P0325 - Anti-reflux Mucosectomy for Refractory Gastroesophageal Reflux Disease: A Systematic Review and Meta-analysis

Rajat Garg, MD¹, Abdul Mohammed, MD², Amandeep Singh, MD¹, Prashanthi N. Thota, MD¹, Tarun Rustagi, MD³, Madhusudan Sanaka, MD^1
1Cleveland Clinic Foundation, Cleveland, OH; ²MetroHealth Medical Center, Cleveland, OH; ³University of New Mexico, Albuquerque, NM

Introduction: Anti-reflux mucosectomy (ARMS) for refractory gastroesophageal reflux disease (GERD) has been reported to have promising results in recent studies. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ARMS in refractory GERD.

Methods: A comprehensive search of multiple databases (through March 2020) was performed to identify studies that reported outcomes of ARMS for refractory GERD. Outcomes assessed included technical success, clinical response, and adverse events. Clinical response was defined as discontinuation (complete) or reduction (partial) of proton pump inhibitors post-ARMS at follow-up. The pooled rates were calculated using random-effect models and the mixed-effect model was used for subgroup analysis.

Results: A total of 307 patients (mean age 46.9 ± 8.1 years) were included from 10 studies. The technical success and clinical response rates were 97.7% (95% confidence interval [CI], 94.6 – 99.0, I² =0) and 80.1% (95% CI, 61.6 – 91.0, I² =84.9), respectively. The pooled rate of complete and partial clinical response was 65.3% (95% CI, 51.4 – 77.0, I² =73.1) and 21.5% (95% CI, 14.2 – 31.2, I² =25.5), respectively. The rate of adverse events was 17.2% (95% CI, 13.1 – 22.2, I2 =1.9) with most common adverse event being dysphagia/esophageal stricture followed by bleeding with rates of 11.4% (95% CI, 8.2 – 15.7, I2 =0) and 5.0% (95% CI, 1.9 – 12.3, I2 = 51.3), respectively. GERD-HRQL (Mean difference {MD}= 14.9, [9.30 - 20.6], I2=85%, p< 0.001), GERD-Q (MD= 4.85, [2.7 – 7.03], I2=95%, p< 0.001) and mean acid exposure time (MD =2.39, [0.47 – 4.3], I2=74%, p=0.01) decreased significantly post-ARMS as compared to pre-procedure without significant difference in DeMeester scores (Figure 1). There was no difference in terms of clinical response and adverse events between ARMS and ARMS with banding on subgroup analysis (Table 1).

Discussion: ARMS is an effective and safe procedure for the treatment of refractory GERD with high rates of clinical response and an acceptable safety profile. It leads to significant improvement in GERD-related quality of life. Prospective randomized trials are needed to validate our findings.


Figure: Figure 1: Forest plot showing mean difference of GERD-HRQL, GERD-Q and mean acid exposure time post-ARMS.

Table 1: Results of meta-analysis with subgroup analysis
Outcome	ARMS	ARMS without banding (A)	ARMS with banding (B)	p-value (A vs B)
Technical success	97.7 (94.6 - 99.0), I2=0, 10 studies	98.1 (94.3 - 99.4), I2=0, 6 studies	96.8 (88.0 - 99.2), 4 studies, I2=0, 4 studies	0.55
Clinical success (reduction or discontinuation of PPI)	80.1 (61.6 to 91.0), I2=84.9, 10 studies	79.2 (53.3 - 92.7), I2=89%, 6 studies	81.7 (49.0- 95.4), I2=54.9%, 4 studies	0.87
Complete clinal response	65.3 (51.4 - 77.0), I2=73.1, 10 studies	63.4 (45.0 - 77.1), I2=68.5, 6 studies	71.6 (46.4 - 88), I2=79.6%, 4 studies	0.41
Partial/Reduction PPI	21.5 (14.2 - 31.2), I2=25.5, 7 studies	24.5 (14.9 - 37.7), I2=0, 3 studies	15.3 (6.6 - 31.7), I2=45.4%, 4 studies	0.3
Adverse events	17.2 (13.1 to 22.2), I2=1.9, 10 studies	16.5 (11.8 - 22.5), I2=24.7, 6 studies	20.7 (12.5 - 32.4), I2=0, 4 studies	0.44
Dysphagia	11.4 (8.2 to 15.7), I2=0, 10 studies	10.5 (7.1 - 15.3), I2=0, 6 studies	15.4 (8.4 - 26.5), I2=0, 4 studies	0.28
Bleeding	5.0 (1.9 to 12.3), I2=51.3, 10 studies	4.4 (1.2 -15.1), I2=69.7, 6 studies	5.9 (1.2 - 24.4), I2=0, 4 studies	0.77
Values are shown as rate, 95% Confidence interval, I2, number of studies. ARMS: Anti-reflux mucosectomy, PPI: Proton pump inhibitors

Disclosures:
Rajat Garg indicated no relevant financial relationships.
Abdul Mohammed indicated no relevant financial relationships.
Amandeep Singh indicated no relevant financial relationships.
Prashanthi Thota indicated no relevant financial relationships.
Tarun Rustagi indicated no relevant financial relationships.
Madhusudan Sanaka indicated no relevant financial relationships.


Rajat Garg, MD¹, Abdul Mohammed, MD², Amandeep Singh, MD¹, Prashanthi N. Thota, MD¹, Tarun Rustagi, MD³, Madhusudan Sanaka, MD¹. P0325 - Anti-reflux Mucosectomy for Refractory Gastroesophageal Reflux Disease: A Systematic Review and Meta-analysis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.