Background and aims Transoral incisionless fundoplication (TIF) is an effective endoscopic treatment for refractory GERD with small or absent hiatal hernia (< 2 cm in length and width). The single-session laparoscopic hernia repair followed by transoral incisionless fundoplication (HH + TIF) aims to repair mechanical defects in the lower esophageal sphincter that leads to GERD in patients with hiatal hernias ≥ 2 cm. The procedure effectively treats GERD without causing added postsurgical dysphagia and gas bloating commonly associated with partial laparoscopic fundoplication. We aimed to assess patient satisfaction, symptom resolution, safety, and proton pump inhibitor use following the HH + TIF procedure. Methods Thirty-three patients underwent single-session laparoscopic hernia repair with intraoperative TIF using the Eso-phyX Z device (EndoGastric Solutions, Inc.) between June 2015 and June 2018. The presence of GERD and normal esophageal motility were confirmed with pH testing and manometry prior to the procedure. Data were collected on pre-and post-procedure symptoms, patient satisfaction, PPI use, and complications. Median post-procedure follow-up with symptom surveys was 9 months (11-29 months). Results Patients reported significant decreases in common GERD symptoms including heartburn, regurgitation, cough, and hoarse voice. Eighty-one percent (27/33) of patients were off daily PPIs. Ninety-four percent (31/33) of patients reported 75% or greater satisfaction with the procedure and outcomes. One patient had a superficial mucosal laceration after the procedure, likely due to vomiting, which was treated conservatively. Conclusions The majority of patients reported 75% or greater satisfaction with the procedure and had an improvement in GERD symptoms as well as decreased PPI use. There were no serious adverse events.

Background: Missed visualization of colonic surface area is likely a major cause of missed neoplasia at colonoscopy and subsequent postcolonoscopy cancer. Novel technology that calculates missed surface area in near real time could improve endoscopic technique and adenoma detection, and provide an objective measure of procedure quality. Aims: To determine percentage of colonic surface area missed at colonoscopy using a 3D reconstruction of colonoscopy video. Methods: We developed and evaluated a new medical imaging analysis and display system that reconstructs colonoscopy video into a 3D rendering of the colonic surface called a colonoscopogram, or C-gram. The C-gram reconstructions of video sections taken from patients at a single center were then used to calculate missed surface area. To make the C-grams, useful video frames of colonic mucosa were first culled automatically via video fingerprinting. The spatial position of the useful frames' pixels was determined using artificial intelligence and individual frames of 3D textured colonic surface rendered. These frames were then fused into w10cm. sections. Last, angular gaps in which one wall of the colon was not seen were calculated as a proportion of total colonic surface of the C-gram section. Results: Seven colonic 10cm. sections from 4 colonoscopies performed by a single endoscopist were reconstructed into the 3D rendering. Missed colonic surface area per section ranged from 0 to 28.6% (Table 1). The mean surface area missed was 9.6% (95% CI 1.2-18.0%). Figure 1 shows missing areas of one reconstructed colonic section. Conclusions: The 3D reconstruction of colonic sections at colonoscopy demonstrated that overall, at least 9.6% of mucosal surface was not visualized at the exam. We aim in the future to additionally calculate gaps in which the proximal surface of the colonic haustra are not seen, gaps due to overlying stool or fluid, and longitudinal gaps during which the endoscope is moved during times of non-visibility. More work is needed to validate the technology and correlate the missed surface area to adenoma detection rate and other clinically relevant measures. This novel technology holds potential to alert endoscopists to missed mucosa and improve adenoma detection, as well as provide an objective measure of individual procedure quality.

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