We demonstrate the use of counter mucosal incisions as an innovative technique to
relieve tension during anti-reflux mucosal plasty with valve (ARM-P/V) ([Video 1]) [1]. This approach was developed to mitigate the risk of dehiscence at the cardia closure
site. ARM-P/V is a minimally invasive procedure for gastroesophageal reflux disease
(GERD). This procedure reconstructs the mucosal flap valve to enhance anti-reflux
function. The success of ARM-P/V depends on the secure closure of an artificial mucosal
defect. However, elevated tension at the closure site may compromise stability, increasing
the risk of dehiscence and negatively impacting procedural outcomes.
Counter mucosal incisions were applied during anti-reflux mucosal plasty with valve
(ARM-P/V) to relieve tension, preventing dehiscence and improving closure stability
in a 38-year-old patient with refractory gastroesophageal reflux disease (GERD).Video
1
In this case, a 38-year-old patient with proton pump inhibitor-refractory GERD underwent
ARM-P/V with the application of bilateral counter mucosal incisions ([Fig. 1]
a). After creating a mucosal valve using the endoscopic submucosal dissection technique
([Fig. 1]
b) and securing the valve with clips ([Fig. 1]
c), two linear counter incisions, approximately 3 cm in length, were placed 2 cm lateral
to the primary defect ([Fig. 1]
d). These incisions effectively relieved tension surrounding the closure site. A submucosal
saline injection was administered before making the incisions to elevate the mucosa
and protect the underlying muscle layer. Closure of the defect was performed using
the dead space-eliminating technique [2], facilitated by the MANTIS clip (Boston Scientific, Marlborough, Massachusetts,
USA), achieving secure mucosal apposition with low tension ([Fig. 1]
e). Follow-up endoscopic evaluations on postoperative days 1 and 4 ([Fig. 1]
f) confirmed stable closure with no evidence of dehiscence. The procedure was completed
without complications, and the incorporation of the counter mucosal incision technique
did not prolong the procedural time. This procedure is simple and associated with
a low risk of bleeding, making it both safe and efficient.
Fig. 1
a Endoscopic image prior to anti-reflux mucosal plasty with valve showing an open hiatus.
b Creation of the mucosal valve using the endoscopic submucosal dissection technique.
c Fixation of the valve with clips. d Bilateral counter mucosal incisions to relieve tension. e Closure of defect using MANTIS clip. f Endoscopic image on postoperative day 4 showing stable closure of the defect.
This novel approach of ARM-P/V draws inspiration from plastic surgery techniques,
particularly fasciotomy in compartment syndrome. By applying advanced tissue management
principles to high-tension endoscopic closures, counter mucosal incisions represent
a promising advancement for achieving stable closures in GERD treatment.
Endoscopy_UCTN_Code_TTT_1AO_2AJ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
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