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

Bell RC, Cadière GB - Surg Endosc (2010)

Bottom Line: Gastroesophageal 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.A key element of the technique involves rotating the fundus around the esophagus with a tissue mold during gastric desufflation.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.

View Article: PubMed Central - PubMed

Affiliation: Swedish Medical Center & SurgOne, P.C, 400 W Hampden Place, Suite 230, Englewood, CO 80110, USA. rbell@surgone.com

ABSTRACT

Background: Gastroesophageal 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.

Methods: The 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.

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Related in: MedlinePlus

The liver compresses the gastroesophageal junction less with the patient in supine than in the left lateral decubitus position
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Fig3: The liver compresses the gastroesophageal junction less with the patient in supine than in the left lateral decubitus position

Mentions: It is feasible to perform the procedure on a gurney rather than an operating room table. The patient is placed mostly supine to lessen pressure on the GE junction from the liver (Fig. 3). The procedure is performed under general endotracheal anesthesia with an emphasis on complete diaphragm relaxation. This often is difficult to communicate to the anesthetist who is looking for twitches on a skin-applied monitor; our experience indicates that the diaphragm requires more muscle relaxant than other muscles. During the procedure, difficult insufflation of the stomach or the presence of hiccups is indicative of incomplete relaxation. Oral tracheal intubation avoids potential epistaxis, which can obscure the operative field; however, nasotracheal intubation may be useful in patients with a small hypopharynx, such as pediatric patients.Fig. 3


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

Bell RC, Cadière GB - Surg Endosc (2010)

The liver compresses the gastroesophageal junction less with the patient in supine than in the left lateral decubitus position
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3116120&req=5

Fig3: The liver compresses the gastroesophageal junction less with the patient in supine than in the left lateral decubitus position
Mentions: It is feasible to perform the procedure on a gurney rather than an operating room table. The patient is placed mostly supine to lessen pressure on the GE junction from the liver (Fig. 3). The procedure is performed under general endotracheal anesthesia with an emphasis on complete diaphragm relaxation. This often is difficult to communicate to the anesthetist who is looking for twitches on a skin-applied monitor; our experience indicates that the diaphragm requires more muscle relaxant than other muscles. During the procedure, difficult insufflation of the stomach or the presence of hiccups is indicative of incomplete relaxation. Oral tracheal intubation avoids potential epistaxis, which can obscure the operative field; however, nasotracheal intubation may be useful in patients with a small hypopharynx, such as pediatric patients.Fig. 3

Bottom Line: Gastroesophageal 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.A key element of the technique involves rotating the fundus around the esophagus with a tissue mold during gastric desufflation.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.

View Article: PubMed Central - PubMed

Affiliation: Swedish Medical Center & SurgOne, P.C, 400 W Hampden Place, Suite 230, Englewood, CO 80110, USA. rbell@surgone.com

ABSTRACT

Background: Gastroesophageal 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.

Methods: The 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.

Show MeSH
Related in: MedlinePlus