Feasibility and effectiveness of laparoscopic transgastric stapler-assisted circumferential esophageal mucosectomy and simultaneous fundoplication in a pig model

Abstract

Laparoscopic transgastric stapler-assisted mucosectomy (SAM) has been described for minimally invasive circumferential en bloc resection of Barrett's esophagus (BE). Conceivably long-term disease control might be achieved by adding antireflux surgery after resection of BE by SAM. The aim of this study was to assess the feasibility of combined SAM and fundoplication in one laparoscopic procedure in six pigs. Furthermore, the competence of the gastroesophageal junction (GEJ) was assessed at baseline, after SAM, and after subsequent laparoscopic fundoplication. At each measuring point reflux measurements were repeated 6 times in each pig. Blue-colored water was infused into the stomach to provoke reflux. Intragastric yield pressure and volume were recorded until drainage of blue solution (DBS) was noted. Time to reflux was measured by DBS and by multichannel intraluminal impedance (MII). In all animals SAM followed by laparoscopic fundoplication was feasible in a single session. A weakening of the GEJ was found after SAM, indicated by decreased yield pressure (11.5 mmHg vs. 8.5 mmHg; P < 0.001), time to DBS (90 seconds vs. 60 seconds; P = 0.008) and MII (80 seconds vs. 33 seconds; P < 0.001). After additional Nissen fundoplication the GEJ competence was restored, with measurements returning to baseline values (time to DBS 99 seconds; P = 0.15; MII 76 seconds; P = 0.84). The yield pressure increased from 11.5 mmHg at baseline to 19.7 mmHg after SAM and fundoplication (P < 0.001). Laparoscopic fundoplication and SAM may be combined in a single laparoscopic session. Although the GEJ was weakened after SAM, Nissen fundoplication restored the GEJ as an effective reflux barrier in this experiment. For clinical validation, the results need to be confirmed in a prospective human trial.

Figure 1

a: Principle of transgastric stapler-assisted mucosectomy: By help of three transabdominal-transgastric trocars two mucosal pursestring sutures are placed in the distal esophagus orally and aborally of the Barrett Epithelium. The anvil of the circular stapler is inserted and the purse-string sutures are tightened around the spine of the anvil. By firing the stapler a circumferential mucosectomy specimen is obtained. Staples approximate the mucosal borders and no mucosal defect is left open. b: After mobilization, the fundus is positioned in a loose manner around the esophagus. The 360°-Nissen-fundoplication is secured with three sutures.

Figure 2

Setting for intraoperative measurement of the competence of the gastroesophageal junction. A) Clamp to close the duodenum, B) Gastrostomy for suction of blue-colored water between the measurement, C) Tube and instrument for intragastric pressure measurement, D) Tube for infusion of blue-colored water by means of a roll-pump.

Figure 3

Combined impedance probe and gastric tube that was positioned in the esophagus.

Figure 4

Sample for detection of provoked reflux by multichannel intraluminal impedance (MII) measurement at baseline. A) Start of infusion of blue-colored water into stomach, B) time to detection of reflux by MII, C) line connecting the time points when decrease in impedance at different impedance segments occurs.

Figure 5

Mean time and 95% confidence interval for first detection of reflux by drainage of blue solution (DBS) and multichannel intraluminal impedance (MII) at baseline, after stapler assisted mucosectomy (SAM), and after SAM and fundoplication. After fundoplication in 19 measurements the reflux barrier was insurmountable and no reflux could be provoked. The respective values for the measurements after SAM and fundoplication are those of the remaining 17 measurements when reflux could still be provoked.

Figure 6

Mean time and 95% confidence interval for yield volume at baseline, after stapler assisted mucosectomy (SAM), and after SAM and fundoplication. After fundoplication in 19 measurements the reflux barrier was insurmountable and no reflux could be provoked. The respective values for the measurements after SAM and fundoplication are those of the remaining 17 measurements when reflux could still be provoked.

Figure 7

Mean time and 95% confidence interval for yield pressure at baseline, after stapler assisted mucosectomy (SAM), and after SAM and fundoplication. After fundoplication in 19 measurements the reflux barrier was insurmountable and no reflux could be provoked. The respective values for the measurements after SAM and fundoplication are those of the remaining 17 measurements when reflux could still be provoked.