Application of Transoral Incisionless Fundoplication

Introduction

The function of the digestive system is to digest food and to change it into simple absorbable forms. The stomach is one of the key organs of the digestive tract. This J-shaped organ acts as a storage site for food and helps to break down complex food into simple forms. Gastric juice plays a pivotal role in this process. As gastric juice is highly acidic, it should be confined to the stomach only. Backflow of the acidic contents into the esophagus may irritate.

What Is GERD?

GERD, or gastroesophageal reflux disease, is a chronic condition of the gastrointestinal system due to the retrograde flow of the stomach's contents to the esophagus. The pH of the gastric juice is between 1.5 to 3.5. This severe acidic juice causes increased acid exposure to the esophagus and esophageal lumen. As a result, erosion of the esophageal lining causes severe discomfort. Around 18 to 27 percent of the adult population in the United States is suffering from this condition.

Pathophysiology

The main components of gastric juice are hydrochloric acid and different enzymes like pepsin and lipase. The presence of hydrochloric acid is responsible for the acidic nature of the gastric juice. Several protective mechanisms of the stomach help prevent injury of the gastric tissues due to the acidic contents.

Anti-reflex barrier, a complex anatomical zone, presents the retrograde movement of the acidic contents into the esophagus. This anatomical zone consists of the lower esophageal sphincter, the extrinsic crural diaphragm, and the gastroesophageal flap valves.

Disorder of the lower esophageal sphincter is responsible for this condition. Usually, the lower esophageal sphincter maintains a high-pressure zone. A decreased pressure of the lower esophageal sphincter and lower relaxation of the lower esophageal sphincter is associated with dysfunctioning of the lower esophageal sphincter. Chronic decrease in the lower esophageal resting tone is also another reason responsible for gastroesophageal reflux disorder.

The factors associated with such causes are:

• Medications like calcium channel blockers and nitrates.

• High-fat diet, smoking, chronic alcoholism, and chocolate.

• Hiatal hernia is another factor associated with this disorder. Hiatal hernia causes separation of the crural diaphragm from the lower esophageal sprinter. This causes increased exposure of gastric acid to the esophagus.

• Decreased gastric emptying is another factor responsible for gastroesophageal reflux disorder. Increased retention of acid causes distension and retrograde movement of the acid into the esophagus.

• Increased esophageal sensitivity is another contributory factor in the development of GERD. Thermal, mechanical, and chemical stimuli increase the sensitivity and cause acid movement into the esophagus.

Symptoms

The symptoms of gastroesophageal reflux disorder are:

1. Heartburn is the most common symptom of GERD. Patients often complain of chest pain and a burning sensation in the chest radiating toward the throat. Pain is squeezing in nature, most commonly felt in the mid portion of the chest and abdomen. Pain may also radiate toward the back, neck, and jaw.

2. Sourness in the back of the mouth, which is most commonly noticed during the morning.

3. Erosion of the lingual surface of the teeth and burning sensation in the tongue.

4. Increased incidence of throat clearance and hoarseness can be seen.

5. Fullness and the presence of a lump in the throat can be felt by the patients.

What Are the Treatment Options?

The treatment option for GERD include:

1. Lifestyle modification is the key treatment modality. Patients are advised to avoid spicy food, alcohol, and smoking.

2. Proton pump inhibitors are the most common drug used for this purpose. Drugs like Lansoprazole, Omeprazole, Esomeprazole, and Pantoprazole help to reduce the secretion of acids. Other than this, H2 blockers like Cimetidine and Ranitidine can also be prescribed.

3. Surgical options like Nissen fundoplication (surgical treatment for tightening the junction between the esophagus and stomach) and treatment of hiatal hernia can be done.

What Is Transoral Incisionless Fundoplication Procedure?

Transoral incisionless fundoplication is done through two different technologies. These are EsophyX technology and MUSE technology. The procedure is as follows:

Pre-Operative Procedure:

Before the surgical procedure, pre-operative endoscopic evaluation is done. The distance from the incisor to the gastroesophageal junction is determined. Also, the dimension of the diaphragmatic hiatus is determined. If a hiatal hernia is present, determining the size of the hernia is necessary. It should be remembered that defects of more than three centimeters in size can not be treated in this procedure. Patients suffering from primary motility disorders should be avoided.

• Procedure:

  • The EsophyX technology is designed to rebuild the valve from inside the stomach, using a transoral approach to create a partial fundoplication that measures 270 degrees in circumference and three centimeters in length. An endoscope is inserted into the center channel of the EsophyX device and provides direct visualization for this procedure. While under general anesthesia, the device and endoscope are gently glided through the patient's mouth and into the stomach. The stomach is inflated, and the endoscope is advanced and retroflexed so that it looks up at the gastroesophageal junction. The valve reconstruction starts with the engagement of the helical retractor at the gastroesophageal junction. Then the tissue is retracted into the tissue mold. As the EsophyX device is rotated, wrapping the fundus toward the lesser curvature of the stomach. A small hiatal hernia can be reduced, and the intra-abdominal length of the esophagus can be restored using suction built into the device. The trigger handle deploys a pair of non-absorbable polypropylene fasteners above the gastroesophageal junction to oppose the fundus to the esophagus. This retract wrap opposed process is repeated in specific locations to ultimately create an omega-shaped valve. Approximately 20 serosa fuse fasteners are placed during the procedure to recreate physiological anatomy and help prevent it from entering the esophagus. Studies show that in the weeks following, serosal fusion occurs by creating a layer of fibrous and fibrous-elastic tissue that secures full-thickness glycation.

  • In the second method, an ultrasound-based machine, also known as a medigus ultrasonic surgical endostapler (MUSE), is used. The patient is positioned in the supine position in this technique under general anesthesia with endotracheal intubation. The abdomen is inflated with carbon monoxide, and the stapler is passed 5 centimeters past the gastroesophageal junctions. The appropriate location of the stippling is selected through endoscopy. Under ultrasonic guidance, stippling should be done, and the location of the stippling should be 60 to 180 degrees of the valve circumference.

• Post-Operative Care: Post-operative care with the application of antibiotics and antiemetics should be continued. Esophageal pain and transient pharyngeal irritation may persist for 48 hours. A liquid diet should be continued for two weeks, and a soft diet must be given to the patients for four weeks. Proton pump inhibitors must be discontinued for seven days, and heavy exercises must be avoided for one month.

What Are the Complications?

The surgical complications involving these procedures are rare. These are:

1. Esophageal bleeding.

2. Sore throat.

3. The momentary collapse of the lungs.

4. Chest pain.

Conclusion

Gastroesophageal reflux disorder is a very common chronic disorder. Backflow of the gastric contents destroys the esophageal epithelium. Surgical treatment can be used for the creation of a sprinter-like structure in the gastroesophageal junction. Endoscopic techniques can be very useful in such cases to reduce surgical complications. Through this process, a valve-shaped structure is created that prevents the backflow of gastric juice.