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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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Endoscopic view (left) indicating anterior corner and the location of the diaphragm (lines) where it follows the superolateral course of the fundus. Schematic drawing of laparoscopic view (right) depicting the position of diaphragmatic hiatus in relationship to the fundus, crura, and the gastroesophageal junction. Caution is needed not to incorporate the diaphragm in plication (arrow)
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Fig8: Endoscopic view (left) indicating anterior corner and the location of the diaphragm (lines) where it follows the superolateral course of the fundus. Schematic drawing of laparoscopic view (right) depicting the position of diaphragmatic hiatus in relationship to the fundus, crura, and the gastroesophageal junction. Caution is needed not to incorporate the diaphragm in plication (arrow)

Mentions: The relationship of the stomach to aorta, vena cava, spleen, heart, liver, and diaphragm is important to understand (Fig. 6). The tissue mold can cause trauma to the spleen during retroflexion and opening. Incorrect advancement of the stylet out of alignment with the tissue mold could potentially injure the liver, diaphragm, heart, or great vessels. The diaphragm ventral to the esophageal hiatus runs in a relatively transverse direction (Fig. 7). Along the left edge of the esophageal hiatus, however, the diaphragm courses superolaterally paralleling the fundus (Fig. 8). Failure to recognize this transition can lead to closure of the tissue mold so that it incorporates the diaphragm lateral to the crus, with subsequent stylet and fastener deployment through the diaphragm.Fig. 6


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

Bell RC, Cadière GB - Surg Endosc (2010)

Endoscopic view (left) indicating anterior corner and the location of the diaphragm (lines) where it follows the superolateral course of the fundus. Schematic drawing of laparoscopic view (right) depicting the position of diaphragmatic hiatus in relationship to the fundus, crura, and the gastroesophageal junction. Caution is needed not to incorporate the diaphragm in plication (arrow)
© Copyright Policy
Related In: Results  -  Collection

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

Fig8: Endoscopic view (left) indicating anterior corner and the location of the diaphragm (lines) where it follows the superolateral course of the fundus. Schematic drawing of laparoscopic view (right) depicting the position of diaphragmatic hiatus in relationship to the fundus, crura, and the gastroesophageal junction. Caution is needed not to incorporate the diaphragm in plication (arrow)
Mentions: The relationship of the stomach to aorta, vena cava, spleen, heart, liver, and diaphragm is important to understand (Fig. 6). The tissue mold can cause trauma to the spleen during retroflexion and opening. Incorrect advancement of the stylet out of alignment with the tissue mold could potentially injure the liver, diaphragm, heart, or great vessels. The diaphragm ventral to the esophageal hiatus runs in a relatively transverse direction (Fig. 7). Along the left edge of the esophageal hiatus, however, the diaphragm courses superolaterally paralleling the fundus (Fig. 8). Failure to recognize this transition can lead to closure of the tissue mold so that it incorporates the diaphragm lateral to the crus, with subsequent stylet and fastener deployment through the diaphragm.Fig. 6

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