergoing ARMS experienced postprocedural bleeding, and one patient developed a stricture requiring balloon dilation. These adverse events, although manageable, highlight the need for cautious patient selection and procedural standardization. Previous studies have demonstrated that the extent of mucosal resection—particularly circumferential resection exceeding 270°—correlates with an increased risk of stricture formation due to excessive scarring.7 To address this, modified techniques such as the “butterfly-shaped” ARMS, which preserve bilateral mucosal bridges, have been proposed to maintain efficacy while reducing adverse events.8

Importantly, the safety of ARMS should be considered within its therapeutic potential. Unlike Stretta radiofrequency, ARMS directly reconstructs the anti-reflux barrier via anatomical remodeling. Although Stretta radiofrequency has shown modest improvements in subjective symptoms, it has not consistently demonstrated durable changes in objective reflux parameters or EGJ compliance.9,10 Recent guidelines, including those from the American College of Gastroenterology, have noted that evidence supporting Stretta radiofrequency remains insufficient for broad recommendation.11 In contrast, ARMS may offer a more robust intervention for appropriately selected patients, especially those with visible anatomical defects or endoscopic evidence of advanced esophagitis. Table 1 summarizes the advantages and limitations of the ARMS technique based on the current evidence.

Table 1.

Advantages and limitations of anti-reflux mucosectomy

Advantage	Limitation
∙ Direct anatomical remodeling of the EGJ via fibrosis	∙ Higher risk of adverse events (e.g., bleeding, stricture) compared to Stretta radiofrequency
∙ Significant improvement in objective findings (esophagitis grade, flap valve grade)	∙ Requires technical expertise and experience
∙ Reduces EGJ distensibility, as confirmed by EndoFLIP measurements	∙ Not yet widely standardized in terms of technique or resection extent
∙ Potential for regression of Barrett’s esophagus with acid suppression	∙ Risk of postprocedural dysphagia due to scarring
∙ Comparable symptom relief and PPI withdrawal rates to other modalities	∙ Limited long-term data on durability beyond 1–2 years
	∙ Not suitable for patients with large hiatal hernias or poor mucosal healing

EGJ, esophagogastric junction; PPI, proton pump inhibitor.

Nevertheless, several key areas require further investigation. First, the long-term durability of ARMS must be established through multicenter, prospective trials. Although its short-term efficacy is promising, it remains unclear whether the fibrosis-induced barrier persists beyond two years. Second, ideal candidates for ARMS should be defined through stratified analyses based on baseline EGJ anatomy, motility profiles, and presence of BE. For instance, patients with minor hiatal laxity and Hill grades II–III may derive greater benefits, whereas those with large hiatal hernias or severely impaired peristalsis may be better served by surgical interventions. Third, head-to-head comparisons of ARMS with other emerging endoscopic options, such as transoral incisionless fundoplication or anti-reflux mucosal ablation (ARMA) are warranted. ARMA, a technique that uses ablation rather than resection to induce EGJ fibrosis, has been associated with lower adverse event rates and may represent an alternative for patients at a higher risk of bleeding or stricture.12 However, comparative efficacy data remain limited. Finally, further studies should focus on optimizing procedural techniques. EndoFLIP-guided assessment during or immediately after ARMS may offer real-time feedback on EGJ compliance and help titrate the extent of mucosal resection to balance efficacy and safety. Similarly, adjunctive measures such as postprocedural PPI use or topical steroid application can modulate the healing response and reduce the risk of stenosis.

In summary, ARMS represents a unique and promising endoscopic approach for refractory GERD by targeting the underlying anatomical and physiological mechanisms. Although adverse events must be managed with vigilance, especially among less experienced endoscopists, its potential benefits—especially in improving objective markers and facilitating regression of BE—are substantial.