Anti-reflux mucosal intervention for gastroesophageal reflux disease: a new horizon of endoscopic anti-reflux therapy

Anti-reflux mucosal (ARM) interventions have expanded the therapeutic spectrum for gastroesophageal reflux disease beyond pharmacologic therapy and surgery. This narrative review traces the evolution from anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) to the more recently developed anti-reflux mucoplasty (ARMP) and ARMP with valve (ARMPV). Collectively, the available cohort studies and systematic reviews indicate a clinical response rate of 70-82%, with proton-pump inhibitor discontinuation achieved in up to 55% of cases. The most common adverse events are transient dysphagia (~11%) and post-procedural bleeding (~5%), both of which are manageable endoscopically. Direct defect closure in ARMP shortens the interval to symptom relief and virtually eliminates delayed bleeding, while technical refinements such as the angle booster and counter-mucosal incision have improved access and tension management. When selecting among ARM intervention techniques, we propose ARMP as the first-line option in naïve anatomy, reserving ARMA for redo or post-surgical settings where submucosal fibrosis limits application. Ongoing trials are assessing durability beyond five years, the role of full-thickness suturing that incorporates sling- and clasp-muscle fibers, and applications in bariatric or para-esophageal hernia populations. Future research priorities include standardizing ulcer dimensions to optimize shrinkage, refining patient-reported outcome measures, and clarifying cost-effectiveness relative to fundoplication and magnetic sphincter augmentation. In summary, ARM interventions offers a spectrum of flexible, minimally invasive solutions that can be tailored to individual anatomic and physiological profiles, potentially bridging the treatment gap between long-term acid suppression and surgery.