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, 10 (3), 363-7

Endoscopic Clipping of the Z-line (CMZL) Helps Recognize Anatomical Failures After Nissen Fundoplication: Technical Report of a New Method


Endoscopic Clipping of the Z-line (CMZL) Helps Recognize Anatomical Failures After Nissen Fundoplication: Technical Report of a New Method

Leonid Barkhatov et al. Wideochir Inne Tech Maloinwazyjne.


Introduction: Nearly 15% of patients after laparoscopic antireflux surgery experience recurrence of symptoms or develop new gastrointestinal symptoms. Some of them require redo procedures. It can be demanding to reveal anatomical failure after previous fundoplication.

Aim: To present a method which assists in recognition of anatomical failures after Nissen fundoplication.

Material and methods: Five patients with previous laparoscopic Nissen fundoplication and severe gastrointestinal symptoms were included in this study. During the esophagogastroduodenoscopy (EGDS) two radiopaque metal clips were placed to mark the Z-line ("clips-marked Z-line" - CMZL). It was done to achieve precise visualization of the gastroesophageal junction area in the video contrast investigation. Distinctions between conclusions after the EGDS, ordinary video contrast investigation, video contrast investigation with CMZL and intraoperative findings were analyzed.

Results: All patients underwent laparoscopic refundoplication with good postoperative results. There were 4 cases misdiagnosed by contrast investigation without clips and four cases misdiagnosed by EGDS. Endoscopic clipping helped to recognize correctly all anatomical failures.

Conclusions: Applying CMZL as a routine investigation before redo fundoplication can reduce frequency of misdiagnosis and help to perform redo fundoplication in appropriate patients, but it requires further studies on larger cohorts of patients.

Keywords: endoscopic clipping; failed fundoplication; laparoscopic fundoplication; redo surgery; slipped Nissen.


Photo 1
Photo 1
Two metal clips were placed at the gastroesophageal junction area – Z-line
Photo 2
Photo 2
White arrow – clips placed during the operation; red arrow – endoscopic clips at Z-line
Photo 3
Photo 3
Video contrast investigation after transesophagus clipping. A – Patient 1: one can precisely visualize fundoplication wrap and two metal clips at Z-line. Z-line is located at the wrap area – correct fundoplication. B – Patient 2: metal clips are placed above the wrap area – fundoplication is slipped down to the stomach (“slipped Nissen”). Black arrows indicate clips
Figure 1
Figure 1
Scheme of position of clips in a case of normal fundoplication wrap (A) and “slipped Nissen” (B)

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    1. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc. 1991;1:138–43. - PubMed
    1. Anvari M, Allen C. Five-year comprehensive outcomes evaluation in 181 patients after laparoscopic Nissen fundoplication. J Am Coll Surg. 2003;196:51–7. - PubMed
    1. Bammer T, Hinder RA, Klaus A, Klingler PJ. Five- to eight-year outcome of the first laparoscopic Nissen fundoplications. J Gastrointest Surg. 2001;5:42–8. - PubMed
    1. Lafullarde T, Watson DI, Jamieson GG, Myers JC, Game PA, Devitt PG. Laparoscopic Nissen fundoplication: five-year results and beyond. Arch Surg. 2001;136:180–4. - PubMed
    1. DePaula AL, Hashiba K, Bafutto M, Machado CA. Laparoscopic reoperations after failed and complicated antireflux operations. Surg Endosc. 1995;9:681–6. - PubMed

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