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LETTER TO EDITOR/LED REPLY

Reply to the Letter to the Editor Concerning Anti-reflux Mucosectomy (ARMS) in Sleeve Gastrectomy Patients with GERD and Barrett’s Esophagus Daniel M Felsenreich 1 & Felix B Langer 1 & Gerhard Prager 1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

First and foremost, we would like to thank the authors for their comments on our study “Roux-en-Y Gastric Bypass as a Treatment for Barrett’s Esophagus after Sleeve Gastrectomy” [1] and their interest and further ideas. To sum up, the authors of the letter to the editor consider endoscopic anti-reflux mucosectomy (ARMS) a possible therapy for sleeve gastrectomy (SG) patients suffering from GERD. This method is supposed to induce an anti-reflux mechanism performing a mucosectomy of three-quarters circumferential at the gastroesophageal junction by cicatrization and stricture [2]. So far in the literature, only a few case series are published in patients suffering from GERD with a normal abdominal situs (none of them included patients after SG). Inoue et al. reported successful results in 8 of 10 patients after 2 months and strictures in the two patients with Barrett’s esophagus and the need of repetitive balloon dilatation [2]. Another study by Patil et al. including 62 patients also reported an improvement of GERD in 38 patients (61%) after 12 months [3]. Shimamura and Inoue in a review article also concluded that hiatal hernias of more than 3 cm and motility disorders of the lower esophagus should be considered contraindications to ARMS [4]. Apart from the unpublished case the authors mentioned in their letter to the editor, ARMS in patients after SG suffering from GERD and Barrett’s esophagus has not been described at this point in time. Only two published case reports described ARMS in patients with GERD after SG (without Barrett’s esophagus) and found improvement of GERD after 4.5 and 7 months [5, 6]. To conclude, in the current literature, there is

* Gerhard Prager [email protected] 1

Division of General Surgery, Department of Surgery, Vienna Medical University, Währinger Guertel 18-20, 1090 Vienna, Austria

no evidence that this procedure may be successful in patients with Barrett’s esophagus and GERD after SG. Also, even for patients with normal abdominal situs, the method should still be considered “experimental” due to a lack of evidence in the long-term follow-up. Some concerns that might exhibit that this method cannot behave in the long-term follow-up after SG to bring GERD and Barrett’s esophagus in resolution: &

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Contrary to normal gastric situs is a high-pressure system (because of a tight gastric sleeve with the pylorus in the food stream) with a continuous upward pressure on the thorax, which is very likely indeed to create hiatal hernias in the long-term follow-up [7, 8]. Thus, it is highly probable that ARMS will have no impact in SG patients in a long-term follow-up. A cicatrization or stricture at the gastro-esophageal junction that leads to dysphagia and decreased food uptake