Endoscopic Gastroplicature. El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 
Flexible Endoscopic Suturing. A 24 year-old female, suffering of GERD due to inferior gastroesophageal sphincter incompetence. The patient has these symptoms since 7 years, even using PPI. To overcome the GERD an Endoscopic Anti-Reflux Procedure was performed see below the complete sequence of images and videos clips.

Video Endoscopic Sequence 1 of 10.

Flexible Endoscopic Suturing.

 A 24 year-old female, suffering of GERD due to inferior
 gastroesophageal sphincter incompetence.
 The patient has these symptoms since 7 years, even using
 PPI.
 To overcome the GERD an Endoscopic Anti-Reflux
 Procedure was performed see below the complete
 sequence of images and videos clips.

 For further endoscopic information, download the video clip
 by clicking on the endoscopic image. Wait to be
 downloaded complete then Press Alt and Enter for full
 screen ( Windows Media), Real Player: Ctrl and 3.
 All endoscopic images shown in this Atlas contain
 video clips. We recommend seeing the video clips in full
 screen mode.
                                          Medline.
Endoscopic Anti-Reflux Procedure. The image and the video a flexible device with treads is shown, the tip of flexible endoscopic (flexible Sew-Right Device).

Video Endoscopic Sequence 2 of 10.

Endoscopic Anti-Reflux Procedure.

 The image and the video a flexible device with treads is
 shown, the tip of flexible endoscopic (flexible Sew-Right
 Device).

 

A clamp with threads is suctioning the gastroesophageal junction.

Video Endoscopic Sequence 3 of 10.

 A clamp with threads is suctioning the gastroesophageal
 junction.
The video clip displays flexible Sew-Right Device has been released the tissues (the suction is turned off) with gently movements is withdrawing.

Video Endoscopic Sequence 4 of 10.

 The video clip displays the flexible Sew-Right Device has
 been released the tissues (the suction is turned off) with
 gently movements is withdrawing.

 
4 treads are observed after traction is performed, they will become in 2, after that a titanium clip will be placed to perform the knot.

Video Endoscopic Sequence 5 of 10.

 4 treads are observed after traction is performed, they will
 become in 2, after that a titanium clip will be placed to
 perform the knot.
 
The 4 threads has been converted in 2.

Video Endoscopic Sequence 6 of 10.

 The 4 threads has been converted in 2.

The image and the video clip display the traction exerted by the treads that tied the tissues.

Video Endoscopic Sequence 7 of 10.

 The image and the video clip display the traction exerted
 by the treads that tied the tissues.
The flexible Ti-Knot Device has been placed the titanium clip performing the knot.

Video Endoscopic Sequence 8 of 10.

 The flexible Ti-Knot Device has been placed the titanium
 clip performing the knot.
The gastroplication has been completed. Plication techniques create a mechanical barrier to reflux through apposition of 2 mucosal surfaces at the gastroesophageal junction or in the cardia. The mechanisms as to how endoscopic suturing might improve competence of the gastroesophageal junction, however, remain unclear. The manometric studies that are available are conflicting. Some have reported an increase in basal lower esophageal sphincter (LES) pressure and length. A multicenter study, however, found no impact on sample measures of LES function in reflux disease patients despite evidence of symptom benefit.

Video Endoscopic Sequence 9 of 10.

 The gastroplication has been completed.
 Plication techniques create a mechanical barrier to reflux
 through apposition of 2 mucosal surfaces at the
 gastroesophageal junction or in the cardia.
 The mechanisms as to how endoscopic suturing might
 improve competence of the gastroesophageal junction,
 however, remain unclear. The manometric studies that are
 available are conflicting. Some have reported an increase in
 basal lower esophageal sphincter (LES) pressure and
 length. A multicenter study, however, found no impact on
 sample measures of LES function in reflux disease patients
 despite evidence of symptom benefit.
Final statust of the endoscopic gastroplicature. Patient relief the symptoms. Plication of the gastroesophageal junction by endoscopic suturing has been reported to improve symptoms and reduce acid exposure in patients with gastroesophageal reflux disease (GERD).

Video Endoscopic Sequence 10 of 10.

 Final statust of the endoscopic gastroplicature.
 Patient relief the symptoms.

 Plication of the gastroesophageal junction by endoscopic
 suturing has been reported to improve symptoms and
 reduce acid exposure in patients with gastroesophageal
 reflux disease (GERD).

FLEXIBLE ENDOSCOPIC SUTURING DEVICE. Endoscopic Suturing due to chronic gastroesophageal reflux The image and the video display a retroflexed hiatal hernia. A 35 year-old male, who has been suffering of suffering refracting Gastro Esophageal Reflux Disease (GERD) for the last 4 years.

Video Endoscopic Sequence 1 of 11.

FLEXIBLE ENDOSCOPIC SUTURING DEVICE.


 Endoscopic Suturing due to chronic gastroesophageal
 reflux.
 The image and the video display a retroflexed hiatal hernia.
 A 35 year-old male, who has been suffering of
 suffering refracting Gastro Esophageal Reflux Disease
 (GERD) for the last 4 years.
 
 

Suturing System and standard video endoscopy, sutures are placed in the upper part of the stomach at or just below the LES. Two stitches can be placed and tied together to create a pleat near the LES and treat symptomatic reflux. The image and the video clip display a flexible suturing device which has been passed through the external accessory channel, with a friction-fit adapter and tube guide, provides a pathway for the flexible endoscopic suturing device.

Video Endoscopic Sequence 2 of 11.

 Suturing System and standard video endoscopy, sutures
 are placed in the upper part of the stomach at or just below
 the LES.
 Two stitches can be placed and tied together to create a
 pleat near the LES and treat symptomatic reflux.
 The image and the video clip display a flexible suturing
 device which has been passed through the external
 accessory channel, with a friction-fit adapter and tube
 guide, provides a pathway for the flexible endoscopic
 suturing device.

 
The ESD Flexible Endoscopic Suturing device. It uses the same principal of tightening the junction between the esophagus and the stomach by the placement of sutures. This device has been approved by the FDA and is being studied for the treatment of GERD. The image and the video display the step of sucking enough tissue (mucosa, sub mucosa and muscularis). The needle is then fired into the sucked tissue. We applied the first suture with the first needle and at the same time we removed the valve of suction and in this way it free the tissue from the clamp and we prepared the field for the second suture which is one centimeter away from the first one.

Video Endoscopic Sequence 3 of 11.
 

 The ESD Flexible Endoscopic Suturing device. It uses the
 same principal of tightening the junction between the
 esophagus and the stomach by the placement of sutures.
 This device has been approved by the FDA and is being
 studied for the treatment of GERD.
 The image and the video display the step of sucking
 enough tissue (mucosa, sub mucosa and muscularis).
 The needle is then fired into the sucked tissue.
 We applied the first suture with the first needle and at the
 same time we removed the valve of suction and in this way
 it free the tissue from the pincer and we prepared the field
 for the second suture which is one centimeter away from
 the first one.
 

The image and the video clip display to loosen the tissues, certain maneuvers are observed we prepared the second suture one centimeter away from the first one. In the image observed the process after the tissue which we deliver one suture, with this device. We observed the threads through the cardias and then, we applied the second suture to one centimeter away from the first one. As we look the 4 threads that convert to two with applied traction that is direct out and both tissues gathered.

Video Endoscopic Sequence 4 of 11.

 The image and the video clip display to loosen the tissues,
 certain maneuvers are observed, we prepared the second
 suture one centimeter away from the first one. In the image
 observed the process after the tissue which deliver one
 suture, with this device. We observed the threads through
 the cardias and then, we applied the second suture to one
 centimeter away from the first one. As we look the 4
 threads that convert to two with applied traction that is
 direct out and both tissues gathered.
We prepared the second suture one centimeter away from the first one. In the image observed the process after the tissue which we deliver one suture, with this device. We observed the threads through the cardias and then, we applied the second suture to one centimeter away from the first one.

Video Endoscopic Sequence 5 of 11.

 We prepared the second suture one centimeter away from
 the first one. In the image observed the process after the
 tissue which we deliver one suture, with this device. We
 observed the threads through the cardias and then, we
 applied the second suture to one centimeter away from the
 first one.

We look the 4 threads that convert to two with applied traction that is direct out and both tissues gathered together.

Video Endoscopic Sequence 6 of 11.

 We look the 4 threads that convert to two with applied
 traction that is direct out and both tissues gathered
 together.
 

 
The image and the video are displaying both threads that were observed as four, This happened because they were tractioned outwards. In the image show two threads that previously were four, but after we applied outside traction and the cardia's tissue is suture and close to each other the next step is to tie between the sutures and we use other special clamp with we thread the needle in this clamp with a titanium's clip. And we gaze the other flexible forceps with has the threads attach with a titanium's clip.

Video Endoscopic Sequence 7 of 11.

 The image and the video are displaying both threads that
 were observed as four, This happened because they were
 tractioned outwards.
 In the image show two threads that previously were four,
 but after we applied outside traction and the cardia's tissue
 is suture and close to each other the next step is to tie
 between the sutures and we use other special forceps which
 we thread the needle in this pincer with a titanium's clip.
 And we gaze the other flexible forceps which has the
 threads attach with a titanium's clip.
 
The next step is to perform the knot. The titanium knot mechanically fastens suture together and cuts away excess suture. And those threads position close to the mouth and out from the patient are introducing to other special clamp which is flexible to attach a titanium's clip.

Video Endoscopic Sequence 8 of 11.

 The next step is to perform the knot.
 The titanium knot mechanically fastens suture together and
 cuts away excess suture.
 And those threads position close to the mouth and out from
 the patient are introducing to other special pincer which is
 flexible to attach a titanium's clip.

For more endoscopic details download the video clip by clicking on the endoscopic images.

Video Endoscopic Sequence 9 of 11.

 For more endoscopic details download the video clip by
 clicking on the endoscopic images.
In this step this clamp is withdrawn, the hole of the clamp is observed where the titanium knot is applied and the threads are cut, also this clamp is equipped to cut threads.

Video Endoscopic Sequence 10 of 11.

 In this step this clamp is withdrawn, the hole of the clamp
 is observed where the titanium knot is applied and
 the threads are cut, also this clamp is equipped to cut
 threads.

 
The knot is observed, the threads and the titanium clip The first stich is finish of this form increase the pressure of the inferior gastroesophageal sphincter, this procedure is simple, two to four stitches are required according to the size of the hiatal hernia. This endoscopic procedure is practical and safe. However, since this procedure is quite new, we can not determine at the moment its lasting effects. Because of the patient's benefits, due to the disappearance of gastroesophageal reflux.

Video Endoscopic Sequence 11 of 11.

 The knot is observed, the threads and the titanium clip
 The first stich is finish of this form increase the pressure of
 the inferior gastroesophageal sphincter, this procedure is
 simple, two to four stitches are required according to the
 size of the hiatal hernia.
 This endoscopic procedure is practical and safe. However,
 since this procedure is quite new, we can not determine at
 the moment its lasting effects.
 Because of the patient’s benefits, due to the disappearance
 of gastroesophageal reflux.

Intraluminal Endoscopic Suturing. A 62 year-old female who has been presenting gastroesophageal reflux for 8 years. A hernia of the hiatus with an extended defect is observed which affects the closing mechanism and contributes to the gastroesophageal reflux. Two endoscopic gastroplicaturas were placed.

Video Endoscopic Sequence 1 of 14.

Intraluminal Endoscopic Suturing.

 A 62 year-old female who has been presenting
 gastroesophageal reflux for 8 years.
 A hernia of the hiatus with an extended defect is observed
 which affects the closing mechanism and contributes to the
 gastroesophageal reflux.
 Two endoscopic gastroplicaturas were placed
 
 
In the video clip a hiatus hernia with a defect is observed. Endoscopic suturing causes modest but significant improvement in LES function. First, there is a significant reduction in the triggering of transient LES relaxations (tLESRs) and second, there is a small but significant increase in basal LES pressure. Overall, tLESRs were reduced by 37% at 6 months, but the overall number of reflux episodes was unchanged and there was only a modest decrease in upright GER (14.4% to 9.2%, median values at baseline and 6 months, p< 0.05) and no change in supine reflux. Nevertheless, 7 of 15 (45%) patients were free of symptoms and off medication at 1 yr and 4 of 15 (26%) patients had normal pH values. The speculated mechanism of these changes was twofold. First, the application and possibly associated scarring just below the squamocolumnar junction may reduce the distensibilty of the cardias region of the stomach, the recognized trigger zone for tLESRs. Secondly, scarring may also affect neural pathways, thereby reducing the rate of tLESRs.

Video Endoscopic Sequence 2 of 14.

 In the video clip an hiatus hernia with a defect is observed.


 Endoscopic suturing causes modest but significant
 improvement in LES function. First, there is a significant
 reduction in the triggering of transient LES relaxations
 (tLESRs) and second, there is a small but significant
 increase in basal LES pressure. Overall, tLESRs were
 reduced by 37% at 6 months, but the overall number of
 reflux episodes was unchanged and there was only a modest
 decrease in upright GER (14.4% to 9.2%, median values at
 baseline and 6 months, p< 0.05) and no change in supine
 reflux. Nevertheless, 7 of 15 (45%) patients were free of
 symptoms and off medication at 1 yr and 4 of 15 (26%)
 patients had normal pH values. The speculated mechanism
 of these changes was twofold. First, the plication and
 possibly associated scarring just below the squamocolumnar
 junction may reduce the distensibilty of the cardia region of
 the stomach, the recognized trigger zone for tLESRs.
 Secondly, scarring may also affect neural pathways,
 thereby reducing the rate of tLESRs.
The threads are observed which approaching the tissues.

Video Endoscopic Sequence 3 of 14.

 
 The threads are observed which approaching the tissues.

 

 
In the image and the video clip you can see the placement of the titanium clip through the clamp performing the first gastroplicature in this patient.

Video Endoscopic Sequence 4 of 14.

 In the image and the video clip you can see the placement
 of the titanium clip through the clamp performing the first
 gastroplicature in this patient.

This image and the video clip display the first intraluminal gastroplicature.

Video Endoscopic Sequence 5 of 14.

 This image and the video clip display the first intraluminal
 gastroplicature.

 
Another appreciation of the endoluminal gastroplicature.

Video Endoscopic Sequence 6 of 14.

 Another appreciation of the endoluminal gastroplicature.

 
Retroflexed image of the gastric fundus the final status of this procedure.

Video Endoscopic Sequence 7 of 14.

 Retroflexed image of the gastric fundus the final status of
 this procedure.
Transoral Endoluminal Gastroplications. A follow up after six months. We practiced two endoscopic Endoluminal Gastroplications. She has been our first patient with this new endoscopic suturing method. After the endoscopic gastroplicatures, patient has not reported any GERD symptom and not get any anti reflux drug.

Video Endoscopic Sequence 8 of 14.

        Transoral Endoluminal Gastroplications.

 A follow up after six months. We practiced two
 endoscopicEndoluminal Gastroplications. She has been our
 first patient with this new endoscopic suturing method.
 After the endoscopic gastroplicatures, patient has not
 reported any GERD symptom and not get any anti reflux
 drug.

The image and the video clip display two nodules as results of previously endoluminal gastroplicature six months ago. Two clips of titanium are observed.

Video Endoscopic Sequence 9 of 14.

 The image and the video clip display two nodules as
 results of previously endoluminal gastroplicature six
 months ago. Two clips of titanium are observed.
Retroflexed image, where two nodules can be seen. These nodules were formed with the junction of the tissues, besides, an inflammatory reaction is observed, due to foreign body reaction to the nylon thread, which apparently is useful for increasing the resistance of the sphincter therefore avoiding the reflux, which is the purpose of the procedure. We have one case of silk thread remains, after a gastric surgery performed 20 years ago. The silk thread caused the mucosa inflammatory reaction as a consequence of foreign body reaction sees post surgical status.

 Video Endoscopic Sequence 10 of 14.

 Retroflexed image, where two nodules can be seen. These
 nodules were formed with the junction of the tissues,
 Besides, an inflammatory reaction is observed, due to
 foreign body reaction to the nylon thread, which apparently
 is useful for increasing the resistance of the sphincter
 therefore avoiding the reflux, which is the purpose of the
 procedure.
 We have one case of silk thread remains, after a gastric
 surgery performed 20 years ago. The silk thread caused the
 mucosa inflammatory reaction as a consequence of foreign
 body reaction see post surgical status.

In this retroflexed image are observed two nodules of the endoscopic gastroplicature.

Video Endoscopic Sequence 11 of 14.

 In this retroflexed image are observed two nodules of the
 endoscopic gastroplicature.


 


 
 
In this image we can appreciate the nodule with some foreign body reaction to the nylon thread, this seems to facilitate the development of the fibrosis and increase the resistance of the sphincter. Until now we have had a very good experience with the intraluminal endoscopic suture, since the patients have had a very good results; the acidity has disappeared and we hoped that this effect will remain for a long time. However, only the time will tell the final word, since so far this method has been proved effective, in spite of being new.

Video Endoscopic Sequence 12 of 14.

 In this image we can appreciate the nodule with some
 foreign body reaction to the nylon thread. This seems to
 facilitate the development of the fibrosis and increase
 the resistance of the sphincter.
 Until now we have had a very good experience with
 the intraluminal endoscopic suture, since the patients have
 had a very good results; the acidity has disappeared and
 we hoped that this effect will remain for a long time.
 However, only the time will tell the final word,  since so far
 this method has been proved effective, in spite of being
 new.
 
A follow up one year after.

Video Endoscopic Sequence 13 of 14.
 

A follow up one year after.
A follow up one year after. Retroflexed maneuver.

Video Endoscopic Sequence 14 of 14.

A follow up one year after.

Retroflexed maneuver.