Objective Outcomes Of Ligation-assisted Anti-reflux Mucosectomy In The Treatment Of Gastroesophageal Reflux Disease

Research Background: Gastro-Esophageal Reflux Disease(GERD)is a condition in which the reflux of stomach and duodenal contents into the esophagus causes symptoms such as acid regurgitation,heartburn,and extra-esophageal symptoms,which can recur frequently and even lifelong,severely affecting patients’ quality of life and mental and physical health.Epidemiological studies have shown that the prevalence of GERD in adults in China has reached 7.0%.Currently,Proton Pump Inhibitors(PPIs)and Potassium-competitive acid blockers(P-CABs)are first-line drugs for the treatment of GERD,but 75-90% of patients experience symptom recurrence after discontinuation and require long-term or even lifelong medication,which imposes a huge economic and psychological burden on patients.However,the clinical application of laparoscopic Nissen fundoplication,which is the main surgical treatment for GERD,is limited by its high invasiveness,recurrence,and adverse reactions such as esophageal stenosis and perforation.Less than 5% of GERD patients receive this surgery.GERD patients who are unwilling to take medication for a long time urgently need a more cost-effective and minimally invasive new treatment,and the emergence of endoscopic treatment technology fills the treatment gap for this group of patients.Anti-reflux mucosectomy(ARMS)is a new endoscopic treatment for GERD proposed in recent years,and studies have demonstrated its effectiveness.However,the ARMS procedure is relatively complex,with longer operation times and higher technical requirements.The modified ligation-assisted anti-reflux mucosectomy(L-ARMS)proposed by Professor XXX,my supervisor,is a new endoscopic minimally invasive treatment for GERD based on the principle of the ARMS procedure with improvements in its shortcomings and expanded application.However,its safety and effectiveness still need to be evaluated.Objective: This study aims to investigate the safety and effectiveness of ligation-assisted anti-reflux mucosectomy(L-ARMS)for the treatment of gastroesophageal reflux disease(GERD),determine the appropriate patient population for this procedure,establish individualized and precise surgical plans based on different patient conditions,and improve treatment outcomes.Method: Chapter One: Based on the existing shortcomings of the traditional ARMS procedure,clinical cases were used to attempt modifications to the procedure.The surgical process was recorded and summarized,and postoperative follow-up evaluations were conducted to assess the safety and effectiveness of the modified procedure,with continuous optimization being performed.Chapter Two: Patients who met the inclusion criteria and were seen in the outpatient department of the Department of Gastroenterology at Xiangya Hospital,Central South University,underwent modified anti-reflux mucosal resection surgery and were followed up for six months postoperatively.Treatment efficacy was evaluated by comparing changes before and after surgery in gastroesophageal reflux disease-related health-related quality of life(GERD-HRQL),M.D.Anderson Dysphagia Inventory(MDADI),postoperative PPIs and P-CABs usage,24-hour esophageal p H-impedance monitoring,and esophageal motility testing.The occurrence of intraoperative and postoperative complications in patients was also observed.Chapter 3: Using the 45 patients who experienced transient dysphagia after surgery in the aforementioned clinical study as the experimental group,and the 24 patients who did not experience transient dysphagia as the control group,we conducted a risk factor analysis for the occurrence of transient dysphagia after surgery.We analyzed the differences between the two groups in 13 factors,including gender,age,BMI,alcohol consumption,smoking,eating too fast,overeating,high-fat diet,anxiety status,depression status,Los Angeles classification,hypertension,and esophageal motility.We used univariate analysis and multivariate logistic regression analysis to analyze the predictive factors for the occurrence of transient dysphagia after modified anti-reflux mucosal resection surgery.Chapter 4: Combining the results of the previous three chapters and the clinical experience gained during the study,we established the appropriate patient population for this procedure,established personalized and precise surgical plans based on individual patient conditions,and developed standard surgical procedures and plans for modified anti-reflux mucosal resection surgery.Results: Chapter 1: Based on the principles of simplifying operation and reducing complications,two modifications were made on the basis of the classic ARMS procedure to establish the surgical plan of L-ARMS procedure.This technique uses a snare device to directly perform mucosal stripping along the annular natural mucosal folds at the esophagogastric junction,which can simplify the operation,reduce the technical threshold,reduce intraoperative bleeding,and shorten the operation time.At the same time,the technique also involves the operation of a 4-ring ligation around the mucosal stripping area,which can enhance the short-term efficacy of the procedure.Chapter 2: A clinical safety and efficacy study of L-ARMS procedure in treating GERD was conducted on a total of 69 patients who underwent modified anti-reflux mucosal resection and completed 6months of follow-up after surgery.The results showed that: 1)compared with preoperative scores,the GERD-HRQL score at 6 months postoperatively significantly decreased;2)24-hour esophageal p H-impedance monitoring results showed significant improvements in De Meester scores,the percentage of time with p H<4,the number of reflux events,and the number of long reflux events at 6 months postoperatively compared with preoperative results;3)the mean resting pressure and residual pressure of the lower esophageal sphincter(LES)in patients at 6 months postoperatively significantly increased compared with preoperative levels;4)gastroscopy results showed a significant improvement in the grading of the gastroesophageal flap valve(GEFV)at6 months after L-ARMS treatment compared with preoperative results,and the mucosal damage caused by acid reflux in the lower esophagus significantly improved;5)all patients undergoing modified anti-reflux mucosal resection required PPI medication to control their symptoms before surgery.At 6 months postoperatively,38 patients(55.1%)were able to completely stop taking PPIs,21 patients(30.4%)reduced their medication to less than 3 times a week,and only 10 patients(14.5%)still needed to take standard or higher doses of PPIs.6)Forty-five patients experienced mild dysphagia after discharge,which resolved on its own after 4 weeks without special treatment.There was no postoperative stricture observed during follow-up gastroscopy at 3 and 6 months.Compared with patients without postoperative dysphagia,patients with postoperative dysphagia had better improvement in GERD-HRQL scores and De Meester scores.There were no other significant complications,and the procedure was safe and reliable.Chapter 3: Further analysis of 69 patients who underwent modified anti-reflux mucosal resection surgery in Chapter 2 was conducted to identify the potential risk factors for postoperative dysphagia through a univariate analysis.After analysis,the results showed that among the 13 risk factors,age(>65 years)and mild to moderate esophageal motility disorders were significantly correlated with postoperative dysphagia,and were included in the logistic regression equation.The analysis revealed that age(regression coefficient=1.603,P=0.047,OR=4.968)and esophageal motility(regression coefficient=1.488,P=0.006,OR=4.429)were independent predictors of postoperative dysphagia.Elderly patients(>65 years)and those with mild to moderate esophageal motility disorders were closely related to postoperative dysphagia after modified anti-reflux mucosal resection surgery.These two indicators can be flexibly adjusted before surgery to achieve the highest possible anti-reflux effect and avoid the occurrence of severe postoperative dysphagia.Chapter 4: Based on the surgical technique established in Chapter 1and the clinical safety and efficacy research in Chapter 2,combined with the discovery in Chapter 3 that age and esophageal motility were highly correlated with postoperative dysphagia after L-ARMS surgery,a specific plan for individualized and precise surgical procedures based on different patient situations was established.This included the standard surgical process and plan for L-ARMS surgery,as well as the inclusion and exclusion criteria for this surgery based on clinical practice.Conclusion: The L-ARMS procedure is a new method for treating GERD.This procedure can significantly tighten the patient’s loose lower esophageal sphincter,strengthen the anti-reflux barrier,reduce esophageal acid exposure,relieve GERD symptoms,reduce the use of acid suppression medication,and has no significant complications.This procedure is safe,effective,simple,and fills the gap between drug treatment and surgery,providing a new treatment option for GERD patients.Moreover,the personalized and precise L-ARMS procedure operation plan established in this study for different patients can further improve the treatment effect of the procedure and reduce the incidence of complications.However,the long-term efficacy and safety of this procedure in the treatment of GERD still need to be further evaluated.