Transoral Incisionless Fundoplication Research Articles

Efficacy of different endoscopic treatments for gastroesophageal reflux disease: a systematic review and network meta-analysis

BackgroundThere are no direct comparisons across different endoscopic therapies for gastroesophageal reflux disease (GERD). This study aimed to evaluate the relative effects of different endoscopic therapies in GERD. MethodsFive databases were searched until August 2023 for randomized controlled trials (RCTs) that compared the efficacy of endoscopic band ligation (EBL), Stretta, endoscopic fundoplication (transoral incisionless fundoplication [TIF], endoscopic full-thickness plication [EFTP], and EndoCinch plication procedure [EndoCinch, CR BARD, Billerica, Mass., USA]), or proton pump inhibitors (PPIs)/sham procedure for GERD. Bayesian network meta-analysis was performed. ResultsA total of 19 trials comprising 1181 patients were included. EBL (mean difference [MD], −7.75; 95% credible interval [CrI], −13.90 to −1.44), Stretta (MD, −9.86; 95% CrI, −19.05 to −0.58), and TIF (MD, −12.58; 95% CrI, −20.23 to −4.91) all significantly improved patients’ health-related quality of life score with equivalent efficacy compared with PPIs. TIF and EBL achieved equivalent efficacy in reducing PPIs utility (risk ratio [RR], 0.66; 95% CrI, 0.40–1.05) and both were significantly superior to other endoscopic interventions (Stretta, EFTP, and EndoCinch). Besides, EBL and TIF also could significantly decrease the esophagitis incidence compared with PPIs (EBL [RR, 0.34; 95% CrI, 0.22–0.48] and TIF [RR, 0.38; 95% CrI, 0.15–0.88]). In terms of lower esophageal sphincter (LES) pressure, only TIF could significantly increase the LES pressure (MD, 6.53; 95% CrI, 3.65–9.40) to PPIs. In contrast, TIF was inferior to PPIs in decreasing esophageal acid exposure (MD, 2.57; 95% CrI, 0.77–4.36). ConclusionCombining the evidence, EBL and TIF may have comparable efficacy and both might be superior to Stretta, EFTP, or EndoCinch in GERD treatment.

The role of transoral incisionless fundoplication (TIF) in the management of gastroesophageal reflux disease (GERD) following peroral endoscopic myotomy (POEM): A pilot, prospective, patient-driven study.

Gastroesophageal reflux (GERD) is a concern after peroral endoscopic myotomy (POEM). Transoral incisionless fundoplication (TIF) has been recently described as a possible therapy for post-POEM GERD in case series. We prospectively enrolled patients undergoing POEM who agreed to participate in objective post-procedure GERD evaluation. Patients with objective evidence of GERD and suitable anatomy were offered TIF vs. proton pump inhibitor (PPI) only. Patients who underwent TIF were compared to those on PPI-only therapy after follow-up. Of 21 enrolled POEM patients with objective testing, GERD was found in 11 (52%). Of those eligible for TIF, 4 (40%) opted to pursue TIF and were compared to those on PPI-only therapy (n = 6). Three months post-TIF, 75% of patients had discontinued or significantly decreased PPI. There were no adverse events. GERD health-related quality of life scores were low and comparable between TIF (3.75 ± 6.2) and those who remained on PPI-only therapy (4.1 ± 5). In this pilot, patient-driven prospective study, 75% of patients with post-POEM GERD undergoing TIF had stopped or significantly reduced PPI use. Post-POEM TIF is safe and effective and may be a viable alternative to PPI for POEM-related GERD; however, future studies should include a control arm and post-intervention pH monitoring.

Transoral incisionless fundoplication with or without hiatal hernia repair for gastroesophageal reflux disease after peroral endoscopic myotomy.

Background and study aims Gastroesophageal reflux disease (GERD) following peroral endoscopic myotomy (POEM) occurs in 40% to 60% of patients. There are limited data evaluating antireflux surgery or transoral incisionless fundoplication (TIF) for refractory post-POEM GERD. Patients and methods In a single-center prospective cohort study, consecutive patients with medically refractory post-POEM regurgitation and/or GERD treated with TIF or combined laparoscopic hernia repair and TIF (cTIF) were evaluated. Baseline evaluation: GERD-Health Related Quality of Life (GERD-HQRL) and Reflux Symptom Questionnaire 7-day recall (RESQ-7) questionnaires, EGD, high-resolution manometry (HRM), 48-hour pH test off proton pump inhibitors (PPIs) and impedance planimetry of the esophagogastric junction (EGJ) to calculate the diameter distensibility index (EGJ-DI). A PPI was taken twice daily for 2 weeks after TIF and restarted later if required. Patients returned 9 to 12 months after treatment when all preoperative studies were repeated. Quality of life, pH studies and EGJ metrics before and after antireflux surgery were compared. Results Seventeen patients underwent TIF (n=2, 12%) or cTIF (n=15, 88%) a mean 25±15 months after POEM. At follow-up a mean of 9±1 months after TIF/cTIF, patients required less frequent daily PPIs (n=0.001), were more satisfied (P=0.008), had improved GERD-HQRL (P=0.001), less intensity and frequency of GERD (P=0.001) and fewer reflux episodes (P=0.04) by pH testing. There was no change in EGJ-DI, EGJ diameter, integrated relaxation pressure, % total time pH <4, or DeMeester score. Conclusions TIF and cTIF for difficult-to-control post-POEM GERD appear safe, decrease PPI use and reflux episodes, and improve QOL without significant change in IRP, EGJ compliance, diameter or esophageal acid exposure time.

S1274 Single Session Combined Laparoscopic Hernia Repair with Transoral Incisionless Fundoplication: Initial Experience from a Single Center

S1274 Single Session Combined Laparoscopic Hernia Repair with Transoral Incisionless Fundoplication: Initial Experience from a Single Center

S1245 Patient Outcomes Following Transoral Incisionless Fundoplication and Magnetic Sphincter Augmentation with Concomitant Hiatal Hernia Repair

S1245 Patient Outcomes Following Transoral Incisionless Fundoplication and Magnetic Sphincter Augmentation with Concomitant Hiatal Hernia Repair

New Perspectives in Endoscopic Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease has a high incidence and prevalence in the general population. Clinical manifestations are heterogenous, and so is the response to medical treatment. Proton pump inhibitors are still the most common agents used to control reflux symptoms and for healing esophagitis, but they are not a one-size-fits-all solution for the disease. Patients with persistent troublesome symptoms despite medical therapy, those experiencing some adverse drug reaction, or those unwilling to take lifelong medications deserve valid alternatives. Anti-reflux Nissen fundoplication is an effective option, but the risk of adverse events has limited its spread. In recent years, advancements in therapeutic endoscopy have been made, and three major endoluminal alternatives are now available, including (1) the delivery of radiofrequency energy to the esophago–gastric junction, (2) transoral incisionless fundoplication (TIF), and (3) anti-reflux mucosal interventions (ARMI) based on mucosal resection (ARMS) and mucosal ablation (ARMA) techniques to remodel the cardia. Endoscopic techniques have shown interesting results, but their diffusion is still limited to expert endoscopists in tertiary centers. This review discusses the state of the art in the endoscopic approach to gastroesophageal reflux disease.

Key Decision Making and Technical Aspects of Performing Transoral Incisionless Fundoplication

There are a wide variety of surgical therapeutic options for GERD—ranging from laparoscopic fundoplication, magnetic sphincter augmentation, to advanced endoscopic interventions (eg, transoral incisionless fundoplication, TIF). TIF has emerged as the predominant endoscopic approach for GERD, supported by several randomized trials highlighting the efficacy of this procedure. Its safety profile has similarly been well established. The key to properly utilizing this procedure is patient selection. We here in describe the efficacy, highlight key decision making and technical aspects of performing a TIF, to discuss post-operative care and complications.

Transoral incisionless fundoplication and open hiatal hernia repair: A case report

IntroductionTransoral incisionless fundoplication is a new procedure that has recently emerged as a potential alternative to traditional anti-reflux surgeries. It is a less invasive option with fewer complications and reduced recovery time. Hiatal hernia repair is also commonly performed in conjunction with transoral incisionless fundoplication to improve outcomes. In this case, it details a successful transoral incisionless fundoplication and hiatal hernia repair procedure in a patient with long standing gastroesophageal reflux disease (GERD). The case is unique as it involved a patient with an uncharacteristically large hiatal hernia measuring above 5cm, which is a size that is generally not considered suitable for transoral incisionless fundoplication. The hiatal hernia was repaired with a gastrectomy instead of laparoscopically due to the size and adhesions present.Case detailsThis case report presents an 86 year old female patient with a history of long-standing GERD symptoms from the past 10 years who had failed to respond to medical therapy. Endoscopic imaging revealed a hernia of more than 5cm in size, which was confirmed by a bravo study. A DeMeester score of 446 was reported. The patient was referred for surgery and underwent transoral incisionless fundoplication with hiatal hernia repair. Despite the large size of the hiatal hernia, it was decided to proceed with a transoral incisionless fundoplication (TIF) procedure combined with hiatal hernia repair. The gastrectomy was chosen due to significant adhesions and anatomical distortion, making it difficult to continue laparoscopically. The esophagus was fibrosed to the pericardium, and the stomach was stuck in a retrocardiac position. Laparoscopic removal of the adhesions proved difficult since the patient had friable tissues, and there was a high risk of injury to surrounding organs. The surgery was therefore converted to an open approach, and the hernia was repaired with a gastrectomy. The TIF procedure was performed successfully, and the patient had no complications postoperatively.ConclusionThis case details a successful transoral incisionless fundoplication procedure for GERD in a patient with an uncharacteristically large hiatal hernia. Despite the challenges posed by the hernia’s size and anatomical distortion, the TIF procedure combined with hiatal hernia repair was successful in providing relief from GERD symptoms, with no postoperative complications. The case highlights the potential suitability of TIF as an alternative to laparoscopic fundoplication in patients with large hiatal hernias, although gastrectomy may be necessary in cases with significant adhesions or anatomical distortion.

Endoscopy and Antireflux Surgery: A Technical Review of Pre- and Postoperative Evaluation and Recognizing Patterns of Failure

Endoscopic evaluation after antireflux surgery is a challenge, due to the complexity of anatomy, variations in anatomical repairs, and the various patterns of failure. Studies have demonstrated that endoscopy reports of postoperative examinations are often inaccurate and inconsistent. The key to consistent high quality endoscopic examinations of the integrity of an antireflux surgery is a sound foundation in the native anatomical gastroesophageal junction and an understanding of the anatomy of the various postoperative configurations. This review will clarify the critical details necessary to perform a detailed endoscopic evaluation of the patient with suspected gastroesophageal reflux, and highlight key features to distinguish the intact repair from the dysfunctional one. It first explores the anatomical components of the native gastroesophageal junction and the unique geometric architecture that manifests in the physiologic reflux barrier. Then details the essential structures to evaluate and techniques to perform in an endoscopic examination prior to an antireflux surgery. It then systematically examines the altered anatomy and postoperative changes in endoscopic appearance after Nissen, Toupet, and Dor fundoplication, Collis gastroplasty, magnetic sphincter augmentation, and transoral incisionless fundoplication. Finally, to aid in the endoscopic diagnosis of specific dysfunction, it discusses the various patterns of failure after antireflux surgery, their characteristic endoscopic appearances, and the most useful adjunct testing modalities to augment the endoscopic examination when diagnosis is unclear.

American Foregut Society White Paper on Transoral Incisionless Fundoplication

Gastroesophageal reflux disease (GERD) is a chronic disease on a spectrum that has an array of management options ranging from lifestyle changes, acid suppressive therapy to laparoscopic anti-reflux surgery (LARS). Transoral incisionless fundoplication (TIF) is an endoscopic procedure in the management of GERD that re-establishes and augments the gastroesophageal flap valve (GEFV). TIF is appropriate for patients that do not have a hiatal hernia greater than 2 cm. Patients with a hiatal hernia greater than 2 cm have the option to have either a conventional LARS (laparoscopic hiatal hernia repair with complete or partial fundoplication) or a concomitant laparoscopic hiatal hernia repair with TIF, known as concomitant TIF (cTIF). This white paper summarizes the published outcome data for TIF 2.0 and cTIF to date and outline the best practice approaches including patient assessment, selection, and management for TIF and cTIF.

Invited Commentary on the American Foregut Society White Paper on Transoral Incisionless Fundoplication: Transoral Incisionless Fundoplication: Where Are We and Where Do We Go From Here?

Invited Commentary on the American Foregut Society White Paper on Transoral Incisionless Fundoplication: Transoral Incisionless Fundoplication: Where Are We and Where Do We Go From Here?

Role of Transoral Incisionless Fundoplication in Salvage Therapy for Recurrent Reflux

Background: Gastroesophageal reflux (GERD) occurs when anatomic barriers fail to prevent retrograde movement of stomach contents into the esophagus. When lifestyle and medications fail to relieve patients’ symptoms, anti-reflux procedures can be safe and effective options for addressing the mechanical deficits (such as reduced lower-esophageal sphincter pressure, hiatal hernia, and/or patulous diaphragmatic hiatus) contributing to GERD. When laparoscopic fundoplication treatment of GERD fails, repeat surgical treatment is an option—but comes with risk of increased morbidity when compared to the primary fundoplication. Transoral incisionless fundoplication (TIF) is an endoscopic anti-reflux procedure that may be an alternative option for salvage therapy in patients with recurrent GERD. Methods: This review will explore fundoplication failure, the theoretical role for TIF in this setting, and the literature to support TIF as endoscopic rescue at this time. Literature review of studies reporting TIF for salvage therapy outcomes was performed, revealing 2 published papers. Results: TIF as salvage therapy has been shown in patients with minimal recurrent hiatal hernia but a loose fundoplication to be feasible, safe, and effective with improvement of GERD symptom scores and acid exposure time. However, this has only been shown in small, retrospective studies at this time. Conclusion: TIF may be a reasonable alternative to repeat laparoscopic fundoplication in patients with a small hiatal hernia.

The long-term efficacy of transoral incisionless fundoplication with Medigus Ultrasonic Surgical Endostapler (MUSE) for gastroesophageal reflux disease

BackgroundTo evaluate the long-term efficacy of transoral incisionless fundoplication (TIF) with Medigus Ultrasonic Surgical Endostapler (MUSE) for gastroesophageal reflux disease (GERD).MethodsA total of 16 patients with proton pump inhibitor-dependent gastroesophageal reflux disease had undergone TIF by MUSE in Shanghai General Hospital （Shanghai, China）from March 2017 to December 2018. Patients were followed up at 6 months, and the GERD-health-related quality of life (GERD-HRQL) questionnaire score, the GERD questionnaire (GERD-Q) score, high-resolution esophageal manometry (HREM) and 24 h esophageal pH parameters, the Hill grade of the gastroesophageal flap valve (GEFV) and daily Proton pump inhibitor (PPI) consumption before and after procedure were compared. Patients also were followed up at 3 years and 5 years using a structured questionnaire via phone which evaluated symptoms of reflux, dose of PPI medication and side effects.ResultsFollow-up data were collected from 13 patients, ranging from 38 to 63 months, 53 months on average. 10/13 patients reported symptomatic improvement and daily PPI consumption was stopped or halved in 11/13. After procedure, the mean scores of GERD-HRQL and GERD-Q were significantly increased. The mean DeMeester score, the mean acid exposure time percentage and the mean number of acid reflux episodes were significantly lower. The mean rest pressure at lower esophageal sphincter (LES) had no significant difference.ConclusionTIF by MUSE has significant efficacy in the treatment of PPI-dependent GERD, which can improve symptoms and life quality of patients, and reduce the acid exposure time for long-term. Chictr.org.cn.Trial RegistrationChiCTR2000034350.

Laparoscopic Hiatal Hernia Repair With Concomitant Transoral Incisionless Fundoplication.

Patients with gastroesophageal reflux disease and a large hiatal hernia can have life-disrupting symptoms, such as heartburn, regurgitation, cough, and hoarseness. Gastroesophageal reflux disease symptoms are often treated with proton pump inhibitors and occasionally treated with surgery. The last decade has seen the development of a new procedure-laparoscopic hiatal hernia repair with concomitant transoral incisionless fundoplication. When transoral incisionless fundoplication is performed immediately after a laparoscopic hiatal hernia repair, it may enable the discontinuation of proton pump inhibitors and improve a patient's quality of life. This article explores the development of the transoral incisionless fundoplication procedure as well as its concomitant use after hiatal hernia repair at all stages of perioperative care. Also included is a hypothetical case study that illustrates the perioperative nursing care of a patient undergoing this procedure.

Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis.

We aim to review and quantitatively compare laparoscopic Toupet fundoplication (LTF), Nissen fundoplication (LNF), anterior partial fundoplication (APF), magnetic augmentation sphincter (MSA), radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), proton pump inhibitor (PPI), and placebo for the treatment of GERD. A number of meta-analyses compared the efficacy of surgical and endoscopic procedures for recalcitrant GERD, but considerable debate on the effectiveness of operative strategies remains. A systematic review of MEDLINE databases, EMBASE, and Web of Science for randomized controlled trials (RCTs) comparing the aforementioned surgical and endoscopic GERD treatments was performed. Risk ratio and weighted mean difference were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. Thirty-three RCTs were included. Surgical and endoscopic treatments have similar RR for heartburn, regurgitation, bloating. LTF has a lower RR of post-operative dysphagia when compared to APF (RR 3.3; Crl 1.4-7.1) and LNF (RR 2.5; Crl 1.3-4.4). The pooled network meta-analysis did not observe any significant improvement regarding LES pressure and pH < from baseline. LTF, APF, LNF, MSA, RFA, and TIF had have a similar post-operative PPI discontinuation rate. LTF has a lower rate of post-operative dysphagia when compared to APF and LNF. The pre-post effects, such as GERD-HQRL, LES pressure, and pH <4, should be avoided in meta-analyses because results may be biased. Last, a consensus about the evaluation of GERD treatments' efficacy and their outcomes is needed.

Hiatal hernia repair with transoral incisionless fundoplication versus Nissen fundoplication for gastroesophageal reflux disease: A retrospective study.

Background and study aims Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes. Patients and methods This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2-5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months. Results A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups ( P > 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all P < 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %, P = 0.009). Conclusions Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted.

Efficacy of endoscopic anterior fundoplication with a novel ultrasonic surgical endostapler for gastroesophageal reflux disease: Six-month results from a multicenter prospective trial.

Endoscopic therapy is an option for the treatment of refractory gastroesophageal reflux disease (GERD). We aimed to evaluate the efficacy and safety of transoral incisionless fundoplication with the Medigus ultrasonic surgical endostapler (MUSE™) for refractory GERD. Patients with 2 years of documented GERD symptoms and at least 6 months of proton-pump inhibitors (PPIs) therapy were enrolled in four medical centers from March 2017 to March 2019. The GERD health-related quality of life (HRQL) score, GERD questionnaire score, total acid exposure on esophageal pH probe monitoring, the gastroesophageal flap valve (GEFV), esophageal manometry, and PPIs dosage were compared between the pre- and post-MUSE procedure. All of the side effects were recorded. A reduction of at least 50% in the GERD-HRQL score was observed in 77.8% (42/54) patients. Most patients 74.1% (40/54) discontinued PPIs and 11.1% (6/54) reported a ≥50% dose reduction. The percentage of patients who had normalized acid exposure time after the procedure was 46.9% (23/49). The existence of hiatal hernia at baseline was negatively correlated with the curative effect. Mild pain was common and resolved within 48 h postprocedure. Serious complications were pneumoperitoneum (one case), mediastinal emphysema combined with pleural effusion (two cases). Endoscopic anterior fundoplication with MUSE was an effective treatment for refractory GERD, but still needs refinement and improvement in safety aspect. Esophageal hiatal hernia may affect the efficacy of MUSE. (www.chictr.org.cn, ChiCTR2000034350).

Is peroral endoscopic myotomy the new gold standard for achalasia therapy?

Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. Systematic literature reviews were conducted for 4 key questions regarding thesurgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, analgorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitorsalone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Utilization of Antireflux Mucosectomy and Resection and Plication: A Novel Approach for the Management of Recurrent Gastroesophageal Reflux Disease after Prior Nissen Fundoplication or Transoral Incisionless Fundoplication.

Background: Nissen Fundoplication (NF) and Transoral Incisionless Fundoplication (TIF) are established procedures for the treatment of gastroesophageal reflux disease (GERD). However, the surgically induced plication can loosen over time. This multicenter study aims to evaluate the safety and efficacy of Antireflux Mucosectomy (ARMS) and Resection and Plication (RAP) in symptomatic patients with prior NF or TIF that has become loose. Patients and methods: Eighteen patients were enrolled in the study. Ten had prior TIF, while eight had prior NF. Half of these patients had a Hill Grade 3 Valve while the other half had a Hill Grade 2 valve. Endoscopic submucosal dissection (ESD) was performed in six patients, while endoscopic mucosal resection (EMR) was performed in twelve patients. A follow-up endoscopy was performed at 4-12 weeks. Results: At follow-up, 11 patients had a Hill Grade 1 valve, and seven patients had a Hill Grade 2 valve. All patients had improvement in symptoms for up to 32 months. Conclusions: In this pilot study, ARMS/RAP appears to be an effective option in patients who had prior NF or TIF with recurrent GERD symptoms.