Endoluminal Suturing Research Articles

Internal Tube Occlusion with An Easily Removable Non-Absorbable Double Suture: A Novel Surgical Technique Adjunct for Non-Valved Glaucoma Drainage Devices

To describe a surgical variant for non-valved glaucoma drainage device implants using an easily removable non-absorbable double suture into the lumen of the tube. A retrospective, non-comparative case series of 10 patients who underwent a non-valved glaucoma drainage device implant with an endoluminal double-suture for refractory glaucoma. The sutures were easily removed postoperatively without the need for an operating room. Intraocular pressure, number of medications, and early and late complications were evaluated with a follow-up of 12 months. None of the eyes that underwent an operation developed early or late complications. The first endoluminal suture was removed in all eyes with a mean time of removal of 30 ± 7 days. The second suture was removed in all eyes with a mean time of removal of 90 ± 7 days. No complications were noted, either, after or during suture removal. The mean preoperative IOP was 27.3 ± 4.0 and the postoperative IOP, at the end of the follow-up, was 12.7 ± 1.4. At the end of the follow-up, six patients (60%) achieved complete success and four patients (40%) achieved qualified success. In conclusion, in our case series, the surgical variant allowed for a safe and gradual regulation of the flow during postoperative management. Considering the efficacy of non-valved glaucoma drainage devices, an improvement in the safety profile allows surgeons to broaden the surgical indications.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review.

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Endoluminal Suture-technique for the Stomach Closure of an Experimental Model.

In the modern minimally invasive era, diagnostic and therapeutic endoscopic interventions are one of the most emerging fields. For the new operational techniques, it is a major aim to develop reliable instruments, such as suturing devices for flexible endoscopes. The aim of this study was to assess the feasibility of a safe and reproducible suturing technique with an endoluminal suturing device. The evaluation of the technique was performed in twenty explanted special prepared porcine stomachs. Three different techniques were compared, single stitches, figure-of-eight, or Z-pattern and running sutures in terms of suturing time and bursting pressure. After verification of the reliability of the method, a 3 cm long full thickness incision on the stomach was closed with the endoscopic suturing device in four surviving animals. In our ex vivo studies, we have shown that the figure of 8 or Z- technique is the most optimal for stomach closure without considerable time-cost, thus this technique was chosen as the standard method for the in vivo study. The endoscopic stomach wall suturing was successful in all four cases, the postoperative period was uneventful and ended on the tenth postoperative day with autopsy. With the applied suturing device, the endoscopic suturing of the stomach is safe and reproducible, thus a human application may also be justified.

Internal plication for spring confinement to lengthen intestine in a porcine model.

Short bowel syndrome and its resultant nutritional deficiencies are the most common cause of intestinal failure. Significant intestinal lengthening using intraluminal springs is feasible in porcine models using an external plication technique. We hypothesize that an internal plication technique will yield significant intestinal lengthening, which may lead to future endoscopic spring placement. Uncompressed springs measuring 7.5 cm with a diameter of 1.0 cm were compressed to 2.0 cm. A gelatin-encapsulated compressed nitinol spring was inserted into the jejunal lumen of juvenile pigs and held in place with endoluminal sutures just proximal and distal to the spring-containing segment. A control segment distal to the spring was marked. Pigs were euthanized on postoperative day 7. Spring and control segments were collected for analyses. There was an average lengthening by 72% of the spring segment compared to the control segment. Two out of 7 springs stayed within both sets of plications and doubled in length. Histology showed normal mucosal integrity of the spring segment and plicated areas with similar muscular thickness but increased crypt depth and villus length compared to the control segment. Internal plication resulted in significant bowel lengthening. Five springs had slipped through proximal, distal or both sets of plications, resulting in less lengthening than those that remained fixed. A more consistent methodology for endoluminal suturing is needed to produce more lengthening.

Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect

Abstract Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect. Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated. Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation. Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.

The Osculating Circles Gastroplasty: A Novel Endoscopic Submucosal Resection Enhanced Endoluminal Suturing for Obesity

Endoscopic bariatric therapies have emerged as minimally invasive alternatives to bariatric surgery that augment the therapeutic spectrum as primary and revisional interventions.1 Endoscopic sleeve gastroplasty (ESG) is a primary endoscopic bariatric therapy and involves transoral endoscopic reduction of the gastric reservoir.2 Transoral outlet reduction (TORe) is a minimally invasive option for management of weight regain after Roux-en-Y gastric bypass secondary to dilation of the gastrojejunal anastomosis.

Tamis sin Cierre de la Brecha Quirúrgica

Antecedentes: La cirugía mínimamente invasiva transanal (TAMIS), es una técnica que resulta especialmente útil en lesionesde recto extra peritoneal difíciles para el abordaje por vía anterior.Actualmente sigue siendo controversial el cierre del defecto rectal por debajo de la reflexión peritoneal. La suturaendoluminal es uno de los aspectos más desafiantes del procedimiento y la literatura es discordante con respecto al cierrede la brecha quirúrgica. Nuestro objetivo es realizar un estudio descriptivo de una serie consecutiva de pacientes conlesiones de recto extraperitoneal sometidos a cirugía de TAMIS, dejando el lecho quirúrgico abierto.Objetivo: Descriptivo prospectivo longitudinal.Material y Método: Entre agosto de 2013 y julio de 2019 se incluyeron, en forma consecutiva, todos los pacientes conlesiones de recto extra peritoneal, operados con técnica de TAMIS, que presentaron lesiones benignas ≥ a 3 centímetros dedifícil resolución endoscópica, tumores neuroendocrinos ≤ de 2 cm, adenocarcinomas T1N0 sin signos histológicos de malpronóstico, adenocarcinomas T2N0 con elevado riesgo quirúrgico o que rehusaron la cirugía radical y pacientes con dudasde la remisión completa luego de la neoadyuvancia. Todos los procedimientos fueron realizados por el mismo cirujano y entodos se dejó el lecho quirúrgico abierto.Resultados: En un período de 6 años se trataron 35 pacientes con técnica de TAMIS, con una edad promedio de 61 años±12.El tamaño promedio de las lesiones fue de 3.68±2.1 cm (0.7- 9 cm) y la distancia desde el margen anal al extremo distal de lalesión de 5.7±1.48 cm (3 a 8.5 cm). El tiempo operatorio fue de 39.2±20.5 min y el tiempo de internación de 33±28.2 horas.La anatomía patológica de las lesiones resecadas fue: 15 adenomas, 3 tumores carcinoides y 17 adenocarcinomas. 1 ypT0,4 carcinomas in situ, 4 tumores T1 y 8 tumores T2. En todos los casos se dejó el defecto rectal abierto, con un seguimientomínimo post operatorio de 9 meses. No hubo mortalidad y la morbilidad global fue de 14.2% (5 pacientes). Dos pacientesfueron re internados para el tratamiento del dolor (Clavien-Dindo II) y 3 pacientes (8.5%) presentaron sangrado postoperatorio, de los cuales solo 1 (2.8%) requirió re intervención (Clavien-Dindo III). No hubo complicaciones infecciosas,estenosis de recto postquirúrgicas ni perforaciones hacia la cavidad abdominal.Conclusión: Nuestros resultados permiten describir a la técnica de TAMIS dejando la brecha quirúrgica abierta, como unatécnica con buenos resultados, alta factibilidad y baja tasa de complicaciones.

A Comparison of Distal Endoluminal Graft Fixation Methods: Healing Characteristics of Metallic Stents and the Endoluminal Suture Technique

Rationale: Endoluminal grafts (EG) are a promising alternative to conventional open surgical approaches in the treatment of aneurysmal and occlusive arterial diseases. These devices generally employ metallic stents to secure the proximal and distal EG extents. However, the problem of intimal hyperplasia at the distal EG anastomotic ends similarly affect long-term outcomes as in conventional interposition grafting methods. A technique of distal EG anastomosis using handsewn endoluminal sutures is described and its effects on subsequent development of intimal hyperplasia compared with that of metallic endoluminal stents Methods: Ten adult mongrel dogs underwent bilateral common iliac artery endoluminal grafting procedures. On one side, the distal EG anastomosis was anchored with metallic stents while on the contralateral side the distal EG was secured with endoluminal sutures. The grafts were harvested after one month and the intimal characteristics were observed using histopathological methods. Results: Distal EG metallic stents and endoluminal sutures resulted in similar patency rates of 90%. The average time to deploy distal EG metallic stents was 56 seconds, while the average time to secure the distal EG anastomosis using endoluminal sutures was 3 minutes 42 seconds. Metallic stents induced the development of intimal hyperplasia to a degree greater than endoluminal sutures (316 ± 12 μm vs. 245 ± 30 μm, p< 0.05), but did not affect patency. Conclusion: Hand sewn endoluminal suture technique results in a lesser degree of intimal hyperplasia compared with that produced by endoluminal metallic stents, while the patency rates are comparable. Key words: hyperplasia, stents, suture techniques, arterial occlusive disease

French comment on article Endoscopic gastric reduction with an endoluminal suturing device: a multicenter prospective trial with 1-year follow-up

French comment on article Endoscopic gastric reduction with an endoluminal suturing device: a multicenter prospective trial with 1-year follow-up

Esophagojejunal anastomotic dehiscence successfully repaired by endoluminal suture and stent positioning: Report of a mini‐invasive approach

Watch a video of this article

Standardized development of transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEM) is currently the only one-port system in endoscopic surgery, which a direct endoluminal approach can lead to the target organ through a natural opening of human body. TEM has been applied in colorectal surgery for over 3 decades. Compared with radical surgery, TEM has the advantages, such as quicker recovery, shorter hospital stay and fewer complications. One perfect TEM surgical system, which mainly consists of three parts, namely peculiar rectoscope for surgery, special surgical instruments and imaging system, is the foundation of standardized development of TEM. Accurate preoperative evaluation and staging is the key for good outcomes in TEM technology. In addition to digital examination of rectum, rigid sigmoidoscopy(or rectoscopy) should be routinely performed to confirm the location of the lesion and record it in a "time-in-clock" form. For lesions with undetermined nature, biopsy should be performed. For patients with rectal tumor, pelvic MRI examination can be used on the basis of routine endorectal ultrasonography (ERUS). Endoluminal suture is the challenge for standardized development of TEM, especially for those with large intestinal wall defects. Professional training is required to master suture technique. In 2016, the consensus of experts on TEM technology was formulated by TEM Study Group of Colorectal Cancer Specialty Committee of Chinese Anticancer Association. The recommended surgical indications for TEM include (1)rectal adenoma; (2)early rectal cancer with good histopathological features; (3)extended resection of locally malignant polyps by colonoscopy; (4)other rectal tumors suitable for local resection; (5)benign stricture or anastomotic stricture of the rectum; (6)repair of anastomotic leakage after low anterior resection of rectum; (7)diagnosis of rectal hemorrhage; (8)biopsy of rectum and surrounding lesions; (9)repair of rectovaginal fistula or mucosal flap transposition of the internal mouth of anal fistula; (10)treatment of rectal foreign body. With the maturity of TEM technology, the indication of TEM continues to expand. Nowadays, TEM is applicable to rectal neuroendocrine tumor or gastrointestinal stromal tumor resection, as well as rectovaginal fistula repair. It can even serve as a "bottom-up" operation platform for transanal total mesorectal excision (taTME). This article introduces the standardization of TEM, its current indications, novel implications, and future perspectives, expecting that TEM will be further popularized and healthily developed in China.

Experimental Evaluation of the Optimal Suture Pattern With a Flexible Endoscopic Suturing System.

The ability to perform reliable, secure endoluminal closure of the gastrointestinal tract wall, is a prerequisite to support the progress of the emerging field of endoluminal surgery. Along with advanced clipping systems, flexible endoscopic suturing devices are commercially available. Current systems can replicate traditional surgical suturing patterns in the endoluminal environment. The aim of this study was to evaluate the optimal endoluminal suturing technique using a flexible endoscopic suturing device. Procedures were performed on bench-top simulators containing 20 explanted porcine stomachs. A standardized 3-cm full-thickness incision was created on the anterior wall of each stomach using monopolar cautery. The gastrotomy was closed endoscopically using an over-the-scope suturing device (OverStitch, Apollo Endosurgery; Austin, TX). Three different techniques were used: single stitches, figure-of-8 pattern, and running suture. Material consumption and operation time were recorded and bursting pressure measurement of the closure was performed. No statistically significant differences were identified in suturing time. Suturing time (minutes) was slightly shorter with the figure-of-8 technique (41.14 ± 4.6) versus interrupted (45.75 ± 1.1) versus continuous (51.44 ± 10.0), but the difference was not statistically significant. The number of sutures required was greater in the interrupted group. No significant difference was found in the burst pressure (mm Hg): figure-of-8 (45.85 ± 26.2) versus interrupted (30.5 ± 22.89) versus continuous (32.0 ± 26.5). In the figure-of-8 group, 85.5% of cases were leakproof above 30 mm Hg, while in the other groups only 50% of cases were so. A figure-of-8 suturing pattern seems to be the preferable suturing technique with the endoscopic suturing device.

Migration of endoluminal gastroesophageal stents: A case series

Introduction: Microperforation of the stomach following bariatric surgical procedures is often treated with endoluminal stent placement. Endoluminal stents migrate out of the desired position in a high frequency of cases. case series: this paper reports a series of five cases in which endoluminal stents migrated antegrade into unfavorable positions. One of the cases resulted in the stent migrating into the jejunum where it resulted in a jejunal perforation requiring surgery and bowel resection. After endoscopic repositioning of the stents, endoluminal suture fixation resulted in stabilization of the stents, prevented further migration, and facilitated clinical resolution of gastric fistula. No complications of the endoluminal suture fixation to the esophageal wall occurred, and all patients recovered fully. conclusion: this paper presents five cases of migrated gastroesophageal stents that were successfully secured with endoluminal sutures without complications. Endoluminal suturing may be a technically straightforward and useful solution to the migration of gastroesophageal stents.

Six month outcomes in patients experiencing weight gain after gastric bypass who underwent gastrojejunal revision using an endoluminal suturing device.

Weight gain after Roux-en-Y gastric bypass occurs in approximately 25 % of cases, and this may contribute to recurrence of comorbid conditions. Currently, adequate treatment strategies for this group of patients are limited. Endoscopic narrowing of the gastrojejunal anastomosis may result in a low-risk, minimally invasive treatment alternative compared to standard surgical revision. We assessed short-term outcomes in patients undergoing endoscopic gastrojejunal revisions (EGJR) using an endoluminal suturing device. We performed an institutional review board-approved retrospective analysis of 25 consecutive patients who underwent EGJR. Patients preoperatively presented with a dilated gastrojejunal anastomosis of greater than 15 mm and weight gain. An endoluminal suturing device (Overstitch(TM), Apollo Endosurgery, Austin TX) was used to reduce the diameter of the anastomosis. Follow-up occurred at 2 and 6 weeks, 3 and 6 months, and 1 year Prior to EGJR, patients regained an average of 23.4 ± 13.2 kg from their weight loss nadir and had a mean body mass index of 42.2 ± 6.6 kg/m(2). At 6 weeks, 100 % of patients experienced weight loss (average 5.8 ± 4.4 kg; p < .001). At 3 months, 94 % had weight loss (average 7.0 ± 6.2 kg; p < .001). At 6 months, 91 % maintained weight loss (average 5.6 ± 6.2 kg; p = 0.013). Lastly, at 1 year following EGJR, 100 % of available cases maintained weight loss (average 7.5 ± 6.4 kg; p = 0.057). The average percent excess weight loss was 12.5, 15.4, 12.4, and 17.1 % at 6 weeks, 3 and 6 months, and 1 year, respectively. There was a negative time effect in the mixed effect model using both on-treatment and intent-to-treat analyses, illustrating a significant weight reduction over time. The average follow-up per patient was 146 days. There were no complications reported during the follow-up period. Six month follow-up for EGJR patients demonstrated a low-risk, minimally invasive treatment option to reverse weight gain subsequent to a failed gastric bypass. Procedures presented no complications and may provide an attractive alternative to standard surgical revision.

Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia

Per-oral endoscopic myotomy (POEM) requires advanced flexible endoscopic skills, especially in the management of complications. We present a full-thickness esophagotomy while performing POEM and repair using an endoscopic suturing device. An anterior esophageal 2cm mucosectomy is created 7-10cm proximal to the gastroesophageal junction after a submucosal wheal is raised. A submucosal tunnel is created and extended to 2cm on the gastric cardia. A selective circular myotomy is performed. The mucosectomy is closed using endoscopic clips. An inadvertent full-thickness esophagotomy was created while performing the mucosotomy on an inadequate submucosal wheal. We were able to resume the POEM technique at the initial esophagotomy site. There was a discussion to convert to laparoscopy. However, as we succeeded in creating the tunnel, we continued with the POEM technique. After the selective myotomy was completed, we used an endoluminal suturing device (Overstitch, Apollo Endosurgery, Austin TX) to close the full-thickness esophagotomy in two layers (muscular, mucosal). A covered stent was not an option because the esophagus was dilated, which precluded adequate apposition. The patient had an uneventful postoperative course. At 9-month follow-up, had excellent palliation of dysphagia without reflux. This case demonstrates the importance of identifying extramucosal intrathoracic anatomy, thus emphasizing the need for an experienced surgeon to perform these procedures, or at a minimum to be highly involved. Raising an adequate wheal is crucial before mucosectomy. Inadequacy of the wheal may reflect local esophageal fibrosis. If this fails at multiple locations in the esophagus, it may be prudent to convert to laparoscopy. This case also demonstrates the need for advanced flexible endoscopic therapeutic tools and a multidisciplinary approach to manage potential complications.

Sp854 Early Clinical Experience with a New Endoluminal Suturing Device Used in Multiple Clinical Applications

Tissue apposition is a major part in advanced endoscopy or natural orifice translumenal endoscopic surgery (NOTES). The necessity of secure endolumenal suturing has been outlined several times. We describe our early clinical experience with a new endoscopic suturing device used in multiple clinical applications. The first case described, was a 66-year-old female with a chronic bleeding gastric ulcer. Endoscopic oversew of the fundal ulcer was attempted. The second case described was a 66-year-old female with previous Gastric Bypass Operation and recurrent gastro-gastric fistula.

Transoral gastric volume reduction for weight management: technique and feasibility in 18 patients

Background Endoluminal suturing to reduce the gastric volume might provide an additional option for the treatment of obesity. Potential advantages of a nonoperative endoluminal intervention include less pain, the ability to perform it as an outpatient procedure, and a high level of patient acceptance. The purpose of the present pilot study was to demonstrate the feasibility and procedural safety of transoral gastric volume reduction (TRIM procedure) using the Restore Suturing System in patients with a body mass index of 30–45 kg/m 2. Successful completion of the procedure and adverse events were evaluated at academic/university hospitals. Methods This was a nonrandomized feasibility study performed at 2 institutions. After institutional review board approval, the patients underwent the TRIM endoluminal gastric plication procedure with the Restore Suturing System (Restore device). Gastric plications were completed to approximate the anterior and posterior gastric walls to achieve restriction of the upper stomach. The number and location of successful plications were recorded, and patients were monitored for complications. The present report described the short-term procedural results (≤24 hours after the procedure) of the studied cohort. Results A total of 18 patients were enrolled in the present study. The TRIM procedure was successfully completed in all patients, with placement of 4–8 plications (average 6 per patient). The average procedure time was 125 ± 23 minutes, and no serious or significant procedure-related complications occurred. After the procedure, common patient complaints were nausea, vomiting, and abdominal discomfort. The first 10 patients enrolled were kept overnight according to the study protocol, and the remaining 8 patients were discharged on the day of the procedure. Conclusion Endoluminal suturing using the TRIM procedure and the Restore device was technically feasible, and no serious or significant procedure-related complications were reported. Weight loss, co-morbidity improvement, and durability are under assessment.

Endoskopische transmurale Gastroplicatio in der Refluxtherapie: Eine wirksame Therapie?

Heartburn, the most common symptom associated with GERD, occurs in 10-20 % of the US and western European population. Life long PPI therapy for GERD is often required since symptoms typically recur once therapy has been discontinued. Recently a couple of endoscopic antireflux procedures have been developed. These techniques include injection or implantation of biopolymers and application of radiofrequency. Most of the techniques have been abandoned due to lack of long-term efficacy or serious side effects. Since first generation endoluminal suturing techniques showed insufficient durability, due to suture loss, the transmural plication technique Plicator™ was developed. In a prospective-randomized, sham-controlled trial the Plicator proved superiority concerning reflux symptoms, medication use and esophageal acid exposure. Further technical improvements like the use of 2 sutures are currently investigated.

Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos)

It is unclear whether large gaping perforations of the colon can be closed by the endoluminal route. To evaluate the feasibility and the outcome of closure of large perforations of colon with clips and sutures by using through-the-endoscope novel devices. Prospective animal study. University hospital. Ten pigs. Closure of a 4-cm full-thickness colon perforation freshly created by an insulated-tip knife with the InScope Multi-Clip Applier (n = 6) and with the tissue approximation device (n = 4). (a) Technical feasibility of closure, (b) clinical monitoring for 2 weeks, (c) necropsy (day 14), (d) healing by a dye-leak test and histology. Endoluminal closure of a 4-cm-long colon perforation was successful in 9 of 10 animals. The clips failed to close a gaping wide colon perforation in 1 animal. The sutures were successful in the closure of both nongaping and gaping perforations. Successful closure resulted in a leakproof sealing at 2 weeks and prevented clinical peritonitis in all the animals in the clip-closure group and in 3 of 4 animals in the suture-closure group. Necropsy at 2 weeks revealed mild peritonitis in 2 of the 5 animals in the clip closure group and in 2 of the 4 animals in the suture-closure group; none developed fecal peritonitis. None. Endoluminal closure of a 4-cm colon perforation with clips was successful in the majority of cases. Sutures were useful in the closure of gaping colon perforations that could not be closed with clips.

GERD: Interventionelle Therapie

A couple of minimally-invasive, endoscopic antireflux procedures have been developed during the last years. Beside endoscopic suturing these included injection/implantation technique of biopolymers and application of radiofrequency. Radiofrequency (Stretta) has proved only a very modest effect, while implantation techniques have been abandoned due to lack of long-term efficacy (Gatekeeper) or serious side effects (Enteryx). While first generation endoluminal suturing techniques (EndoCinch, ESD) demonstrated a proof of principle their lack of durability, due to suture loss, led to the development of a potentially durable transmural plication technique (Plicator). In a prospective-randomized, sham-controlled trial the Plicator procedure proved superiority concerning reflux symptoms, medication use and esophageal acid exposure (24-h-pH-metry). While long-term data have to be awaited to draw final conclusions, technical improvements will drive innovation in this field.