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Background: Three antireflux operations-gastroplasty, fundoplication, and anterior gastropexy-were developed for performance at flexible endoscopy without laparotomy or laparoscopy. Methods: An endoscopic sewing machine mounted on a standard gastroscope, endoscopic knotting devices, overtube, and nylon thread were used to perform these operations in adult beagle dogs. Results: Gastroplasty (n = 10) was accomplished by suturing the anterior and posterior wall of the stomach to create a gastric tube (neoesophagus) along the lesser curve. An anatomic arrangement similar to fundoplication (n = 6) was achieved by invaginating the esophagus and fixing it to the stomach 2 cm distal to the cardioesophageal junction. Anterior gastropexy (n = 6) was performed using a technique similar to that used in creating percutaneous gastrostomies. There was no mortality. Ninety percent of sutures were seen atrepeat endoscopy at 4 to 8 week intervals. The gastroplasty group was selected for more extensive evaluation. Manometry using a three-channel perfused catheter system before and after the procedures showed an increase in the lower esophageal sphincter pressure (preoperative median 4.6 mm Hg; postoperative median 13.33 mm Hg, p = 0.008) and cardiac yield pressures (preoperative median 10 mm Hg; postoperative median 19 mm Hg, p = 0.007). Conclusions: This study demonstrates the feasibility of performing antireflux operations at flexible endoscopy, without laparoscopy or laparotomy, by use of endoluminal suturing techniques. (Gastrointest Endosc 1996;44:133-43.)

Background: New thread-cutting techniques were developed for use at flexible endoscopy. A guillotine was designed to follow and cut thread at the endoscope tip. A new method was developed for guiding suture cutters. Efficacy of Nd:YAG laser cutting of threads was studied. Experimental and clinical experience with thread-cutting methods is presented. Methods: A 2.4 mm diameter flexible thread-cutting guillotine was constructed featuring two lateral holes with sharp edges through which sutures to be cut are passed. Standard suture cutters were guided by backloading thread through the cutters extracorporeally. A snare cutter was constructed to retrieve objects sewn to tissue. Efficacy and speed of Nd:YAG laser in cutting twelve different threads were studied. Results: The guillotine cut thread faster (p < 0.05) than standard suture cutters. Blackloading thread shortened time taken to cut thread (p < 0.001) compared with free-hand cutting. Nd:YAG laser was ineffective in cutting uncolored threads and slower than mechanical cutters. Results of thread cutting in clinical studies using sewing machine (n = 77 cutting episodes in 21 patients), in-vivo experiments (n = 156), and postsurgical cases (n = 15 over 15 years) are presented. Conclusions: New thread-cutting methods are described and their efficacy demonstrated in experimental and clinical studies. (Gastrointest Endosc 1996;44:667-74.)