Anti-Reflux Procedures Old and New

Physiologic Pressures

• Body systems are LOW pressure systems:
1. Mean Arterial Pressure < 100 mmHg <
2.3 m deep pool = 300 cm H2O = 230 mmHg
• Plots scaled to appear large

Anti Reflux Procedures Old and New 1




LES Pressures

Anti Reflux Procedures Old and New 2



Pressures are low in health and disease
Low pressures prevent reflux in spite of gastric contractions

Gastric Peristaltic Wave
Fundus flattens, body contracts

Fundus flattens body contracts





Angle of His flattens and disappears in either health or disease.


• Torus around distal esophagus
• Pressure in the wrap compresses the distal esophagus
• Equal pressures = no pressure gradient, no back flow






After Anterior Fundoplication
• Stomach contracts Intra-gastric pressure↑
• Fundus compress esophagus
• Intra gastric = intra-esophageal pressure
• EQUAL pressure = No backflow

Iafter Anterior Fundoplication







Partial Vs. 360 Fundoplication

Equal Clinical Efficacy by RCTs and Meta-analyses

Anterior FP
• Fundus anterior
• Forceful body contraction OPENS GEJ
• Patients Can Burp
• No dysphagia
• Inconsistent pH
Nissen FP
• Fundus all around
• Forceful body Contraction CLOSES GEJ
• Difficult to Burp
• Dysphagia
• Consistent pH

Is Post-procedure pH a Good Measure of Success?
• pH = - log [H+]
• Measure of concentration – not quantity
• at pH 2 [H+] = 100 times > at pH 4
• By Comparison
• Lemonade pH ~ 2; Orange juice ~2.5; Coca-Cola ~3
• Lemonade does not produce esophagitis

• Multiple short episodes?
• Low quantities of gastric juice?

Questions about Fundoplication
• Success Rate
• Excellent in traditionally high volume centers
• Poor by inexperienced hands
• Durability
• Patients maintain lifestyle
• Many return to PPI at 10 years
• Preoperative - symptomatic on high dose
• Post operative asymptomatic on lower dose
• Complications
• Low Rate of Referrals

Progress to Less Invasive Operations

Progress to Less Invasive Operations





Progress to Less Invasive GERD Rx

• Old Methods - New Access
Progress to Less Invasive GERD Rx





Some Trans-oral Options

• Stretta™ - Scarring of the distal esophagus
• Esophyx® - Produces a nipple valve (anatomically similar to Belsey Mark IV)
• MUSE™ - Anterior Fundoplication

MUSE™ Endoscopic Fundoplication
• Trans-Oral stapled anterior fundoplication
• Stapling controlled by ultrasonic sight
• FDA cleared and CE marked
• Single operator

MUSE endoscopic fundoplication






MUSE vs. AF (Dor–Thal)





Well executed MUSE   Anterior Fundoplication

MUSE vs LAP – Endoscopic View

 MUSE vs LAP Endoscopic View







• Inside View
• Sides Switched
• Left is Right
• Anterior is Posterior
• Difficult Orientation


Incorrect Staple Placement

• Staples the lesser curve to the esophagus
• Difficult to asses intuitively
• Gastric Body Contraction – Pull right side of Esophagus =
1. Open GEJ = Recurrence
2. May cause acute tear or leak

Staple Placement Aid

Identify Lesser Curve – Direction of Rugae; Pulsation of left gastric artery

Staple placement aid






Correct Staple Placement

Correct staple placement







• MUSE = New way to old procedure
• Correctly placed quintuplets = effective reflux barrier
• Correlation of endoscopic view and outside view unintuitive
 Learning curve shorter for surgeons than gastroenterologists