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Transoral incisionless endoscopic fundoplication guided by impedance planimetry to treat severe GERD symptoms after per-oral endoscopic myotomy

      A 61-year-old man with a history of type II achalasia and an Eckardt score of 6 underwent per-oral endoscopic myotomy (POEM). He presented 4 months after the procedure with GERD (score of 36 on GERD questionnaire) and an Eckardt score of 0. Upper endoscopy revealed LA grade C esophagitis, and a ph-Impedance study demonstrated a DeMeester score of 123.8. Transoral incisionless endoscopic fundoplication was then performed (Video 1). Preprocedure impedance planimetry was performed to obtain baseline measurements. A transoral staples device was advanced into the stomach through an overtube. Retroflexion facilitated the identification of the stapling location, and the endosonographic view guided the placement of the first set of staples (Fig. 1A-1C). Impedance planimetry was performed between staple placement to assess the esophageal distensibility and to ensure an adequate fundoplication. Four sets of staples were fired (Fig. 1D) to modify the esophageal distensibility from 5.1 to 3.2 mm2/mm Hg at 30 mL balloon insufflation, and from 7.5 to 4.9 mm2/mm Hg at 40 mL balloon insufflation. At 4 months’ follow-up, the patient showed significant improvement of his symptoms with a score of 13 points on the GERD questionnaire and a 50% decrease in the DeMeester score in a ph-Impedance follow-up study.
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      Figure 1A, Preprocedure endoscopic view. Retroflexion revealed a hiatal hernia. B, The stapler device tip is bent to press the fundus against the esophagus. C, Sonographic view reveals adequate positioning of the alignment pins before the placement of staples. D, Postprocedure view of the fundoplication. Reinforcement of the cardia simulating a surgical wrap (white arrows mark the staple sets).
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