Laparoscopic redo fundoplication after Enteryx® injection

This video presents a Toupet fundoplication procedure performed for a patient who had recurrent gastro-esophageal reflux 3 years after endoscopic injection of the inert polymer ‘Enteryx’ into the gastro-esophageal junction (GEJ). The polymer can be seen around the GEJ, leading to extensive inflammatory adhesions in the hiatal region.

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Laparoscopic redo fundoplication after Enteryx® injection

Authors

D Mutter, B Dallemagne, C Bailey, J Marescaux

Abstract

This video presents a Toupet fundoplication procedure performed for a patient who had recurrent gastro-esophageal reflux 3 years after endoscopic injection of the inert polymer ‘Enteryx’ into the gastro-esophageal junction (GEJ). The polymer can be seen around the GEJ, leading to extensive inflammatory adhesions in the hiatal region.

Keywords

toupet, fundoplication, enteryx, gastro-esophageal, hiatal

Media type

Surgical video

Duration

08'00''

Publication

2007-02

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E-publication

WeBSurg.com, Feb 2007;7(02).
URL: http://www.websurg.com/doi-vd01en1904.htm

Laparoscopic redo fundoplication after Enteryx® injection

1. Patient positioning 00'08''

We present the case of a 35-year-old who had placed a polymer injection of Enteryx® for reflux esophagitis. After this, there was a mild improvement. However, reflux symptoms soon recurred, and a gastroscopy confirmed the existence of esophagitis stage 1. He had marked symptoms and therefore it was decided to perform a fundoplication laparoscopically. The patient was placed in a French position with the surgeon between the legs.

2. Dissection of right crus of diaphragm 00'40''

Dissection commences with opening of the lesser omentum. Following this, we isolate to look for the crus of the diaphragm. We can see that there is significant inflammation around this area. We manage to liberate the right crus. However, the large amount of inflammation makes it very difficult to identify the normal plane of dissection that we usually comfortably come across at this stage. We can see in the foreground the accessory branch of the artery to the liver. This is preserved throughout the procedure. We continue the dissection with monopolar diathermy. We rapidly identify the crus of the diaphragm. We continue the dissection in inflamed tissue, which must be performed gently and carefully. Around the hiatus, there is severe inflammation due to the polymer injection that has gone in before. Little by little, the esophagus is liberated. We are able to move behind in order to mobilize it as we would in a standard fundoplication. However, due to the large amount of inflammatory tissue, bleeding occurs, which also distorts the field of vision and makes the dissection quite difficult.

3. Dissection of left crus of diaphragm 02'21''

The dissection continues slowly and gently using diathermy and blunt dissection. The next step is to pass a tape round behind the esophagus. Once this has been performed, this enables retraction to be placed at the level of the cardia and the esophagus.

4. Dissection of diaphragmatic hiatus 02'45''

The dissection continues into the hiatus. We can see the crus on the left and the right beautifully demonstrated. The inflammatory filmy adhesions are divided using monopolar diathermy and the hook. We can see the Enteryx® polymer ring coming into view now. It is hard, it’s firm and it distorts the surrounding tissues as well as indenting into the esophagus itself. Now move round behind the esophagus, the Enteryx® ring makes it difficult. As you can see, there are inflammatory adhesions to this polymer. It was designed to relive the symptoms of gastroesophageal reflux disease. We see here the technique of ideal injection. It is placed right into the sphincter itself. However, in this case, what we believe happened was, that the injection was placed perhaps erroneously resulting in extravasation of polymer outside of the esophagus. Therefore, not only did this not cure the patient’s symptoms but also led to significant inflammatory adhesions around the esophagus, which makes the redo procedure that much more difficult. We continue to clear off the adhesions and also to carefully define the esophagus and surrounding tissue so that we can perform the wrap. We see the posterior vagus nerve here. We find the bipolar diathermy is very useful to help dissection and also of course to ensure that there is vascular control at all times. The polymer ring is shown here, and the problem we then had and then encountered was where to position the wrap.

5. Fundoplication 05'05''

Were we to do this in a position that was above where the Enteryx® had been injected, over the ring itself, or then we perhaps considered doing below the ring? However, this would then push the cardia into the chest. So in the end, it was decided that we would do it over the ring. This would ensure that the cardia was maintained intra-abdominally. We can see from the needle going through that the Enteryx® is hard, the polymer is set very hard there. We take a small bite of that, and then continue, and in this case, we decided to perform a Toupet. This is to ensure that there was not excessive constriction at this level, which might result in dysphagia. We felt that the 270 degree Toupet would be both efficient and effective in preventing reflux and also possibly in this situation, which is complicated by the polymer injection to prevent the problem of dysphagia postoperatively.

6. Approximation of diaphragmatic crura 06'25''

The next stage is to re-approximate the left and right crus. The sutures are lowered using a knot pushing device. This means that we can throw the knot outside of the patient and then lower with this knot pushing device. This is a very effective system in order to maintain tension. The wrap is now secured to the hiatus. This is once again done with extracorporeal sutures, which are then pushed down using the knot pushing device. We see here where the Enteryx® is. The polymer is just right below the hiatus and will be highlighted as we see now. The patient made an excellent recovery postoperatively and went home on day 2. We performed contrast studies 6 months postoperatively. They showed that there was not a stenosis, nor reflux and the radio-opaque polymer can be seen just adjacent to the lower esophagus.