Microvasive gastric stapler: the device, technique, and preclinical results

Preclinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gastroesophageal reflux disease

BACKGROUND

Laparoscopic fundoplication provides good reflux control, but side-effects due to the surgical procedure are known. Different endoluminal techniques have been introduced, but all with disappointing results.

OBJECTIVE

Evaluation of the feasibility and safety of a new device, which enables a totally endoluminal anterior fundoplication for the treatment of gastroesophageal reflux disease (GERD).

MATERIAL

The device is a modified video gastroscope, which incorporates a surgical stapler (using standard 4.8 B-shaped surgical staples) and an ultrasonic sight. The cartridge is mounted on the shaft and the anvil is at the tip. This enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge.

METHOD

Sixteen female swine of mixed breed were used in the study; 12 underwent the endoscopic procedure, and 4 were used a controls to monitor weight gain. The 12 study animals were sacrificed at 2, 4, and 8 weeks (4 pigs each time) and visually inspected for complications, healing, and fundoplication. The study was sponsored by MediGus Ltd. and monitored for compliance with good laboratory practice (GLP) regulations by an external company (Econ Inc.), which is GLP certified by the German Federal Government. It was conducted at the animal testing facility of the Charité Virchow Clinic in Berlin.

RESULTS

The procedure went smoothly in all pigs; median procedure time was 12 min (range 9-35 min). At sacrifice, the stapled area had healed well, all animals had a satisfactory 180° anterolateral fundoplication, and there were no procedure-related complications.

CONCLUSIONS

Creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. Proof of efficacy must await clinical trials, which are underway.

Endoscopic treatment modalities for gastroesophageal reflux disease

A debate has been going for decades between surgeons and gastroenterologists about the treatment of choice for gastroesophageal reflux disease (GERD). The lower esophageal sphincter (LES) has been historically far from the reach of gastroenterologists, who adopted the symptomatic treatment as their approach to reflux disease through reduction of gastric acid. As for surgeons, reaching the LES was only possible by invading the thoracic or abdominal cavity. Although their approach was later refined to become "minimally" invasive, it was still deemed too invasive by others to allow it to be the "gold standard." Simple logic should lead one to think about the "natural route" as the easiest way to reach the LES. This concept has opened the door for the new era of GERD treatment through "endoscopic modality." Seven different techniques are currently being used to treat patients with GERD. We review the mechanism of action, potential side effects, efficacy, durability, and results from the most recent or largest experience of each. This review shows that endoscopic treatment has definitely earned its place as a viable option for GERD treatment in selected patients. With the available data from clinical trials, it is not possible to determine the best modality available, and the endoscopic treatment of choice is to be determined with further studies.