Transoral rotational esophagogastric fundoplication: technical, anatomical, and safety considerations

Abstract

BackgroundGastroesophageal reflux disease (GERD) results primarily from the loss of an effective antireflux barrier, which forms a mechanical barrier against the retrograde movement of gastric content. Restoration of the incompetent antireflux barrier is possible by longitudinal and rotational advancement of the gastric fundus about the lower esophagus, creating an esophagogastric fundoplication. This article describes the technique of performing a rotational and longitudinal esophagogastric fundoplication, performed transorally using EsophyX.MethodsThe transoral incisionless fundoplication (TIF) technique enables the creation of a full-thickness esophagogastric fundoplication with fixation extending longitudinally up to 3.5 cm above the Z-line and rotationally more than 270 degrees around the esophagus. A key element of the technique involves rotating the fundus around the esophagus with a tissue mold during gastric desufflation. Anatomic considerations and use of the device’s tissue invaginator to push the esophagus caudally are important to ensure safe positioning of the plications below the diaphragm. The steps of the technique are described in detail, and suggestions are given about patient selection and care, as well as prevention and management of complications.

Does Measurement of Esophagogastric Junction Distensibility by EndoFLIP Predict Therapy- responsiveness to Endoluminal Fundoplication in Patients With Gastroesophageal Reflux Disease?

“…One of the newer endoscopic approaches aimed to improve EGJ competence is transoral incisionless fundoplication (TIF) with the Esophyx device. One hypothesis states that the TIF procedure restores the gastroesophageal junction by rotating the fundus around the esophagus and creating a partial fundoplication, 20 thereby restoring EGJ distensibility with reduction in the volume of refluxate since flow across the EGJ is proportional to the opening diameter raised to the fourth power. 12 The EndoFLIP technique is a new method to assess EGJ distensibility.…”

“…Six months after TIF, GERD symptoms had improved according to the reduction in GERD-HRQL scores (from 26 [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]) to 10 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20], P < 0.01). Common use of acid suppressive medication was discontinued by 67% of patients, whereas 19% used PPIs occasionally and common use was present in 14%.…”

“…20 Patients were placed in the left lateral decubitus position after induction of general anesthesia. All procedures were performed by an experienced team of a gastroenterologist and a surgeon.…”

New Options for the Management of GERD

“…2). The endoscopic plicating and suturing mechanism works in a complex but coordinated way as described by Bell et al [15]. Plication is facilitated by a vacuum-powered tissue invaginator, a tissue mold, which retroflexes to push tissue against the device for plication and a helical screw that allows caudal manipulation of tissue between the mold and shaft.…”

“…A liquid diet without carbonation for 2 weeks followed by a soft diet for 2 weeks is recommended [13]. A water-soluble contrast study prior to discharge is recommended by some authors [15].…”