Endoscopically-directed single-port intragastric fundoplication, sleep, and myotomy, a preclinical study. Authors include Arios Hernandez, Barham Abudea, Ana Garcia, Elisa Petrayan, and Andrew Storm. These are our disclosures. The performance of endoscopic transoral therapy is limited by the need to achieve triangulation for tissue exposure, dissection, instrumentation, as well as the small channel size of an endoscope. This video aims to demonstrate the safety and feasibility to perform novel intragastric procedures in the endoscopy suit through the use of a novel percutaneous endoscopic trocar placed in a fashion similar to a PEG tube, allowing the use of dual laparoscopic and endoscopic instrumentation. This was an acute preclinical lab approved by our Institutional Animal Care and Use Committee. We included two domestic female pigs, one to study the feasibility of an intragastric stapled-sleep gastroplasty and fundoplication at the gastroesophageal junction, and the other was studied in the performance of an endoluminal myotomy at the GE junction. In each animal, a 12-millimeter intragastric transabdominal trocar was placed to allow the use of a laparoscopic stapler device. A 2D-scope helix-type tissue grasping device was used to manipulate full thickness intragastric tissue, and an over-the-scope clip system was deployed to close the intragastric trocar track at the end of each procedure. To begin the procedure, the introduction of the intragastric trocar is simple and similar to a pulpercutaneous endoscopic gastrostomy technique, using a standard gastroscope, angiocatheter, needle access, wire exchange, and external wire traction. After installation of the trocar, the directionality may be reoriented as needed before and while introducing laparoscopic tools. To test the feasibility of performing a partial fundoplication for the treatment of gastroesophageal reflux disease, a 2D-scope helix catheter is used to grasp full thickness tissue from the gastric cardia. Tissue is manipulated through the scope movements within the jaws of the transabdominal stapling tool. Multiple 60-millimeter cartridges can be fired with a rechargeable stapler to achieve safe and effective full thickness resection. In the course of performing the procedure, the 45-millimeter cartridges or even laparoscopic scissors can be used as well to resect less thick or residual tissue. Extraction of the resected tissue may be achieved either per oral or through the intragastric trocar. A final pass with the gastroscope to the esophago-gastric junction demonstrates reduction of the lumen from the fundoplication, with moderate difficulty passing the endoscope to the previously patent gastroesophageal junction. A retroflex view of the fundus and cardia shows no adverse events such as bleeding or perforation at the end of the maneuver. To perform an intragastric stapler gastroplasty for therapy of obesity, similar techniques are applied using the 2D-scope helix catheter to grasp tissue from the anterior gastric body starting from distal to proximal. We secure the tissue between the rechargeable laparoscopic stapler jaws before we fire 60 and 45-millimeter cartridges following a linear pattern to the length of the gastric body. Using the stapling device articulating joint allowed the stapler to reach and effectively perform gastroplasty even in areas very proximal to the trocar. After using five cartridges, we were able to appreciate a significant reduction of the gastric cavity with no bleeding or further adverse events. To examine the feasibility of gastroesophageal myotomy for therapy of achelation, again tissue was grasped using through the scope helix device. Tissue from the gastroesophageal junction was brought within the jaws of the transabdominal stapling device, and two staple cartridges were fired linearly progressing upstream within the junction to simulate a myotomy. Upon the endoscope removal, the gastroesophageal junction is visibly more patent after transection. Before external abdominal traction removal of the transgastric trocar device, a guide wire was passed through the trocar to ensure visualization of the location of the introduction site after trocar removal. Once the trocar was removed, a through-the-scope twin grasper was used to bring the edges of the gastric defect together before the over-the-scope clip was deployed. The final examination of the gastric cavity demonstrates adequate closure of the trocar insertion site. In conclusion, single-port intragastric staple procedures such as partial foam duplication, stapled-slip gastroplasty, and gastroesophageal junction myotomy are feasible to the novel use of transgastric abdominal trocar, permitting the combined strengths of both endoscopic and laparoscopic approaches to intragastric procedures. Future preclinical studies are needed to ensure effectiveness and safety of these procedures in the short and long term.

preclinical study

intragastric procedures

percutaneous endoscopic trocar

laparoscopic and endoscopic instrumentation

feasibility of intragastric stapled-sleep gastroplasty