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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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Bothcatheter-basedandwirelesssystemsallowforthequantificationofsix variablesincludingtotal/upright/supinetimethatthepHislessthan4, numberofrefluxepisodes,numberofepisodeslongerthan5minutes,and longestepisode.Thesevariablescanbecombinedtocalculatethe “DeMeesterscore,”whichisusedbymanysurgeonsasdefinitiveevidence forthepresenceofGERD.

■ Bariumesophagram

■ Thisisadynamicfluoroscopicstudythatcharacterizesbothanatomicand functionalaspectsoftheesophagus.Itinvolvesmultipleswallowsof bariumandbarium-coatedsolidfood.

■ Thetwomostimportantthingstocharacterizewithabariumesophagramare thepositionoftheGEjunctionrelativetothediaphragmatichiatusand overallesophagealmotility.Thepresenceofalargehiatalhernia(FIG2) orsignificantesophagealdysmotilityisacontraindicationforanyofthe threeprocedures.

■ Esophagramscanalsoidentifythepresenceofrefluxthatischaracterizedby thespontaneousrefluxofbariumbackintotheesophagus.However,they arelesssensitivethanpHstudiesandthusanegativefindingheredoesnot

ruleoutGERD.

■ Videorecordingofthisstudyiscrucialbecauseitallowsthesurgeonto activelyassessesophagealperistalsisandthefunctionalsignificanceof hiatalhernias.

■ Manometry

■ Esophagealmanometryusespressuretransducerswithinatransnasalcatheter toprovidedataregardingtheLESrestingpressure,LESabdominaland totallength,andadequacyofLESrelaxation.Italsocharacterizes esophagealmotilitybyquantifyingtheamplitude,duration,and propagationofeachcontraction.

■ Thepresenceofsignificantesophagealdysmotilityisacontraindicationforall threeprocedures.

■ Multichannelimpedancetestingandgastricemptyingstudiesarealsousedon occasiontoidentifynonacidicGERDandassessgastricfunctionality, respectively.

TECHNIQUES

TRANSORALINCISIONLESSFUNDOPLICATION

■ ApprovedbytheU.S.FoodandDrugAdministration(FDA)in2007,theonly TIFdevicethatiscurrentlyavailableforuseintheUnitedStatesisthe EsophyXdevice(EndoGastricSolutions,Redmond,WA).

■ EsophyXre-createstheLESbyplicatingthedistalesophagusandthegastric cardiatogether,thuscreatinganantirefluxvalvesimilartothatofa laparoscopicNissenfundoplication.

■ Thedeviceconsistsofahandle,an18-mmdiametershaft,atissueinvaginator composedofholesinthesideofthedevice(whichareconnectedtoasuction device),anarticulatingarm,whichapproximatesgastricandesophageal tissueanddeploysthetissuefasteners,ahelicalscrew,twostylets,and20 polypropyleneH-fasteners(10plicationsets)(FIG3).

PreoperativePlanning

■ Atourinstitution,generalanesthesiaisadministeredandtheprocedureis performedintheoperatingroom.

■ Nasotrachealintubationisperformedsotheoropharynxcanbeusedentirelyfor theEsophyXdevice.Abiteblockisplacedtoprotecttheteethfromthe deviceandscope.

■ Twophysiciansperformtheprocedure.Onemanipulatestheendoscopewhile theothercontrolsthedevice.

Positioning

■

Afterintubation,thepatientisplacedintotheleftlateraldecubituspositionwith theheadelevatedslightly(FIG4).

■ Prophylacticantibioticsareadministeredbeforetheprocedurebeginsbecause transluminalfastenersareplaced,whichmayincreasetheriskof postoperativeinfections.

PlacementoftheTransoralIncisionlessFundoplicationDeviceintothe Stomach

■ Preprocedureendoscopyisperformedtoverifyanatomiclandmarks.

■ A56-Frbougieisinsertedintotheesophagusandthenremovedtofacilitate subsequentpassageoftheEsophyXdevice(FIG5).

■ TheEsophyXdeviceislubricatedandastandardendoscopeisthreadedthrough thedevice(FIG6).Bothareplacedthroughabiteblockandadvanced throughtheesophagusintothestomach.

■ Thescopeisadvancedintothegastriclumenandthenretroflexedtoexaminethe GEjunction.Usingastandard,high-flowinsufflator,thestomachis insufflatedwithcarbondioxidetoapressureof15mmHgviatheworking channeloftheendoscope.Oncethearticulatingarmisvisualizedwithinthe stomach,thescopeiswithdrawnintothedevice,thearticulatingarmis flexed,andthescopeisthenadvancedbackintotheretroflexedposition withinthegastriclumen(FIG7).

■ Usingtheretroflexedview,theGEjunctionisenvisionedasaclockfacewith the12o’clockpositionlocatedatthelessercurvature,the6o’clockposition atthegreatercurvature,andthe9o’clockpositionlocatedalongtheposterior gastricwall(FIG8).

AnteriorRotationalPlicationFasteners

■ Theclosedarticulatingarmisplacedatthe12o’clockposition(FIG9A).The helixretractorportionofthedeviceisalsoatthe12o’clockpositionand

advancedintothesquamocolumnarjunction(FIG9B).Theentiredeviceis thenadvanceddistallyacoupleofcentimetersandrotatedclockwiseonthe screen.Thisallowsthearticulatingarmtobeopenedandthehelicalretractor disengagedfromthearticulatingarm.

■ Thearticulatingarmisthenrotatedbacktothe6o’clockposition,partially closed,andpulledback1to2cm(FIG9C).TheGEjunctionisadvanced caudallybyapplyingtensiontothehelicalretractor.

■ Thestomachisthendesufflatedandthearticulatingarmisrotatedtowardthe1 o’clockposition.Thismaneuverrotatesthefundusanteriorlyaroundthe esophagustherebyinitiatingthefundoplication.Externally,thehandleofthe

deviceisrotatedapproximately180degrees(FIG10).Thishasbeen describedintheliteratureasthe“BellRollmaneuver.”

■ Thehelicalretractorandarticulatingarmaresecuredinplaceandthesuctionis applied.

■ ThefirstH-fastenersetisthendeployed.

■ ThestomachisthenreinsufflatedtovisualizedeploymentofapairofH fasteners.TwosetsofadditionalHfastenersaresubsequentlyplacedat varyingdistancesfromtheGEjunction.

■ Thiswillresultintheplacementofsixfasteners1to3cmabovethe squamocolumnarjunction.

PosteriorRotationalPlicationFasteners

■ Thehelixretractorportionofthedeviceismaintainedatthe12o’clockposition.

■ Thearticulatingarmisrotatedcounterclockwisethroughthelessercurvetothe8 o’clockposition,partiallyclosed,andpulledback1to2cm.TheGEjunction isadvancedcaudallybyapplyingtensiontothehelicalretractor.

■

The“BellRoll”maneuverisagainperformed,butthistimeintheclockwise direction(clockwiseonthescreen).Thestomachisdesufflatedandthe articulatingarmisrotatedclockwisetothe11o’clockposition.This maneuverrotatesthefundusposteriorlyaroundtheesophagus(FIG11).

■ Thefirstsetofposteriorrotationalplicationfastenersisthendeployed.

■ TheprocessisthenrepeatedtoplacetwoadditionalsetsofHfastenersat varyingdistancesfromtheGEjunction.

AnteriorCornerLongitudinalPlication

■ Toaddressagapintheanteriorcomponentoftheplicationthatisoften appreciatedonlyaftertheanteriorandposteriorsetshavebeenplaced,an anteriorcornerplicationsetisoftenplaced.

■ Thearticulatingarmisrotatedcounterclockwisethroughthelessercurvetoward the1o’clockposition.

■ Tensionisappliedtothehelicalretractorcaudallyandtheapproximatingarmis pulledproximallywhiledesufflatingthestomach.

■ TwoadditionalsetsofH-fastenersaredeployedaroundthe1o’clockposition.

GreaterCurveDeepPlication

■ Thepurposeofthismaneuveristofixatethegreatercurvatureslightlymore proximallyontheesophagus.Thislengthenstheantirefluxvalve.

■ Thehelixretractorisdisengagedfromthe12o’clockpositionandre-engagedat thesquamocolumnarjunctionatthe6o’clockposition.

■ Thereticulatingarmismovedintothe5o’clockpositionandoneortwosetsof fastenersare2to4cmproximaltothesquamocolumnarjunction(FIG12).

■ Thenewlyconstructedantirefluxvalveshouldbe200to300degreesin circumference.

InspectionoftheNewlyCreatedAntirefluxValve

■ Thedeviceandendoscopearewithdrawntogetherandthenendoscopeis removedfromtheEsophyXdevice.

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