title: Endoscopic clipping of the Z-line (CMZL) helps recognize anatomical failures after Nissen fundoplication: technical report of a new method.
abstract: BACKGROUND
  Nearly 15% of patients after laparoscopic antireflux surgery experience recurrence of symptoms or develop new gastrointestinal symptoms. Some of them require redo procedures. It can be demanding to reveal anatomical failure after previous fundoplication.
  
  
  OBJECTIVE
  To present a method which assists in recognition of anatomical failures after Nissen fundoplication.
  
  
  METHODS
  Five patients with previous laparoscopic Nissen fundoplication and severe gastrointestinal symptoms were included in this study. During the esophagogastroduodenoscopy (EGDS) two radiopaque metal clips were placed to mark the Z-line ("clips-marked Z-line" - CMZL). It was done to achieve precise visualization of the gastroesophageal junction area in the video contrast investigation. Distinctions between conclusions after the EGDS, ordinary video contrast investigation, video contrast investigation with CMZL and intraoperative findings were analyzed.
  
  
  RESULTS
  All patients underwent laparoscopic refundoplication with good postoperative results. There were 4 cases misdiagnosed by contrast investigation without clips and four cases misdiagnosed by EGDS. Endoscopic clipping helped to recognize correctly all anatomical failures.
  
  
  CONCLUSIONS
  Applying CMZL as a routine investigation before redo fundoplication can reduce frequency of misdiagnosis and help to perform redo fundoplication in appropriate patients, but it requires further studies on larger cohorts of patients.
authors.affiliation: The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway ; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
authors.forename: Leonid
authors.initials: L
authors.lastname: Barkhatov
authors.affiliation: The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway ; Surgical Department, Finnmark Hospital, Kirkenes, Norway.
authors.forename: Airazat M
authors.initials: AM
authors.lastname: Kazaryan
authors.affiliation: Radiology Department, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
authors.forename: Steinar
authors.initials: S
authors.lastname: Aasen
authors.affiliation: The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway ; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway ; Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
authors.forename: Bjørn
authors.initials: B
authors.lastname: Edwin
keywords: endoscopic clipping; failed fundoplication; laparoscopic fundoplication; redo surgery; slipped Nissen