Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model.
BACKGROUND
Endoluminal operations for gastroesophageal reflux currently are limited by the inability to visualize and manipulate structures outside the wall of the gut. This may be possible by using EUS. The aims of this study were the following: to define the EUS anatomy of structures outside the gut that influence reflux, to place stitches in the median arcuate ligament, to perform posterior gastropexy, and to test the feasibility of crural repair under EUS control in pigs.


METHODS
In survival experiments in 22 pigs, by using a linear-array echoendoscope, the median arcuate ligament and part of the right crus were identified and punctured with a needle, which served as a carrier for a tag and thread. These were anchored into the muscle. An endoscopic sewing device was used, allowing stitches to be placed through a 2.8-mm accessory channel to any predetermined depth. New methods allowed knot tying and thread cutting through the 2.8-mm channel of the echoendoscope.


RESULTS
Stitches were placed through the gastric wall into the median arcuate ligament, and one stitch was placed just beyond the wall of the lower esophageal sphincter. The stitches were tied together and locked against the gastric wall. Median lower esophageal sphincter pressure, determined manometrically, was 11 mm Hg before surgery and 21 mm Hg after stitch placement (p=0.0002). The length of the lower esophageal sphincter increased from a median of 2.8 cm before the procedure to 3.5 cm after the procedure. At the postmortem, the median force required to pull the tags out of the median arcuate ligament was 2.8 kg.


CONCLUSIONS
This study demonstrates that transgastric gastroesophageal reflux surgery, by using stitching under EUS control, can significantly increase lower esophageal sphincter pressure in pigs.
Fritscher-Ravens
Annette
A
Academic Department of Gastroenterology, The Royal London Hospital-Whitechapel, London, United Kingdom.
Mosse
C Alexander
CA
Mukherjee
Dipankar
D
Yazaki
Etsuro
E
Park
Per-Ola
PO
Mills
Tim
T
Swain
Paul
P
D000818:Animals; D004195:Disease Models, Animal; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D019160:Endosonography; D005764:Gastroesophageal Reflux / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006551:Hernia, Hiatal / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D008365:Manometry; D013536:Suture Techniques; D013552:Swine