Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication

Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome

Our study aimed to assess whether intraoperative esophagogastric junction (EGJ) distensibility measurement using the EndoFLIP EF325 catheter (Crospon Ltd., Galway, Ireland) could potentially be used to guide laparoscopic Heller's myotomy (LHM), potentially modifying the operation outcome and comparing this clinically to our previous technique of gastroscopic assessment. Following a full diagnostic assessment with manometry and endoscopy patients with achalasia were divided into two groups. A retrospective cohort of patients operated on between 2007 and 2010 had a gastroscopy-guided LHM (G-LHM) with a standardized myotomy of 8 cm on the esophagus and 3 cm on the stomach. From 2010, patients were prospectively studied with an EndoFLIP-guided LHM (E-LHM). The length of the myotomy was dictated by intraoperative distensibility monitoring of the EGJ. All patients with achalasia recorded Urbach quality of life scoring preoperatively and 6 months postoperatively. A further group of normal laparoscopic control patients (E-LC) without any esophageal pathology also underwent intraoperative EGJ distensibility monitoring. Thirty-eight patients took part, 15 in the E-LC group, 8 in G-LHM group and 15 in the E-LHM group. We revealed that patients with achalasia in the E-LHM group had a significantly smaller EGJ cross-sectional area and distensibility than the E-LC group. Myotomy and fundoplication increased the distensibility of the EGJ to a value greater than normal control patients. Patients in the G-LHM group had a standard myotomy of 11 cm; patients in the E-LHM group had a variable length myotomy of 6 cm (IQR 5.0-6.0). In both G-LHM and E-LHM groups, there was a significant improvement in patient's quality of life with no significant difference between the groups. Our study has shown that the EndoFLIP system was effective at measuring distensibility changes during LHM. LHM significantly increases the distensibility of the EGJ and also significantly improves patient symptoms. E-LHM may reduce the overall myotomy length, and this does not appear to compromise the clinical outcome.

Esophagogastric junction distensibility in hiatus hernia

Hiatus hernia is known to be an important risk factor for developing gastroesophageal reflux disease. We aimed to use the endoscopic functional lumen imaging probe (EndoFLIP) to evaluate the functional properties of the esophagogastric junction. EndoFLIP assessments were made in 30 patients with hiatus hernia and Barrett's esophagus, and in 14 healthy controls. The EndoFLIP was placed straddling the esophagogastric junction and the bag distended stepwise to 50 mL. Cross-sectional areas of the bag and intra-bag pressures were recorded continuously. Measurements were made in the separate sphincter components and hiatus hernia cavity. EndoFLIP measured functional aspects such as sphincter distensibility and pressure of all esophagogastric junction components and visualized all hiatus hernia present at endoscopy. The lower esophageal sphincter in hiatus hernia patients had a lower pressure (e.g. 47.7 ± 13.0 vs. 61.4 ± 19.2 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the common esophagogastric junction in controls. In hiatus hernia patients, the crural diaphragm had a lower pressure (e.g. 29.6 ± 10.1 vs. 47.7 ± 13.0 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the lower esophageal sphincter. There was a significant association between symptom scores in patients and EndoFLIP assessment. Conclusively, EndoFLIP was a useful tool. To evaluate the presence of a hiatus hernia and to measure the functional properties of the esophagogastric junction. Furthermore, EndoFLIP distinguished the separate esophagogastric junction components in hiatus hernia patients, and may help us understand the biomechanics of the esophagogastric junction and the mechanisms behind hiatal herniation.

Functional lumen imaging of the gastrointestinal tract

This nonsystematic review aims to describe recent developments in the use of functional lumen imaging in the gastrointestinal tract stimulated by the introduction of the functional lumen imaging probe. When ingested food in liquid and solid form is transported along the gastrointestinal tract, sphincters provide an important role in the flow and control of these contents. Inadequate function of sphincters is the basis of many gastrointestinal diseases. Despite this, traditional methods of sphincter diagnosis and measurement such as fluoroscopy, manometry, and the barostat are limited in what they can tell us. It has long been thought that measurement of sphincter function through resistance to distension is a better approach, now more commonly known as distensibility testing. The functional lumen imaging probe is the first medical measurement device that purports in a practical way to provide geometric profiling and measurement of distensibility in sphincters. With use of impedance planimetry, an axial series of cross-sectional areas and pressure in a catheter-mounted allantoid bag are used for the calculation of distensibility parameters. The technique has been trialed in many valvular areas of the gastrointestinal tract, including the upper esophageal sphincter, the esophagogastric junction, and the anorectal region. It has shown potential in the biomechanical assessment of sphincter function and characterization of swallowing disorders, gastroesophageal reflux disease, eosinophilic esophagitis, achalasia, and fecal incontinence. From this early work, the functional lumen imaging technique has the potential to contribute to a better and more physiological understanding of narrowing regions in the gastrointestinal tract in general and sphincters in particular.

Esophageal motility disorders

The diagnosis of esophageal motility disorders has been greatly enhanced with the development of high-resolution esophageal manometry studies and the Chicago Classification. Both hypomotility disorders and hypercontractility disorders of the esophagus have new diagnostic criteria. For the foregut surgeon, new diagnostic criteria for esophageal motility disorders have implications for decision-making during fundoplication and may expand the role of surgical therapy for esophageal achalasia by clarifying diagnostic criteria.

Assessing pyloric sphincter pathophysiology using EndoFLIP in patients with gastroparesis

BACKGROUND

Pyloric dysfunction has been associated with gastroparesis, particularly diabetic gastroparesis. Endoscopic functional luminal imaging probe (EndoFLIP) uses 16 sensors inside a balloon that is inflated inside a sphincter to assess physiologic characteristics. The aim of this study was to measure the pressure, diameter, cross-sectional area (CSA), and distensibility of the pylorus using EndoFLIP in patients with gastroparesis. In addition, the relationship between pyloric pathophysiology with gastroparesis etiology, symptoms, and gastric emptying was assessed.

METHODS

EndoFLIP was performed in 54 patients (39 idiopathic gastroparesis, 15 diabetic gastroparesis). The EndoFLIP catheter was passed endoscopically so that the balloon straddled the pylorus. Pressure, diameter, CSA, and distensibility of the pylorus were measured at 20, 30, 40, and 50 cc balloon volume.

KEY RESULTS

Pyloric sphincter contour was seen best at 40 cc balloon distension (diameter 12.2 ± 0.44 mm, CSA 125.2 ± 9.15 mm(2), pressure 18.0 ± 1.23 mmHg, length 1.59 ± 0.34 cm, distensibility 10.7 ± 2.57 mm(2)/mmHg). There was a wide range seen in diameter (5.6-22.1 mm) and distensibility (1-55 mm(2)/mmHg) of the pylorus. Symptoms of early satiety and postprandial fullness were inversely correlated with pyloric sphincter diameter and CSA. No significant difference was seen between diabetic and idiopathic gastroparetics.

CONCLUSIONS & INFERENCES

EndoFLIP is a novel technique that can be used to assess pyloric physiologic characteristics. Early satiety and postprandial fullness were inversely correlated with diameter and CSA of the pyloric sphincter. No significant differences were seen comparing diabetic and idiopathic gastroparetics. This technology may be of benefit to help select patients with pyloric sphincter abnormalities.