On this page
At a glance
- Incisionless treatments are for selected patients with confirmed reflux and no large hiatal hernia.
- ARMA uses a flexible endoscope to create controlled healing at the top of the stomach, which tightens and reshapes the valve — no implant or fasteners are left behind.
- In a 2026 randomized, sham-controlled trial, most patients treated with ARMA had meaningful symptom improvement at six months.
- TIF builds a partial valve held with fasteners; the valve is looser than a surgical fundoplication, and many patients still need medication.
What “incisionless” means
Both treatments on this page are performed through the mouth with a flexible endoscope, under anesthesia, with no cuts in the skin. They are designed for a narrower group of patients than surgery. As with any anti-reflux procedure, reflux must first be confirmed by testing, and manometry should show that the esophagus squeezes well enough to push food through a tighter valve.
Neither treatment repairs a large hiatal hernia. When a significant hernia is present, a laparoscopic repair with a fundoplication or LINX is usually the better path.
ARMA — anti-reflux mucosal ablation
How it works. Using a standard flexible endoscope, a small, carefully shaped area of the lining at the top of the stomach, just below the lower esophageal valve, is treated with ablation energy. As that area heals, the tissue contracts, tightening and reshaping the valve so less stomach content can flow back into the esophagus. ARMA developed from an earlier technique called anti-reflux mucosectomy (ARMS), which removes a strip of lining instead of ablating it.
Why it is a promising option:
- No skin incisions, and no implant, device, or fasteners left in the body — the new valve shape comes from the body’s own healing
- Performed with standard endoscopic instruments
- Recovery is usually quick
- Encouraging results in controlled research: in a 2026 randomized trial of 58 patients whose reflux symptoms persisted despite optimized PPI therapy, 71% of those treated with ARMA had at least a 50% improvement in a standard reflux quality-of-life score at six months, compared with 4% after a sham (placebo) procedure. Reflux measured on pH-impedance testing also improved, and about a third of ARMA patients were completely off PPIs.
What to know. ARMA is still an emerging procedure, and long-term results are still being gathered. The main recognized side effect is difficulty swallowing if the healing area narrows too much; some patients need an endoscopic dilation to stretch it. It is best suited to people with confirmed reflux and no hiatal hernia or only a small one.
TIF — transoral incisionless fundoplication
How it works. A device passed through the mouth alongside an endoscope folds tissue at the top of the stomach up against the lower esophagus and holds it with a series of fasteners, creating a partial valve a few centimeters long. The most widely studied version is TIF 2.0, performed with the EsophyX device.
Limitations:
- The valve it creates is looser and shorter than a surgical fundoplication.
- Many people continue to need reflux medication. In the TEMPO trial, 34% of the participants evaluated at five years were taking daily PPIs, and three participants had later operations.
- It depends on a dedicated device and leaves fasteners in place.
- It is limited to people without severe esophagitis (Los Angeles grade C or D) and with no hiatal hernia or one of 2 cm or less, which is the group the ACG guideline suggests may be considered for TIF.
Other endoscopic options
Stretta applies radiofrequency energy to the lower esophageal muscle. The ACG guideline recommends against it, based on the available evidence.
Choosing among incisionless and surgical options
The right procedure depends on hernia size, test results, esophageal function, and how much reflux control you need. Incisionless surgery is one of Dr. Speer’s areas of specialized expertise. Learn more in her professional profile. The treatment comparison summarizes how the options differ, and a consultation is the place to discuss which ones fit your situation.
Common questions
What is ARMA, and who may be a candidate?
ARMA (anti-reflux mucosal ablation) is an incisionless, endoscopic procedure that tightens and reshapes the reflux valve through controlled healing of the lining at the top of the stomach. It may suit people with confirmed reflux and no hiatal hernia or only a small one.
ARMA is done through the mouth with a standard flexible endoscope, so there are no skin incisions, and no implant or fasteners are left behind. As the treated area heals, the tissue contracts and firms up the valve.
It is an emerging option with encouraging early results, including a 2026 randomized, sham-controlled trial in which most treated patients had meaningful symptom improvement at six months. Long-term results are still being gathered. The main side effect to know about is difficulty swallowing if the area narrows as it heals, which sometimes needs an endoscopic dilation. Like all anti-reflux procedures, ARMA requires reflux to be confirmed by testing and esophageal function to be checked with manometry first.
What is TIF, and what are its limitations?
TIF (transoral incisionless fundoplication) builds a partial reflux valve from inside the stomach using a device passed through the mouth and a series of fasteners. It is limited to a narrow group of patients, and the valve is looser than a surgical fundoplication.
TIF is considered only for people with confirmed reflux who don’t have severe esophagitis and have no hiatal hernia or one of 2 cm or less. It relies on a dedicated device and leaves fasteners in place.
Compared with a surgical fundoplication, TIF creates a shorter, less robust valve, and many people continue to need reflux medication afterward. For people who want an incisionless approach, newer options such as ARMA may be discussed; for people who need stronger or longer-lasting reflux control, surgery is usually the better choice.
Sources
- Chavan D, Koduri KK, Singh AP, et al. Role of antireflux mucosal ablation in “reflux-predominant” refractory gastroesophageal reflux disease — a randomized sham-controlled trial. Endoscopy. 2026;58(5):456–464.
- Inoue H, Tanabe M, de Santiago ER, et al. Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors — a pilot study. Endosc Int Open. 2020;8(2):E133–E138.
- Rodríguez de Santiago E, Sanchez-Vegazo CT, Peñas B, et al. Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) for gastroesophageal reflux disease — a systematic review and meta-analysis. Endosc Int Open. 2021;9(11):E1740–E1751.
- Katz PO, et al. ACG Clinical Guideline for the Diagnosis and Management of GERD. Am J Gastroenterol. 2022;117(1):27–56.
- Trad KS, et al. The TEMPO trial at 5 years — transoral fundoplication (TIF 2.0) is safe, durable, and cost-effective. Surg Innov. 2018;25(2):149–157.
This page is general education. It can’t account for your history, test results, or other conditions, so please discuss your situation with your own clinician.