A potential simple endoscopic antireflux method, "the Ripple Procedure" to reduce distensibility at the esophagogastric junction in a porcine model

Background and aims: Currently available endoscopic or minimally invasive antireflux modalities are not widely accepted due to high procedure cost or inconsistent results. Therefore, a simpler and less technically demanding method is required. We evaluated the feasibility and efficacy of new endoscopic antireflux method (the Ripple Procedure) using functional lumen imaging probe (FLIP). Methods: This 5-week survival study included 10 domestic pigs (control, n = 4; experimental [Ripple], n = 6). The procedure includes the following steps: (i) semicircular marking along the lesser curvature of the cardia; (ii) submucosal injection; and (iii) semicircular mucosal incision along the marking. Endoscopic and FLIP evaluations were performed preoperatively and on postoperative days (PODs) 14 and 35. Technical feasibility was evaluated, and FLIP parameters, including the distensibility index (DI) at the esophagogastric junction (EGJ) and histopathological findings, were compared between groups. Results: The median procedure time was 28 (23.5-33.8) min. There was no significant difference in dysphagia score and body weight between groups. On POD 35, the Ripple group showed significantly lower EGJ DI at 30 mL [2.0 (1.3-2.5) vs 4.9 (2.7-5.0), P = 0.037]. The EGJ DI was significantly reduced at 30 mL, compared with that at the baseline level [- 59.0% (- 68.8% to - 32.1%) vs 27.8% (- 26.3% to 83.1%), P = 0.033]. Histologic evaluation revealed submucosal granulation tissues near the mucosal incision site, with increased intervening fibrosis between lower esophageal sphincter fibers in the Ripple group. Conclusion: The EGJ DI significantly decreased after the Ripple Procedure; hence, the procedure appears to be feasible and effective in this porcine model.restrictio