Revision of failed Nissen fundoplication using combined antireflux mucosal ablation and endoscopic full-thickness fundoplasty. These are our disclosures. This case involves a 57-year-old male with a past medical history of GERD, status post Nissen fundoplication that was done in 2004. He also has a history of obesity with a BMI of 31, long segment bare esophagus with multifocal low and high grade dysplasia, and T1A adenocarcinoma status post endoscopic mucosal resection and radiofrequency ablation of bare esophagus with complete eradication of intestinal metaplasia. He's undergoing active surveillance. Previous endoscopy showed LA grade C esophagitis and a post-endoscopic eradication therapy stricture in the setting of noncompliance with proton pump inhibitor or PPI therapy. Surveillance EGD showed persistent esophagitis, an area of non-dysplastic bares recurrence in loose fundoplication with a 2-centimeter hiatus diameter and an approximately 1-centimeter axial hernia. Functional lumen imaging probe using an 8-centimeter catheter demonstrated a mean diameter of 13.5 millimeters and a mean esophagogastric junction distensibility index of 2.3. Given the borderline flip values, A second bite was performed along a lesser curvature and then the interrupted suture pattern was cinched. After removal of the endoscopic suturing system, repeat endoscopy was performed to re-evaluate. We confirmed no complications and also there was an improved appearance of the fundoplication and transverse hiatus. Because there were no intraprocedural complications, the patient was discharged on post-op day one and he was discharged on a post-fundoplication diet in four weeks of PPI therapy. At his six-week follow-up, the patient had a GERD-Q score of six, which indicated a low likelihood of GERD and he also had no complaints of dysphagia. The plan after that visit was for an EGD with ambulatory pH monitoring at four to six months. The clinical implications of this case are that endoscopic techniques are emerging as an alternative to surgical revision and select patients with failed fundoplication. An example would be those with a hiatal hernia less than or equal to two centimeters. Single-channel endoscopic suturing systems with better retroflexion capabilities may simplify fundoplasty. In conclusion, although TIF is feasible, safe, and effective for those with recurrent GERD after failed fundoplication without significant axial hernia, anatomic restrictions may preclude insertion of the device. An example of such restrictions includes a stricture or a cervical osteophyte. Antireflux mucosal ablation with endoscopic full thickness fundoplasty is a viable alternative if TIF is not available or if it's not technically feasible.

Nissen fundoplication

endoscopic techniques

GERD

hiatal hernia

full-thickness fundoplasty