Prof. J. ZEHETNER (Switzerland) Anti-reflux surgery Reflux Stop

Good morning, I'm Luigi Bonavina from Milano, Italy. Professor Dugo is also here with me

and we are going to assist and to look at a very interesting entire reflux procedure. This is an

innovative procedure for controlling reflux using a special prosthesis. I don't want to anticipate

we are waiting so that the connection is established. We're already in the OR and

the setup is done. So I see that they can get the connection ready. Can you see the

intraoperated picture? Yes. Yes. Yes. Here. So you see here, I'm, we were waiting already. So

male patient with a long history of reflux, typical symptoms, heartburn, regurgitation,

and we did a full functional workup. We can talk about that a little bit later. So I'm starting off

opening up the barsflexida. This is a similar approach that I do in every reflux case. Sometimes

Sometimes I put a clip, but I use those ceiling devices and I start the preparation.

I use a normal troker position.

My troker position is the camera slightly above the umbilicus.

And now I start here on the right cruise.

I have the camera slightly above the umbilicus, maybe like five to six centimeter above.

And then I have my left and my right hand that you see working.

working and I have my assistant holding the camera and also putting traction on the stomach.

Now we need, we use the Nathanson liver retractor that helps us to elevate the liver.

And now I'm here behind the esophagus. This is the left cruise here, trying to create a tunnel

as far as I see and then I start opening up the anterior adhesions here. So it's a mix of gently

sweeping versus using the energy devices and for the reflux stop procedure I use a bipolar device.

This is the N-seal device, and I use it because I have to take down the short gastrics in those operations, like you will see later on, and I just don't trust that much the ultra-cision devices for the short gastrics, and therefore, for those cases, I prefer the bipolar sealing devices.

devices like you see now the patient had a not too big hiatal hernia but still we need to dissect

for this procedure far up but as I will take down the short gastrics I start now

looking at the spot where the short gastrics go down and up and I start in the between the upper

and the second third of the stomach or you could say another landmark would be in the middle of the

spleen i think it's not that important where you start here but you want to mobilize the fundus

and that's easier done when you start lower down where you can make a nice

uh window so i have a very good assistant with me today um she's a surgeon herself and uh

And I'm just, we're just checking the anatomy.

So here's the pylorus and drum fundus.

So she's a very good assistant.

So without telling her what she has to do,

she's helping me with her right hand to open up that area

so I can dissect the short gastrics.

And in her left hand, she's holding the camera.

We use a 10 millimeter, 30 degree optic.

Can you hear me, everything?

thing yes perfect so the reflex top procedure is according to the ifu currently um limited to

hiatal hernias up to three centimeters um i think uh in the near future we can

think uh extend that indication hopefully to larger hiatal hernias like we do for other

reflux procedure I think right away I use it in my patients in a study protocol already in hernias

up to seven centimeters and I'm hopefully being able to publish these results next year so here

my assistant grabs now the lower fundus because that opens the window to get really here a safe

dissection of the fundus of the upper part of the spleen sometimes you wish you have an extra hand to

move the fat out of the way but i think it's better that my assistant holds as you see the

stomach here and let me go back here and find a better position to hold it yeah i think now we

i see you prefer not to encircle the esophagus since the beginning of the procedure

Yeah. You do that routinely in anti-reflex surgery? You like to do this kind of dissection first?

Yes. In the Nissan and 2-pair cases, I do it in the same way because I think once you open up,

anyway, you have to open up that plane. So I think I have a safe access here to the left cruise.

And once I've dissected that part, then we will now, I think I'll finish up the dissection here, and then we'll think about putting easy flow drainage for retraction.

Okay.

Sorry, in order to compare your technique to your ordinary or to the standard Nissen fundipalcation, do you think that this kind of dissection, I'm not talking about the mediastine of dissection, I'm talking about the fundic dissection,

is the same extension you perform for any kind of nissan or yes not more than that

uh no the so uh to be honest the funding dissection here is exactly the same that's a

lymph node here and uh i i want the way i learned nissan and tupe fund application was always

to have a very tension-free rep and while there are surgeons who are doing let's say a tupe fund

application without mobilization of the funders um i think you end up with some twisting or kinking

sometimes not always so let me put the drainage now and let's give me the easy flow okay here we

go okay so i always um use this easy flow drainage rather than a pen roast uh i think it's a little

bit uh stiffer and easy to handle and i always put a clip so you see now what we want to achieve now

is the dissection in the hiatus now we have maybe one or one and a half centimeter of intra-abdominal

length and uh big spleen and so you you see the posterior mediastinum here the aorta

these are some landmarks that we'll have to to look at later again when we do then the esophagogastric

placation and here i really have to dissect up into the mediastinum because for this technique

what we need is really like four to four and a half centimeter of intra-abdominal length

uh without without too much traction so i have my assistant pulling so i can see uh really where

the fibers are that i have to separate and i think it's safer if you have a good tension

some surgeons do the first part without tension and only the last one and a half centimeter with

tension i think if you have a good assistant and he's with you for a while they they pretty know

how to to handle the tissue okay so we see the anterior and posterior vagal nerve we dissected

here the hiatus with the left and the right cruise. I'm just taking away here a little bit

of tissue so I have a better access to suture. I think the crew have good tissue and I think

we can start with the suturing part. I'm checking now on the length of the esophagus. I think I've

enough so i'm getting in the sutures so this is a gore suture that's used the uh that i'm using

that since i spent the time in the u.s as you know i was in los angeles at usc and there i started to

use this suture it's a gore suture from the gore company and that it's a foamed ptfe suture and

And what is nice about the suture, it's several conditions.

One is the suture is foam, so there can be some tissue ingrowth later.

Second is, as you see, it's somehow flexible, but not that flexible like a proline.

And it's stiff, but not as stiff as the proline.

And it's not as soft as an ethibone.

so there is some memory effect and that makes it very easy as you see to throw your sutures

and i like it it's used in cardiac surgery actually to suturing aortic valves and that's

where where we saw it and learned it and and we use for sure a bigger suture than the use

in cardiac surgery so i do figure of eight stitches at the crura um there are some indications i

I do a reinforcement with bladgets, not in those cases.

I think the indication of a mesh is a different topic.

I think for this case here, we'll close up the cura first.

And so usually do two stitches

and here you see the peritoneum back there.

I dissected it a little bit off, unfortunately,

but I want to get deep bites here

to approximate the crura what I don't want to do is to make the suture too tight

because I want to not compress the tissue and cause ischemia let's let me make this a zero

gore suture it's a two oh gore suture but as it's foamed it looks thicker yes it's interesting to

to see your suturing technique,

because it reminds me of so many years ago

when I visit USC at the time,

Tom DeMuth has moved there from Omaha, Nebraska to LA.

And he was, you know, a priest of hiatus surgery.

So this was exactly the same thing.

Nowadays, we are trying to move towards

slowly reabsorbable meshes in this part of the operation

in some specific cases especially the ones that associate a uterine with the reflux what do you

think about absorbable meshes in that position phasics or something like that exactly so yes

my time at USC we you know at USC I have some bleeding here that I want to take care of

for a second um okay i put the the surgery cell that's something i use quite a lot

because it it helps for you know negative surface to stop the bleeding without doing too much

burning around that area but if it's not stopping i might have to use a bipolar here

burn too much going back to your question so i have experience with the bio a and i've experienced

with the phasix mesh and uh since um since since by the beginning of my training i never used

actually permanent meshes because wherever i was uh switzerland or austria or in the u.s i was in

an institution where they had bad experience with permanent meshes uh you know erosions or

migrations and that's why i got scared and i also had here in switzerland in the last seven years i

had to operate on two patients uh where we had those problems um so before i continue about the

mesh let me just show you quickly uh this is about the esophageal length that i want and i closed the

height as i think close enough and um i'm working now a little bit to remove this fat bed here on

the angle of his so i used the bio a but now i'm using the phasix and i'm not using the phasix

routinely and mostly the reason i'm not using it routinely is first of all costs and so i i i use

it in all recurrent hyaluronias and in primary cases only if it's really a defect where i think

the closure alone is is not strong enough and i have good experience with the phasix

uh the and i like it i think you should avoid to put it too close to the esophagus as well

because it stays 10 to 18 months and in my experience i had one case where i had a severe

dysphagia due to the phasic smash because it stays quite stiff for a long time so i place it

not too close i'm just checking if i got that fat pad out stucked in the trocar okay so i think

putting meshes on the hiatus is uh it's there is an indication but i don't see indication anymore

for permanent meshes i rather uh do a redo case than having a permanent mesh uh in the esophagus

or the stomach so now i'm preparing you see my assistant is twisting a little bit the esophagus

and we see basically or we can see that there is the posterior vagal nerve and now i'm preparing

basically the edge of the fundus because we want to do two layers of sutures to fix the fundus

to suture the fundus to the esophagus that's basically one of the three basic principles

of this procedure the first one is the hyaluronic closure like we know from a lot of studies and

And, you know, previous experience that we need for a reflux control or for a 90 to 100% success rate in reflux control, we need to close the crura.

And there's still a lot of things we could talk about closing the crura and the recurrence because that's still the Achilles heel, which I see in reflux surgery.

surgery. So I took away this fat bed. And now we see because I really want the suture

line to be clean. And now I want to see if that lines up better. And then let's get the

sutures ready. So for this suture line here, I use a V-lock suture. I want to understand

a little bit better now the fundus here because I really want to have then the tip of the

the fundus on top so we talked about the first principle the hiatus now we're working on the

second principle that's closing up that angle of his and creating this uh basically flap valve

so i use now here non-resorbable sutures the v-lock i'm doing here a running sutures because i

like to save time in surgery when it's safe and i think this is a permanent suture and the

the barbed suture will create some fibrosis and that's something uh that we want that we

want here a stable connection between the let me take a deeper bite okay and so the esophagus is

slightly twisted as you see so this is the anterior side and we're nearly on the posterior

your side so i'm first stitch okay this is posterior wall of the fundus and uh lateral

left lateral edge of the esophagus correct exactly okay and you and you keep going with

posterior wall that that's good in order to have an a kind of uh um any circumferences like

like application for maybe 45 degrees around the esophagus or what?

Yeah, I would say, so one second.

Okay.

So there are like three to four stitches.

You see the fat pad here is annoying me already.

I should have taken that off before to see it better.

So until now, we didn't put tension on the esophagus,

but now we'll put a little bit tension to get maybe one more stitch.

so at the end at the end this placation at the end this placation will end up like

if you have a 30 the if the esophagus is 360 degrees this will cover a quarter of it so i

would say at least 80 to 110 degrees yeah yeah and uh so i locked the last suture i went back we

we cut it off yeah cleaning the camera so now we have a nice picture it's important so let's get

the second suture ready so the second suture line i want to place now next to the anterior vagal

nerve uh so like two centimeter anterior of that one and i think it's important that there is no

tension between these two sutures because um so maybe here and then we go more

anterior now so what is important if you use a running suture here is that you don't pull it

too tight because if you pull it too tight it will shorten the whole uh it will shorten the whole

the whole esophagus or the placation and that could cause then an area with this motility

so you see i tried to grab not too close on the stomach equal bites esophagus stomach

so for the sutures i think this part you could do single sutures um i don't like that suture

too much on the hiatus yet i know some colleagues are using this at the hiatus i'm a little bit

worried that a permanent barbed suture could cause when the hiatus failed like a sharp edge

edge but I don't have any you know data on that it's expert opinion I would say let me make one

more stitch up there so now we're pulling a little bit more on the esophagus then going back a little

bit to lock that stitch I don't think you need a clip or anything and basically I'm cutting off

this suture another question sometimes come up do you do the hiatal closure with or without the

bougie um i learned it with the bougie i then went doing it without the bougie and i'm pretty

comfortable using no bougie so um you see here that's the posterior suture line you see it

professor bonavina you're here so this is the posterior suture line yeah and um that's very good

and here you see the anterior so we are covering up about uh 90 beginners here should be

careful to avoid the posterior vagus nerve doing the twisting of the esophagus yes you agree with

that yeah so now i'm doing one more stitch in the middle between the two suture rows

it's kind of a extra stitch to make sure that that there is a good closure of the gastric

placation uh on the top and that there is no an open lip yeah in the original technique it was

suggested to do three stitches on top i'm doing only the middle one i think that's enough

but so you you might see the somewhere else different they did do three stitches on top

i do just the middle one and i use a rest of one of the gore sutures i used before

so basically that was the last stitch on top the single suture stabilizing let's check again

hiatus is closed i'm happy with the closure i think if you put tension on there is a bigger

bigger hole but if you release the tension now I don't want to make it too narrow and now we're

looking on where is the right spot where is the edge of the fundus because now we want to get

to the third principle of the reflux stop procedure and that is actually putting in the

reflux stop device into a fundic pocket and the fundic pocket has to end up on top of the lowest

of a geosphincter that's basically the third principle that we want to stabilize and i'm using

here just the sponge to to get a feeling where this could end up and now i'm getting another

core suture non-resorbable to start making a kind of a pearl string suture or tobacco suture

in english i think it's pearl string suture that we want to create like a little

roof for the positioning it's very helpful to do this future before you introduce the device

because it gives you some stability because the way we introduce the device later through the

port um we lose one assistant hand to hold the reflux top in place and that therefore it's good

if that roof is already positioned you see this creates like a little pocket already and i leave

the needle behind. We use this suture later to close the reflux stop from top to bottom.

So we already assembled before the case the reflux stop device. The reflux stop is a

silicone ball, you can say, consisting out of five little pieces. It's about two centimeter

in diameter. The weight is nine gram and it's assembled on the back table with a

vascular suture around it and the the principle or the basic idea behind it is that if there is

uh if there would be in any rare case an erosion into the stomach that the vascular suture

is dissolved and those five pieces fall apart and there would not be a bowel obstruction

so that's assembled on the back table and then loaded onto a trocar it's a 22 millimeter trocar

and with a deployment tool we will bring in the device and the deployment tool is something that

we just put for the device placement then we will remove the deployment tool once

one or so the troco for the troco for the insertion is is basically part of the deployment

tool okay and um so we're getting everything ready so we are back here this is the troco

that we were talking about you see okay uh it's a 22 millimeter troco and the reason i don't put

it right from the beginning is that i think if you put it just for the procedure and as it's a

dilation you see now i put in the deployment tool this is the reflux top and now i want to

this you see the the five pieces there's one center piece and then four pieces around with

the vial suture and now i'm the i'm pushing it now into the right position before i hand over

the instrument to my assistant so now she's pushing it into the pocket you see the roof helps

stops to avoid that it slips out sometimes when we want to show it it slips still out but

today i think we have a good spot so i want to close that lower edge here and make sure then

that the reflux stop ends up above the lower esophageal sphincter i've done now you know

more than 60 cases. And in all cases, I could do the reflux top procedure except one. And that was

a patient, she had a very big hiatal hernia, unexpectedly bigger than in the preoperative

workup. And after all the mobilization I did, I had still a short esophagus with only two or

three centimeter length. And at that point, I thought it doesn't make sense to put the reflux

stop uh somewhere on the fundus just to do the procedure so in that case i switched my

strategy and did actually a collis tupe fund application uh because that was the only way

i i thought i'd recently able to to get enough esophageal length and then i didn't do the

reflex top so this is the closure of i again do kind of some purse string sutures with the

non-resorbable v-lock take that out and as you see the deployment tool is in my way here

i will have to go back with the top suture to close up that little hole that stays open there

i always need a clean camera i'm sorry but that's uh people who saw me operating they know i don't

like to operate with the dirty camera because we need a good picture here to be really able to do

the right thing so you see the top suture the lower suture and we need a nice picture here

let's get rid of all that so the trocker is part of the deployment tool as well as this metal rod

what you see and now i do the second stitch to to cover up the lower part so the pocket should

should be snug but not too snug as you can imagine if you would suture something too tight

it could cause then you know ischemia so that's why I take here the suture a little bit wider

to be sure that I do a fundic to fundic closure here but not putting too much tension on the

tissue here some surgeons also use single stitches but I think it's important to use a

non-absorbable suture from glycation and so on, we know that absorbable suture here could be a

possible reason the tissue gets detached again. And that's the other reason why I like a running

suture, because as you will see in a second, I run one suture up and one suture down. So with

two suture rows over the implant, it's very unlikely that I would see that the implant ends

up somewhere in the abdominal cavity so this is the top stitch which i want to invaginate a little

bit to make it look nicer let me do another stitch now downsize to lock it and my assistant is still

holding the deployment tool in place but let me cut off the suture and then we can actually get

rid of the deployment tool because cleaning the camera so as i said some people do here four or

or five interrupted stitches i like the running stitch so i take the needle out and um now the

device uh sorry the implant is not visible anymore so we run now the second suture down

and let's take the deployment tool out first you see you just push basically on the back the inside

rod and that releases the implant uh we take it out and i take it out right away with the

troker and put in a five millimeter troker back with and I use some towel clamps to avoid

losing too much air here so I'm putting now two towels clamp outside to avoid that we lose too

much air but I think as I have only a short time with the big troker I don't see that the patients

have actually more pain there and I can have my assistant putting again traction now on the

esophagus so i'm just reinforcing the first suturo i did and you see it's advisable to remove

all the fat when you do the taking down of the short gastric and the way my imagination of the

device ends up is actually pretty close to the previous short gastric so that's why i think

and in my opinion it's uh mandatory to to really do a takedown of the short gastrics

i should have removed this little fat piece but it's okay i can suture around it and so i'm

following my previous suture line but down here yeah i'll show you that there's still a little

hole where we could actually see the device let me show you because the first suture down there

didn't close that well so that's where i want to really make sure that we suture down correctly

and we're pretty much at the end of the procedure stitch back to lock it i'm not doing any additional

sutures so i'm not fixing the wrap or the partial glycation to the crew or or or to the die to the

the diaphragm. I think what's key here is that you have basically a procedure that stabilizes

the distal esophagus and the LES in the abdominal cavity. And so you see where the implant ends up,

it's above the LES. And I think we have a nice result here. And that's where the implant should

should end up it should be end up at the las or a centimeter above and that's why you need those

four and a half centimeter mobilization and as you see now there's no tension on the easy flow

and it's it's not that you have the feeling that the reflux top device is riding on the diaphragm

so let me cut away the easy flow so we check it last time the posterior suture line

interior suture line the reflux top is in place and uh i'm i'm pretty happy with the with the

result and uh yeah thank you so much for joining us and uh i'll let my assistant close and scrub

out and be available for some more questions okay good thank you i think this was a very very

very precise and elegant procedure and I guess that now as soon as professor Zahetner is back

we can ask him about the learning curve of the of the procedure at the same time I invite the

audience if you have any questions just to submit raise your hands I think we'll have

have probably five or ten minutes left hello hello how are you great procedure great thank you

precise and elegant i was telling the audience about the the what do you think you did you have

done 60 of those procedures yes which which is the learning curve what what how many how many

procedure this is not so easily reproducible it takes ability skills special skills and you have

to mobilize this this esophagus very well down in the abdomen and then you have to put the

the reflex stop just above the sphincter as you said yeah yeah so i i think first of all

this is for sure a procedure where you need to have experience with nissen and tupe fund application

and you should have i would say you know ideally upper gi is your field of interest or you do at

least 25 procedures a year you know i do about between 120 and 150 reflex cases a year but i

think 25 a year would be the absolute minimum because you need some experience to do the

mediastinal dissection do they correctly you have to have experience with hiatal closure

and then you should have experience with what I think intracorporeal suturing it helps a lot

and I like to make those procedures today to like 45 minutes and it can take sometimes an hour or

one and a half hour it's not about time but I think if you struggle with intracorporeal suturing

suturing or running suturing, then you have to practice that. One way would be, and I heard

colleagues who were thinking about, you know, robotic surgery and those advantages. In my hands,

I like a lot laparoscopic suturing, and therefore I feel pretty comfortable. The learning curve is

interestingly, I think even in experienced hands, it takes, you know, five to 10 cases to understand

then the the assembling of the implant and doing the surgery uh but after that i think

while it seems at the beginning a little bit more complicated sutures i like the procedure i like to

do it and uh it's not something that i'm saying no it's a lot of suturing no i i actually enjoy

uh the assembling of it uh uh the the putting the procedure together because i i see a lot of

happy patients and the big advantage of this procedure is really that they they have still

a natural function at the end so they have less bloating they have less flatulence they have the

ability to belch there's nothing around the esophagus it's less dysphagia and in in my

population we had some dysphagia that we had to dilate but in those three patients they were all

patients with really poor esophageal motility and preoperative dysphagia and was kind of expected

and even they got a good results after two balloon dilations. Would you exclude some

patients based on preoperative motility? I mean at the beginning you know when when I started

two and a half years ago I wanted to really start in a safe way so I said okay I want to do it in

patients who were really poor as of agility motility. And I don't want to do any rep or

partial rep. And that's why in my selection, my first 20 patients were all with poor as of agility

motility. And despite such a selection, I had actually good results. And so now as the procedure

gets more popular, I have a lot of patients coming to me asking for this procedure. So while for a

a lot of surgeons this procedure seems tricky or difficult or or or why do you use the implant and

how for most of the patients it seems quite reasonable uh if you explain them that the les

if it's in the hiatus or on top will get insufficient by the pressure changes but when

it stays in the abdomen you have that the body pressure or abdominal cavity pressure that

that actually augments the sphincter in that area.

Excellent.

I think our time has expired.

I don't see any questions, so everything was clear.

Thank you, Jörg.

Was a pleasure to see you again.

Thank you.

Bye. Okay.

Thank you so much, and thanks everyone for watching.