Use of an intragastric trocar to perform a novel stapling procedure for reflux disease

Abstract

Background and study aims A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure.

Materials and methods Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days.

Results The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm²/mmHg, 2.7 ± 0.7 mm²/mmHg post-procedurally, and 3.0 ± 0.8mm²/mmHg on day 14. Average change in distensibility pre- and post-procedure was –2.3 ± 1.8 mm²/mmHg (95 % confidence interval [CI] –0.5 to 5.1, P = 0.08) while change in pre- and day 14 distensibility was –2.0 ± 1.4 mm²/mmHg (95 % CI –0.1 to 4.2, P = 0.06).

Conclusions An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days.

• References

• 1 Storm AC, Aihara H, Skinner MJ. et al. Long-term successful closure of a percutaneous intragastric trocar tract with crossing full-thickness sutures in a porcine model. Endoscopy 2018; 50: 626-630
• 2 Storm AC, Aihara H, Thompson CC. Novel intragastric trocar placed by PEG technique permits endolumenal use of rigid instruments to simplify complex endoscopic procedures. Gastrointest Endosc 2016; 84: 518-522
• 3 Storm AC, Aihara H, Skinner MJ. et al. A simply placed percutaneous intragastric trocar for use of laparoscopic tools in endoscopy. Gastrointest Endosc 2016; 84: 1051-1052
• 4 Katz PO, Dunbar KB, Schnoll-Sussman FH. et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117: 27-56
• 5 Huang X, Chen S, Zhao H. et al. Efficacy of transoral incisionless fundoplication (TIF) for the treatment of GERD: a systematic review with meta-analysis. Surg Endosc 2017; 31: 1032-1044
• 6 Su B, Dunst C, Gould J. et al. Experience-based expert consensus on the intra-operative usage of the Endoflip impedance planimetry system. Surg Endosc 2021; 35: 2731-2742
• 7 Ilczyszyn A, Botha AJ. Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication. Dis Esophagus 2014; 27: 637-644
• 8 Perretta S, Dallemagne B, McMahon B. et al. Video. Improving functional esophageal surgery with a “smart” bougie: Endoflip. Surg Endosc 2011; 25: 3109
• 9 Hoppo T, McMahon BP, Witteman BPL. et al. Functional lumen imaging probe to assess geometric changes in the esophagogastric junction following endolumenal fundoplication. J Gastrointest Surg 2011; 15: 1112-1120
• 10 Rinsma NF, Smeets FG, Bruls DW. et al. Effect of transoral incisionless fundoplication on reflux mechanisms. Surg Endosc 2014; 28: 941-949
• 11 Ohashi S. Laparoscopic intraluminal (intragastric) surgery for early gastric cancer: A new concept in laparoscopic surgery. Surg Endosc 1995; 9
• 12 Tonouchi H, Mohri Y, Tanaka K. et al. Laparoscopic intragastric surgery using GelPort. J Laparoendoscop Adv Surg Tech 2006; 16: 146-148
• 13 Walsh R. Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors. J Gastrointest Surg 2003; 7: 386-392
• 14 Sahm M, Pross M, Lippert H. Intraluminal resection of gastric tumors using intragastric trocar technique. Surg Laparosc Endosc Percutan Tech 2011; 21: e169-e172
• 15 Zhang H, Chen J, Chen C. The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis. J Minim Access Surg 2021; 17: 147
• 16 Khashab MA, Vela MF, Thosani N. et al. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91: 213-227
• 17 Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R. et al. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J Gastroenterol 2014; 20: 7739-7751
• 18 Jain R, Maple JT, Anderson MA. et al. The role of endoscopy in enteral feeding. Gastrointestinal Endoscopy 2011; 74: 7-12
• 19 Park S-K, Kim JY, Koh S-J. et al. Complications of percutaneous endoscopic and radiologic gastrostomy tube insertion: a KASID (Korean Association for the Study of Intestinal Diseases) study. Surg Endosc 2019; 33: 750-756
• 20 Hirano I, Pandolfino J, Boeckxstaens G. Functional lumen imaging probe for the management of esophageal disorders: expert review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol 2017; 15: 325-334
• 21 Smeets FGM, Keszthelyi D, Bouvy ND. et al. Does measurement of esophagogastric junction distensibility by EndoFLIP predict therapy-responsiveness to endoluminal fundoplication in patients with gastroesophageal reflux disease?. J Neurogastroenterol Motil 2015; 21: 255-264
• 22 Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 2011; 15: 113-121
• 23 Shaher Z. Port closure techniques. Surg Endosc 2007; 21: 1264-1274
• 24 Vegesna AK, Braverman AS, Miller LS. et al. Comparison of human and porcine gastric clasp and sling fiber contraction by M2 and M3 muscarinic receptors. Am J Physiol Gastrointest Liver Physiol 2010; 298: G530-G534
• 25 Chung H, Kim SH, Shin SK. A potential simple endoscopic antireflux method, “the Ripple Procedure” to reduce distensibility at the esophagogastric junction in a porcine model. Surg Endosc 2020; 34: 5017-5022