PMC6043920_01
(A) Three suturing sites in the gastric tube were marked. (B) Two semi-full-thickness sutures were placed and tied with a cinching device at 3-o'clock and 9-o'clock directions, respectively. Then, a small posterior gap was closed using 2 additional sutures. (C) A capsule-based reflux testing system was placed. After the procedure, the (D) front and (E) reverse image.
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After submucosal saline injection in a standard fashion, the gastric mucosa was semi-circumferentially incised to expose the muscle layer in between anterior and posterior suturing sites (Figure 1A). Then, a small posterior gap was closed using 2 additional sutures (Figure 1B). After the procedure, a capsule-based reflux testing system (Bravo Reflux Capsule; Medtronic, Dublin, Ireland) was placed above the prior anastomosis (Figure 1C). The funnel was successfully created with our technique using OverStitch (Figure 1D and E).
Morphological evaluation using Gastrografin (A) before and (B) after funnel creation. (C) No reflux on Gastrografin study 12 months postoperatively. (D) Marked improvement in postoperative pH profile compared with preoperative data.
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Although the "reflux angle" was +30  (head-up) before funnel creation, this decreased < -20  (head-down) immediately after the procedure (Figure 2A and B). At 1 month postoperatively, a trivial reflux of Gastrografin over the funnel at -20 , but most of the contrast medium remained on the anal side of the funnel. At 12 months after procedure, the trace amount of reflux flow was observed at 0  (Figure 2C). However, no further pH drop was observed even during sleep and meal on POD 2 (Figure 2D).
(A) The funnel observed 1 and 12 months postoperatively, showing its durability. (B) Rapid and persistent improvement in endoscopic findings and (C) DAUGS20 scores.
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It revealed that all sutures were still in situ and the funnel remained intact even 12 months after procedure (Figure 3A). Diffuse esophagitis, which was observed preoperatively, resolved partially in 1 month postoperatively and further improved in 12 months (Figure 3B). The total score before funnel creation was 65 points, but it improved to 26 points at 12 months after procedure (Figure 3C).