ARMA (antireflux Mucosal Ablation) consists of ablating the subcardial mucosa to induce scar retraction that closes cardial incompetence. The main difference with ARMS is that the gastric tissue is not resected here, but rather it is destroyed to try to achieve the same effect.

Gastric mucosal ablation can be done both with Spray coagulation (as we present in this case), and with Argon-plasma, which is another day-to-day technique used by most endoscopists.

The original technique was described using spray coagulation and a TT-Knife to apply it and as a rescue technique for patients who had undergone an ARMS and who had not had a satisfactory result, although we can use it without problem and on patients naive. In the little published literature, it seems that the results are very similar in previously untreated patients.

A couple of technical details.

1. The ablation must be deep, and not superficial as we usually do when we apply Argon, we have to reach the submucosa. A very good option is, prior to the application, inject the entire subcardial area with physiological serum marked with carmine, and apply the coagulation until we see that we destroy the mucosa and we see blue.
2. We will work very, very close in retroflex, so having an endoscope with good retroflexion or, an in this case, with a 550 series sonoscape endoscope, which flexes up to 210º, will be necessary to get to where we want to go.
3. Using a cap (I like rigid oblique caps for this) stabilizes our position and helps us maintain the correct distance, which allows us to do the technique more quickly and safely. I think it is mandatory to use it.
4. The original technique was described by H. Inoue using a triangle knife (and it goes great ,of course), but honestly it seems like a very expensive material for this. I have modified it using the tip of a diathermy snare taken only 1-2 mm from its sheath, with the same results and you will see it in the video.