Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
The last stitch is a posterior gastropexy taking the posterior aspect of the stomach to the crus; doing this beforehand is 'cheating' because the stomach should sit there without tension — Michael Rosen, Gastroesophageal Reflux Disease · 17:06
Gastroesophageal Reflux Disease
Listen →
An interactive discussion about gastroesophageal reflux disease between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is a professor of surgery at the Cl
podcast33:57 · Jul 2026
Endoscopic Reflux Management2 items
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
Watch →
This video was part of the Video Loop during the SAGES 2020 Virtual Meeting. Topic: Flexible Endoscopy Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery. Jessica Ardila-Gatas, MD, Joshua Landreneau, MD,
video · Jul 2026
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
Watch →
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery Verify to continue To continue, please confirm that you're a human (and not a spambot). Checking if the site connection is secure vimeo.com needs t
video · Jul 2026
Pyloromyotomy Techniques2 items
Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis
Read →
Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparosco
article · Jul 2026
Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis
Read →
Per-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.
article · Jul 2026
Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors
Read →
Journal of Gastrointestinal Surgery - Myogenic neoplasms of the stomach are the most common submucosal mass. Their natural history is indeterminate, and surgical resection is advised regardless of...
article · Jul 2026
Featured picks for families are being prepared — the summaries above are written for you.
Expert statements from the recordings in this collection.
Gastroesophageal Reflux Disease
For initial GERD management in a patient never on PPIs, start with 20mg daily Prilosec for 6 weeks
Michael Rosen2:27
PPIs are preferred over H2 blockers because they don't need to be taken as often, last longer, and are more convenient as once-daily drugs
Michael Rosen2:59
There is mounting data that lifetime use of proton pump inhibitors has consequences associated with it
Michael Rosen3:34
At minimum, patients with GERD symptoms requiring continued PPI therapy need upper endoscopy to assess esophagitis and rule out Barrett's esophagus
Michael Rosen4:06
In 2016, for a patient without esophagitis, no hiatal hernia, and no Barrett's, more workup is needed before keeping them on PPIs indefinitely, especially in young active people due to concerns about osteoporosis and other issues
Michael Rosen5:02
A Bravo pH study is preferred over traditional pH monitoring because it's easier for the patient (no nasal tube)
Michael Rosen5:50
The Bravo capsule is placed 6 centimeters above the EG junction and can measure 48 hours of pH data
Host summaryJeff Ponsky summarizes what Dr. Michael Rosen said — not the host's own clinical position5:57
Bravo pH testing should be done off PPIs to allow for symptom correlation, which is important for setting patient expectations about what surgery will improve
Michael Rosen6:19
Manometry is not needed at initial workup but is essential before any surgical discussion
Michael Rosen6:51
The primary reason for manometry before fundoplication is to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function
Michael Rosen11:19
Before doing routine manometry for reflux workup, achalasia cases requiring Heller myotomy were rare; now with routine manometry, achalasia is found more frequently because patients with achalasia can have heartburn from food stasis and fermentation in the esophagus
Jeff Ponsky11:47
On manometry, look for total relaxation of the lower esophageal sphincter with swallowing and a low resting LES pressure to support the diagnosis of reflux disease
Michael Rosen12:24
Distal esophageal amplitudes on manometry help tailor the fundoplication type, with detailed discussion needed about postoperative dysphagia expectations in patients with poor esophageal motility, and consideration of the difference between full wrap and Toupet
Michael Rosen12:38
For laparoscopic Nissen fundoplication, a full mediastinal dissection is important to create scar tissue and reduce recurrences, and also provides more esophageal length
Michael Rosen14:14
Taking down the short gastric vessels during Nissen makes it easier to avoid twisting the wrap and to see exactly what is being brought around
Michael Rosen14:38
It's important to bring the posterior aspect of the stomach to the anterior aspect so there's a ridge of short gastrics behind the GE junction
Michael Rosen14:45
The way a Nissen is created is highly variable, and one downside of this operation that makes it hard to reproduce data is that everybody does it just a little bit differently without great standardization
The geometry of the wrap is critically important; if it doesn't look right after putting it together, take it down and reestablish it
Jeff Ponsky15:35
A common mistake is grabbing the posterior greater curve too low on the left when creating the wrap, which results in being too high on the right and too low on the left, trapping a portion of the fundus above
Jeff Ponsky15:50
A common mistake when younger was making the wrap too long because of having good intraabdominal esophageal length; this adds to dysphagia
Michael Rosen16:19
For Nissen fundoplication, use 3 sutures with silk, making the wrap about 2 centimeters long (nothing longer); first stitch is stomach to stomach to allow positioning adjustment, then stomach-esophagus-stomach just above GE junction, then another above that
Michael Rosen16:37
The last stitch is a posterior gastropexy taking the posterior aspect of the stomach to the crus; doing this beforehand is 'cheating' because the stomach should sit there without tension
Michael Rosen17:06
Earlier in career, a 56 French bougie was used for crural closure, but with more experience it's needed less and less; now close the crus without a bougie
Michael Rosen17:42
The crus should be closed enough so the esophagus has a little V-shaped triangle of air below it; as experience increases, the crural closure is made tighter
Michael Rosen18:00
In patients with connective tissue disease and weak peristalsis (below 20 mmHg) with very weak LES, the key is to have a clear discussion that the goal is to improve reflux without creating dysphagia, because the esophageal pump doesn't work well enough to overcome a full wrap
Michael Rosen19:05
For patients with weak motility, a Toupet fundoplication (posterior 270-degree wrap) is performed in the vast majority of cases
Michael Rosen19:38
For Toupet fundoplication, perform formal esophageal dissection with Penrose drain, go up into chest, mobilize for intraabdominal esophagus length, take down short gastrics, create posterior 270-degree wrap about 2.5 to almost 3 cm long with 3 sutures on either side (esophagus to stomach), then do posterior gastropexy of stomach to posterior crus
Michael Rosen19:44
For Toupet, only one stitch is used for posterior gastropexy to the crus (not to each side) to avoid angulating things awkwardly and pulling the stomach
Michael Rosen20:33
The hardest transition of becoming an attending 12 years ago doing foregut surgery was managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues, and learning when to intervene
It's critical to tell patients preoperatively that fundoplication changes things: it will change how you swallow, how your stomach works, and how acid moves out of your body
Michael Rosen22:03