Laparoscopic Nissen Fundoplication after Transoral Incisionless Fundoplication (TIF)

Oscar M Crespin, M, D, Brant K Oelschlager, M, D, Carlos A Pellegrini, M, D. University of Washington Medical Center.

 Introduction:

Transoral incisionless fundoplication deploys polypropylene fasteners to coapt gastric fundus to lower esophagus, radially, creating a partial esophagogastric fundoplication.

The Long-term outcomes of TIF are unknown, which makes patient decision and counseling difficult.The difficulty and safety of performing a Nissen fundoplication after TIF is paramount in this decision. Case reports have shown good outcomes of Nissen after TIF, although varying degrees of difficulty have been described.

The aim of this video presentation is to show two cases of laparoscopic Nissen fundoplication after TIF failures.

The easy case is a 75 years old patient with previous TIF and recurrence of symptoms 3 months after the procedure and an abnormal Bravo pH study.

The more difficult case is a 64 years old patient with previous TIF and recurrence of symptoms 3 months after the procedure with an abnormal Bravo pH study.

Conclusions:

Preoperative workup to select patients for TIF may underestimate the size of hiatal hernias.

Difficulties in the dissection of the GEJ after TIF are variable from minimal to very difficult.

We have found difficult dissections when: More fasteners are placed and when the fasteners are attached to the crura and prei-esophageal tissue.

In our experience, a TIF does not seem to negatively affect the outcome of subsequent Nissen fundoplication

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