Endoluminal fundoplication – the Hill procedure

Abstract

Endoluminal operations for reflux are currently limited by the inability to visualise and manipulate structures outside the wall of the gut. This may be possible using endoscopic ultrasound (EUS). The aim of this study was to define EUS‐anatomy of structures outside the gut which influence reflux; to place stitches in the median arcuate ligament (MAL); to perform posterior gastropexy (Hill procedure) and test the feasibility of crural repair under EUS control in pigs. In survival experiments in 14 pigs, using linear array echo‐endoscopes the MAL 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 echo‐endoscope. Stitches were placed through the gastric wall into the MAL and one just beyond the wall of the lower esophageal sphincter (LES). They were tied together and locked against the gastric wall. Preoperative manometry showed a median LES pressure of 11mm/Hg and 21 mm/Hg after stitch placement (p = 0.0028). The length of the LES increased from median 2.8 cm pre‐procedure to 3.5 cm post‐procedure. At post mortem, the force to pull the tags out of the MAL was 2.8 kg median. This study shows that transgastric gastro‐esophageal reflux surgery using stitching under EUS control can significantly increase the lower oesophageal sphincter pressure in pigs.

• Reflux
• suturing
• endoscopy
• ultrasound
• hernia