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Al Asadi H, Najah H, Edelmuth R, Greenberg JA, Marshall T, Salehi N, Lee YJ, Riascos MC, Finnerty BM, Fahey TJ, Zarnegar R. Impedance planimetry (EndoFLIPTM) and surgical outcomes after Hill compared to Toupet fundoplication. Surg Endosc 2024; 38:1020-1028. [PMID: 38097749 DOI: 10.1007/s00464-023-10640-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Endoluminal functional lumen imaging probe (EndoFLIP) provides a real-time assessment of gastroesophageal junction (GEJ) compliance during fundoplication. Given the limited data on EndoFLIP measurements during the Hill procedure, we investigated the impact of the Hill procedure on GEJ compliance compared to Toupet fundoplication. METHODS Patients who underwent robotic Hill or Toupet fundoplication with intraoperative EndoFLIP between 2017 and 2022 were included. EndoFLIP measurements of the GEJ included cross sectional surface area (CSA), intra-balloon pressure, high pressure zone length (HPZ), distensibility index (DI), and compliance. Subjective reflux symptoms, gastroesophageal reflux disease-health related quality of life (GERD-HRQL) score, and dysphagia score were assessed pre-operatively as well as at short- and longer-term follow-up. RESULTS One-hundred and fifty-four patients (71.9%) had a Toupet fundoplication while sixty (28%) patients underwent the Hill procedure. The CSA [27.7 ± 10.9 mm2 vs 42.2 ± 17.8 mm2, p < 0.0001], pressure [29.5 ± 6.2 mmHg vs 33.9 ± 8.5 mmHg, p = 0.0009], DI [0.9 ± 0.4 mm2/mmHg vs 1.3 ± 0.6 mm2/mmHg, p = 0.001], and compliance [25.9 ± 12.8 mm3/mmHg vs 35.4 ± 13.4 mm3/mmHg, p = 0.01] were lower after the Hill procedure compared to Toupet. However, there was no difference in post-fundoplication HPZ between procedures [Hill: 2.9 ± 0.4 cm, Toupet: 3.1 ± 0.6 cm, p = 0.15]. Follow-up showed no significant differences in GERD-HRQL scores, overall dysphagia scores or atypical symptoms between groups (p > 0.05). CONCLUSION The Hill procedure is as effective to the Toupet fundoplication in surgically treating gastroesophageal reflux disease (GERD) despite the lower CSA, DI, and compliance after the Hill procedure. Both procedures led to DI < 2 mm2/mmHg with no significant differences in dysphagia reporting (12-24) months after the procedure. Further studies to elucidate a cutoff value for DI for postoperative dysphagia development are still warranted.
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Affiliation(s)
- Hala Al Asadi
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Haythem Najah
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | | | - Jacques A Greenberg
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Teagan Marshall
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Niloufar Salehi
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Yeon Joo Lee
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Maria Cristina Riascos
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Brendan M Finnerty
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Thomas J Fahey
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA.
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Miller JD, Kemple BP, Evans JK, Clayton SB. A Comparison of Functional Luminal Imaging Probe With High-resolution Manometry, Timed Barium Esophagram, and pH Impedance Testing to Evaluate Functional Luminal Imaging Probe's Diagnostic Capabilities. J Clin Gastroenterol 2024:00004836-990000000-00253. [PMID: 38227842 DOI: 10.1097/mcg.0000000000001966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE The aims of this study are to determine the functional luminal imaging probe's (FLIP) diagnostic utility by comparing FLIP measurements with results from other esophageal evaluation standards. BACKGROUND The FLIP is an esophageal evaluation technique performed at the time of endoscopy. Few studies have evaluated FLIP diagnostic capabilities compared with the established testing techniques, including high-resolution manometry (HRIM), time barium esophagram (TBE), and 24-hour impedance-pH monitoring. PATIENTS AND METHODS A retrospective review was performed for 413 preintervention patients who underwent FLIP testing during endoscopy. Data from HRIM, 24-hour pH monitoring, and TBE were compared. RESULTS Abnormal Distensibility Index (DI) was associated with abnormal integrated relaxation pressure (IRP; P = 0.003). Average DI was higher in patients with abnormal IRP (>15 mm Hg) when a hiatal hernia was present (P = 0.025). The total agreement between correlated diagnoses from FLIP and HRIM was 33.5%. DI was not associated with acid exposure time on pH monitoring. Agreement between FLIP and TBE was 49% with a sensitivity of 98.1% and a specificity of 36.5%. A 60 mL distension had a significantly lower detection rate than 40 mL and 50 mL for active peristalsis and was unaffected by pressure (P < 0.05). CONCLUSIONS FLIP as an adjunct to HRIM is supported by strong metric correlation. FLIP was not correlated to pH monitoring findings, suggesting FLIP is not useful in reflux assessment. The agreement between FLIP and TBE was lower than in previous studies. Hiatal hernia impacted the normality between DI and IRP, not between FLIP and TBE. We suggest analyzing peristaltic patterns on panometry at all fill volumes to optimize detection.
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Affiliation(s)
| | - Brendan P Kemple
- Wake Forest University School of Medicine
- Department of Medicine, Medical College of Georgia
| | - Joni K Evans
- Biostatistics and Data Science, Wake Forest University School of Medicine
| | - Steven B Clayton
- Department of Medicine, Section on Gastroenterology, Wake Forest University School of Medicine
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Wang TN, Underhill J, Tamer R, Perry KA, Haisley KR. Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery. Surg Endosc 2024; 38:377-383. [PMID: 37803186 DOI: 10.1007/s00464-023-10418-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/29/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study. METHODS Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant. RESULTS Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3 kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001). CONCLUSION Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD.
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Affiliation(s)
- Theresa N Wang
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA.
| | - Jennifer Underhill
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA
| | - Robert Tamer
- Department of Surgery, Center for Surgical Health Assessment, Research and Policy, The Ohio State University, Columbus, OH, USA
| | - Kyle A Perry
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA
| | - Kelly R Haisley
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA
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Amundson JR, Kuchta K, VanDruff VN, Wu H, Campbell M, Hedberg HM, Ujiki MB. Experience with Impedance Planimetry for Surgical Foregut Disease in 1,097 Cases. J Am Coll Surg 2023; 237:35-48. [PMID: 36896984 DOI: 10.1097/xcs.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The geometry and compliance of gastrointestinal sphincters may be assessed by impedance planimetry using a functional lumen imaging probe (FLIP). We describe our institutional foregut surgeon experience using FLIP in 1,097 cases, highlighting instances where FLIP changed operative decision making. STUDY DESIGN A retrospective review of an IRB-approved prospective quality database was performed. This included operative and endoscopic suite foregut procedures using FLIP between February 2013 and May 2022. RESULTS During the study period, FLIP was used a total of 1,097 times in 919 unique patients by 2 foregut surgeons. Intraoperative FLIP was used during 573 antireflux procedures and 272 endoscopic myotomies. FLIP was also used during 252 endoscopic suite procedures. For those undergoing preoperative workup of GERD, starting in 2021, esophageal panometry was performed in addition to standard FLIP measurements at the lower esophageal sphincter. In 77 cases, intraoperative FLIP changed operative decision making. During antireflux procedures, changes included adding or removing crural sutures, adjusting a fundoplication tightness, choice of full vs partial wrap, and magnetic sphincter augmentation sizing. For endoscopic procedures, changes included aborting peroral endoscopic myotomy or Zenker's peroral endoscopic myotomy, performing a myotomy when preoperative diagnosis was unclear, or performing additional myotomy. CONCLUSIONS FLIP is a useful tool for assessing the upper esophageal sphincter, lower esophageal sphincter, pylorus, and secondary esophageal peristalsis that can be used in a wide variety of clinical situations within a foregut surgeon's practice. It can also function as an adjunct in intraoperative decision making.
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Affiliation(s)
- Julia R Amundson
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Kristine Kuchta
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Vanessa N VanDruff
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Hoover Wu
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Michelle Campbell
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - H Mason Hedberg
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Michael B Ujiki
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
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Greenberg JA, Palacardo F, Edelmuth RCL, Egan CE, Lee YJ, Dakin G, Zarnegar R, Afaneh C, Bellorin O. Quantifying physiologic parameters of the gastroesophageal junction during robotic sleeve gastrectomy and identifying predictors of post-sleeve gastroesophageal reflux disease. Surg Endosc 2023; 37:1543-1550. [PMID: 35859010 DOI: 10.1007/s00464-022-09450-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sleeve gastrectomy is among the most commonly-performed procedures for morbid obesity. However, patients occasionally develop post-sleeve gastroesophageal reflux disease (GERD). Identifying patients most at risk for this complication remains difficult. We aimed to correlate intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the gastroesophageal junction (GEJ) during robotic sleeve gastrectomy in an attempt to identify predictors of post-sleeve GERD symptoms. METHODS A retrospective chart review of a prospectively maintained database identified 28 patients in whom robotic sleeve gastrectomy was performed utilizing EndoFLIP™ technology between January and September 2021. Intraoperative LES measurements at the GEJ including cross-sectional area (CSA), distensibility index (DI), intra-balloon pressure, and high-pressure zone (HPZ length) were correlated with post-operative GERD. RESULTS GEJ CSA, pressure, and DI increased over the course of the surgery (CSA pre-op: 31 (IQR 19.3-39.5) mm2 vs. post-op: 67 (IQR 40.8-95.8) mm2, p < 0.001; pressure: 25.8 (IQR 20.2-33.1) mmHg vs. 31.5 (IQR 28.9-37.0) mmHg, p = 0.007; DI 1.1 (IQR 0.8-1.8) mm2/mmHg vs. 2.0 (IQR 1.2-3.0) mm2/mmHg, p = < 0.001), whereas HPZ length decreased (2.5 (IQR 2.5-3) cm vs. 2.0 (IQR 1.3-2.5) cm, p = 0.022). Twenty-three patients (82.1%) completed a post-operative GERD questionnaire. Fifteen (65.2%) had no GERD symptoms before or after surgery; 5 (21.7%) reported new post-sleeve GERD symptoms; 3 (13.0%) reported exacerbation of pre-existing GERD symptoms. Patients with new or worsening GERD symptoms had higher post-sleeve DIs (3.2 (IQR 1.9-4.5) mm2/mmHg vs. 1.5 (IQR 1.2-2.4) mm2/mmHg, p = 0.024) and lower post-sleeve LES pressures (29.9 (IQR 26.3-32.9) mmHg vs. 35.2 (IQR 31.0-38.0) mmHg, p = 0.023) than those without. CONCLUSIONS An increase in GEJ CSA, pressure, and DI, and a decrease in GEJ length can be expected during robotic sleeve gastrectomy. Patients with new or worsening post-sleeve GERD symptoms have higher post-sleeve DI and lower post-sleeve LES pressure than their asymptomatic counterparts.
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Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Federico Palacardo
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Rodrigo C L Edelmuth
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Caitlin E Egan
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Yeon Joo Lee
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Gregory Dakin
- Department of Surgery, Division of Gastrointestinal Metabolic & Bariatric Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 520 East 70th Street, Starr Pavillion, 8th Floor, New York, NY, 10021, USA
| | - Rasa Zarnegar
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Cheguevara Afaneh
- Department of Surgery, Division of Gastrointestinal Metabolic & Bariatric Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 520 East 70th Street, Starr Pavillion, 8th Floor, New York, NY, 10021, USA
| | - Omar Bellorin
- Department of Surgery, Division of Gastrointestinal Metabolic & Bariatric Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 520 East 70th Street, Starr Pavillion, 8th Floor, New York, NY, 10021, USA.
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Wu H, Attaar M, Wong HJ, Campbell M, Kuchta K, Denham W, Linn J, Ujiki MB. Impedance planimetry (EndoFLIP™) reveals changes in gastroesophageal junction compliance during fundoplication. Surg Endosc 2022; 36:6801-6808. [PMID: 35015103 DOI: 10.1007/s00464-021-08966-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/12/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Compliance is the ability of a hollow organ to dilate and increase volume with an increase in pressure, an accurate representation of food bolus transit through the gastroesophageal junction (GEJ). Impedance planimetry system can calculate compliance (change in volume over pressure) and distensibility (cross-sectional area over pressure) of the GEJ. We aim to describe the changes in compliance during anti-reflux surgery and hypothesize that compliance is a better predictor of patient outcomes than distensibility (DI). METHODS AND PROCEDURES A review of a prospectively maintained quality database was performed. Patients with FLIP measurements during laparoscopic fundoplication between August 2018 and June 2021 were included. GEJ compliance and DI were measured after hernia reduction, cruroplasty, and fundoplication. Patient-reported outcomes were collected through standardized surveys up to 2 years after surgery. A scatter plot was used to identify a correlation between compliance and DI. Comparisons of measurements between time points were made using paired t-tests. Spearman's correlation coefficients (ρ), Wilcoxon rank-sum, and chi-square tests were used to evaluate associations between measurements and outcomes. RESULTS One hundred and forty-four patients underwent laparoscopic fundoplication. Compliance is strongly associated with DI (r = 0.96), and a comparison of measurements showed similar trends at specific time points during the operation. After hernia reduction, compliance at the GEJ was 168 ± 74 mm3/mmHg, cruroplasty 79 ± 39 mm3/mmHg, and fundoplication 90 ± 33 mm3/mmHg (all comparisons p < 0.05). GEJ compliance of 80-92 mm3/mmHg after fundoplication was associated with the best patient-reported outcome scores. A compliance of ≤ 79 mm3/mmHg had the highest percentage of patients who reported dysphagia. CONCLUSIONS Compliance and DI are strongly associated displaying the same directional change during anti-reflux surgery. GEJ compliance of 80-92 mm3/mmHg revealed the best patient-reported outcome scores, and avoiding a compliance ≤ 79 mm3/mmHg may prevent postoperative dysphagia. Therefore, GEJ compliance is an underutilized FLIP measurement warranting further investigation.
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Affiliation(s)
- Hoover Wu
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA.
| | - Mikhail Attaar
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Harry J Wong
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Michelle Campbell
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | | | - Woody Denham
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - John Linn
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
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Wu H, Attaar M, Wong HJ, Campbell M, Kuchta K, Denham EW, Linn J, Ujiki MB. Impedance Planimetry (Endoflip) and Ideal Distensibility Ranges for Optimal Outcomes after Nissen and Toupet Fundoplication. J Am Coll Surg 2022; 235:420-429. [PMID: 35972160 DOI: 10.1097/xcs.0000000000000273] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous research has shown that impedance planimetry-based functional lumen imaging probe (FLIP) measurements are associated with patient-reported outcomes after laparoscopic antireflux surgery. We hypothesize that Nissen and Toupet fundoplications have different ideal FLIP profiles, such as distensibility. STUDY DESIGN A retrospective review of a prospectively maintained quality database was performed. Patients who had FLIP measurements during fundoplications between 2013 and 2021 were included. Reflux Symptom Index, Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire, and dysphagia score were collected for up to 2 years postoperatively. The Wilcoxon rank-sum test was used to compare FLIP measurements vs outcomes. RESULTS Two hundred fifty patients (171 Toupet, 79 Nissen) were analyzed. Distensibility ranges were categorized as tight, ideal, or loose. The ideal distensibility index range of Toupet patients with the 30- and 40-mL balloon fills were 2.6 to 3.7 mm2/mmHg. This range was associated with less dysphagia at 1 year compared with the tight group (p = 0.02). For Nissen patients, the 30- and 40-mL ideal threshold was a distensibility index of ≥2.2 mm2/mmHg. Patients with distensibility exceeding this threshold had a better quality of life than the tight group, reporting better Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire (p = 0.02) and lower dysphagia scores (p = 0.01) at 2 years. CONCLUSIONS Impedance planimetry revealed different ideal distensibility ranges after Toupet and Nissen fundoplications that are associated with improved patient-reported outcomes, suggesting that intraoperative FLIP has the potential to tailor fundoplication.
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Affiliation(s)
- Hoover Wu
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki).,Department of Surgery, University of Chicago Medical Center, Chicago, IL (Wu, Attaar, Wong, Campbell)
| | - Mikhail Attaar
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki).,Department of Surgery, University of Chicago Medical Center, Chicago, IL (Wu, Attaar, Wong, Campbell)
| | - Harry J Wong
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki).,Department of Surgery, University of Chicago Medical Center, Chicago, IL (Wu, Attaar, Wong, Campbell)
| | - Michelle Campbell
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki).,Department of Surgery, University of Chicago Medical Center, Chicago, IL (Wu, Attaar, Wong, Campbell)
| | - Kristine Kuchta
- cNorthShore University Research Institute, Evanston, IL (Kuchta)
| | - Ervin Woodford Denham
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki)
| | - John Linn
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki)
| | - Michael B Ujiki
- From the Department of Surgery, NorthShore University Health System, Evanston, IL (Wu, Attaar, Wong, Campbell, Denham, Linn, Ujiki)
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Greenberg JA, Stefanova DI, Reyes FV, Edelmuth RCL, Thiesmeyer JW, Egan CE, Liu M, Schnoll-Sussman FH, Katz PO, Christos P, Finnerty BM, Fahey TJ, Zarnegar R. Quantifying physiologic parameters of the gastroesophageal junction during re-operative anti-reflux surgery. Surg Endosc 2022; 36:7008-7015. [PMID: 35102431 DOI: 10.1007/s00464-022-09025-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hiatal hernia re-approximation during index anti-reflux surgery (ARS) contributes approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the gastroesophageal (GEJ), while sphincter augmentation contributes approximately 20%. Whether this is seen in re-operative ARS is unclear. We quantify the physiologic parameters of the GEJ at each step of robotic re-operative ARS and compare these to index ARS. METHODS Robotic ARS with hiatal hernia repair was performed on 195 consecutive patients with pathologic reflux utilizing EndoFLIP™, of which 26 previously had ARS. Intra-operative GEJ measurements, including cross-sectional area (CSA), pressure, DI, and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, post-mesh placement, and post-lower-esophageal sphincter (LES) augmentation. RESULTS Both cohorts were similar by sex and BMI and underwent similar procedures. The re-operative cohort was older (60.6 ± 15.3 vs. 52.7 ± 16.2 years, p = 0.03), had more frequent pre-operative dysphagia (69.2% vs. 42.6%, p = 0.01) and esophageal dysmotility on barium swallow (75.0% vs. 35.0%, p < 0.001) but lower rates of hiatal hernia on endoscopy (30.8% vs. 68.7%, p < 0.001) compared to index procedures. Among the re-operative cohort, the CSA decreased by 34 (IQR - 80, - 15) mm2 and DI 1.1 (IQR - 2.4, - 0.6) mm2/mmHg (both p < 0.001). Pressure increased by 11.2 (IQR 4.7, 14.9) mmHg and HPZ by 1.5 (1,2) cm (both p < 0.001). These changes were similar to those seen in index ARS. Diaphragmatic re-approximation contributed to a greater percentage of overall change to the GEJ than did the augmentation procedure, with 72% of the change in DI occurring during hiatal closure, similar to that seen during index ARS. CONCLUSIONS During re-operative ARS, dynamic intra-operative monitoring can quantify the effects of each operative step on GEJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on GEJ physiology than does LES-sphincter augmentation during both index and re-operative ARS.
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Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Dessislava I Stefanova
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Fernando Valle Reyes
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Rodrigo C L Edelmuth
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Caitlin E Egan
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Mengyuan Liu
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Felice H Schnoll-Sussman
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Philip O Katz
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Paul Christos
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA.
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9
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Wu H, Attaar M, Wong HJ, Campbell M, Kuchta K, Denham W, Linn J, Ujiki MB. Impedance planimetry (EndoFLIP™) after magnetic sphincter augmentation (LINX®) compared to fundoplication. Surg Endosc 2022; 36:7709-7716. [PMID: 35169878 DOI: 10.1007/s00464-022-09128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Functional luminal imaging probe (FLIP) use during laparoscopic fundoplication (LF) for gastroesophageal reflux disease is well described. However, there is a lack of data on FLIP measurements during magnetic sphincter augmentation (MSA). This study aims to report our institutional experience in performing FLIP during MSA and to compare these measurements to those obtained during Nissen and Toupet fundoplication. METHODS AND PROCEDURES A retrospective review of a prospectively maintained quality database was performed. Patients who underwent MSA or LF and had FLIP measurements between April 2018 and June 2021 were included. FLIP measurements at the gastroesophageal junction (GEJ) were recorded without pneumoperitoneum at 40 mL balloon fill after hernia reduction, cruroplasty, and MSA or fundoplication. Reflux symptom index (RSI), GERD-HRQL, and dysphagia score were collected up to 2 years. Group comparisons were made using two-tailed Wilcoxon rank-sum and χ2 tests, with statistical significance of p < 0.05. RESULTS Twenty-seven patients underwent MSA and 100 patients underwent LF (66% Toupet, 34% Nissen). Type III hiatal hernia was present in 3.7% of MSA patients versus over 50% for fundoplication patients. Minimum diameter, cross-sectional area, and distensibility index (DI) were lower after MSA device placement compared to Nissen or Toupet fundoplication (p < 0.05). Postoperative follow-up showed no differences in RSI, GERD-HRQL, and dysphagia score between MSA and Nissen fundoplication (p > 0.05). CONCLUSION Intraoperative impedance planimetry provided objective information regarding the geometry of the GEJ during MSA. The ring of magnetic beads restores the anti-reflux barrier and transiently opens with food bolus and belching. The magnetic force of the beads may explain why the DI after MSA is lower yet postoperative quality of life is no different than Nissen fundoplication.
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Affiliation(s)
- Hoover Wu
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA. .,Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA. .,Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA.
| | - Mikhail Attaar
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA.,Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Harry J Wong
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA.,Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Michelle Campbell
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA.,Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | | | - Woody Denham
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - John Linn
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
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10
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Wu H, Attaar M, Wong HJ, Campbell M, Kuchta K, Ungerleider S, Denham W, Linn J, Ujiki MB. Impedance planimetry (EndoFLIP) measurements persist long term after anti-reflux surgery. Surgery 2021; 171:628-634. [PMID: 34865861 DOI: 10.1016/j.surg.2021.08.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE The functional lumen imaging probe provides objective measurements of the gastroesophageal junction during laparoscopic anti-reflux surgery. There is a lack of data on how functional lumen imaging probe measurements change at follow-up. We aim to describe our institutional experience in performing functional lumen imaging probe during postoperative endoscopy after laparoscopic anti-reflux surgery. METHODS A prospectively maintained database was queried. Patients who had postoperative endoscopic functional lumen imaging probe measurements between March 2018 and June 2021 were assessed at different time points from their index laparoscopic anti-reflux surgery using paired t test. Standardized quality of life questionnaires were collected for up to 2 years. Group comparisons were made using the Wilcoxon rank-sum test. RESULTS Fifty-eight patients who underwent laparoscopic anti-reflux surgery (magnetic sphincter augmentation or fundoplication) had postoperative functional lumen imaging probe. Thirty-two intraoperative functional lumen imaging probe values were compared with their postoperative functional lumen imaging probe. Fundoplication values did not differ. Postoperative functional lumen imaging probe distensibility index for magnetic sphincter augmentation patients was decreased (P = .04). Functional lumen imaging probe measurements for all postoperative endoscopies showed that magnetic sphincter augmentation had the lowest distensibility index (P < .01). Dysphagia as a reason for endoscopy had a decrease in distensibility index (P = .03). CONCLUSION Functional lumen imaging probe measurements after fundoplication persist at long-term follow up while patients may have a tighter gastroesophageal junction after magnetic sphincter augmentation. Functional lumen imaging probe has the potential to assess the success or failure after laparoscopic anti-reflux surgery and optimize patient outcomes.
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Affiliation(s)
- Hoover Wu
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL.
| | - Mikhail Attaar
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - Harry J Wong
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - Michelle Campbell
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | | | | | - Woody Denham
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - John Linn
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, IL
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11
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Shah A, Nguyen DT, Meisenbach LM, Chihara R, Chan EY, Graviss EA, Kim MP. A novel EndoFLIP marker during hiatal hernia repair is associated with short-term postoperative dysphagia. Surg Endosc 2021; 36:4764-4770. [PMID: 34713341 DOI: 10.1007/s00464-021-08817-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoluminal functional lumen imaging probe (EndoFLIP) provides an objective measure of the distensibility index (DI) during different parts of hiatal hernia repair. However, the absolute DI measure above a cut-off after creating a barrier alone has not shown a relationship to dysphagia after surgery. We wanted to determine if the change in DI with volume change is associated with dysphagia. METHODS We included patients who had hiatal hernia repair with EndoFLIP values, including two values taken at the end of the surgical case with different volumes of fluid in the balloon (30 mL and 40 mL). We compared the absolute and change in DI during hiatal hernia repair and performed an analysis to determine if there was a correlation with short-term clinical outcomes. RESULTS A total of 103 patients met the inclusion and exclusion criteria. Most of the patients underwent Toupet fundoplication (n = 56, 54%), followed by magnetic sphincter augmentation (LINX, n = 28, 27%) and Nissen fundoplication (n = 19, 18%). There was a significant reduction in the DI from the initial DI taken after mobilization of the hiatus (3 mm2/mmHg) and after the creation of the barrier (1.4 mm2/mmHg, p < 0.001). A minority of patients had a decrease or no change in the DI with an increase in balloon volume increased from 30 to 40 mL (n = 37, 36%). Overall, after 1 month, there was a significant decrease in the GERD-HRQL score from 23 to 4 (p < 0.001) and bloat score from 3 to 2 (p = 0.003) with a non-significant decrease in the dysphagia score from 1 to 0 (p = 0.11). Patients who had a decreased or unchanged DI with an increase in the balloon volume from 30 to 40 mL had a significant decrease in their dysphagia score by 2 points (p = 0.04). CONCLUSION The decreased or unchanged DI with an increase in the balloon volume on EndoFLIP is associated with a significant reduction in dysphagia after surgery. The decrease in DI denotes the esophagus's ability to create higher pressure relative to the change in the cross-sectional area with a larger bolus across the gastroesophageal junction. This measure may be a new marker that can predict short-term outcomes in patients undergoing hiatal hernia repair.
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Affiliation(s)
- Anuj Shah
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Leonora M Meisenbach
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA. .,Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA.
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12
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Paranyak M, Patel R, Grubnyk V, Grubnik V. Influence of Wrap Fixation Technique on the Results of Fundoplication. Surg Laparosc Endosc Percutan Tech 2021; 31:663-668. [PMID: 34183570 DOI: 10.1097/sle.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Different techniques of wrap fixation in laparoscopic Nissen fundoplication (LNF) have been proposed with of the aim to reduce the complications, but the optimal technique is yet to be determined. The aim of our prospective study was to evaluate several techniques of wrap fixation and determine whether the application of a combined approach to perform wrap fixation reduces the failure rate in short-term and long-term follow-up. MATERIALS AND METHODS One hundred two patients with sliding or paraesophageal hiatal hernia (type I or type II), who underwent antireflux surgery were randomized into 2 groups. In group I, LNF was supplemented with suturing the wrap to the diaphragmatic crura (35 patients) or to the body of stomach (16 patients). This was dependent on the strength of the crura (defined as weak or strong). The control group (51 patients) underwent LNF without wrap fixation. All patients were assessed using a validated symptom and quality of life (gastroesophageal reflux disease-Health Related Quality of Life) questionnaire, 24-hour impedance-pH monitoring, and barium swallow. RESULTS At the 48-month follow-up, the overall rate of complications was not significantly different between the 2 groups; however, there was a tendency toward a lower frequency of reoperations in the first group (P=0.059). Fixation of the fundoplication of wrap was noted to lead to significantly lower rates of postoperative dysphagia (P<0.05). These patients (group I) were also found to have significant improvement in gastroesophageal reflux disease-Health Related Quality of Life score (from 19.3±13.2 to 4.3±3.9 vs. from 18.7±11.9 to 9.3±7.7). CONCLUSION Fixation of the Nissen fundoplication wrap has been shown to have a positive impact on the reduction of postoperative dysphagia and leads to an improvement in disease-specific quality of life.
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Affiliation(s)
- Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv
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13
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Using a standardized intra-operative endoflip protocol during fundoplication to identify factors that affect distensibility. Surg Endosc 2020; 35:5717-5723. [PMID: 32970210 DOI: 10.1007/s00464-020-08034-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/16/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The Endoluminal Functional Lumen Imaging Probe (Endoflip) can be used to provide objective measurements of the gastroesophageal junction during fundoplication, and recent publications have suggested that this device could improve surgical outcomes. However, the impact of operative variables has not been clearly reported. The aim of this study is to determine the effect of these variables on functional lumen imaging probe (FLIP) measurements. METHODS Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This database was queried for patients undergoing hiatal hernia repair and fundoplication. The protocol utilized various balloon volumes (30 and 40 ml), patient positions (flat and reverse Trendelenburg) and amounts of insufflation (15 mmHg pneumoperitoneum and no pneumoperitoneum). RESULTS Between August 2018 and February 2020, 97 fundoplications were performed by a single surgeon. Multivariable analysis without interactions demonstrated that a 40 ml volume fill resulted in significantly higher minimum diameter (Dmin), cross-sectional area (CSA), intra-balloon pressure (IBP) and distensibility index (DI) compared to a 30 ml volume fill (p < 0.001). While reverse Trendelenburg positioning resulted in a significantly higher Dmin, IBP and CSA compared to the flat position (all p < 0.05), there was little impact of positioning on DI. Lastly, pneumoperitoneum significantly increased IBP (p < 0.001) but did not affect Dmin (p = 0.697) or CSA (p = 0.757), which resulted in a significant decrease in DI (p < 0.001) when compared to measurements without pneumoperitoneum. Multivariable analysis allowing for interactions demonstrated significant two-way interactions between balloon volume and pneumoperitoneum (p = 0.047), as well as patient position and pneumoperitoneum (p < 0.001). CONCLUSION Surgeons should consider balloon volume and the presence or absence of pneumoperitoneum when interpreting distensibility during or after fundoplication. Additionally, we suggest a formal standardized protocol for FLIP measurements to utilize a 40 ml volume fill in reverse Trendelenburg without pneumoperitoneum.
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14
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Su B, Wong HJ, Attaar M, Kuchta K, Linn JG, Haggerty SP, Denham W, Ujiki MB. Comparing short-term patient outcomes after fundoplication performed over a traditional bougie versus a functional lumen imaging probe. Surgery 2020; 169:533-538. [PMID: 32919782 DOI: 10.1016/j.surg.2020.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The functional lumen imaging probe is a balloon-based catheter that can be used as a bougie during fundoplication. Our goal was to compare the short-term, quality-of-life outcomes and esophageal-injury rate after fundoplication over a functional lumen imaging probe compared to a traditional bougie. METHODS This is a retrospective review of a quality database at a single center. Three-week and 6-month Reflux Symptom Index, Gastroesophageal Reflux Disease-health Related Quality of Life, and dysphagia scores were compared. The need for endoscopy and dilation between the groups was also compared. RESULTS Between 2008 and 2020, 423 fundoplications were performed over a bougie and 62 over the functional lumen imaging probe. Six months after surgery, the functional lumen imaging probe group reported significantly worse dysphagia scores (1.5 ± 1.0 vs 1.1 ± 0.3, P = .007), but rates of endoscopy (4.8% vs 5.0%, P = .966) and dilation (4.8% vs 3.8%, P = .723) were similar. There were no differences between Reflux Symptom Index and Gastroesophageal Reflux Disease-health Related Quality of Life scores. The rate of bougie-related injuries was 2.1% vs 0% for the functional lumen imaging probe group. CONCLUSION Patients undergoing fundoplication over the functional lumen imaging probe had comparable short-term outcomes compared with those over a traditional bougie. The rate of esophageal injury while using the functional lumen imaging probe is lower than a bougie and may be preferable for fundoplication creation.
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Affiliation(s)
- Bailey Su
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Department of Surgery, University of Chicago, IL.
| | - Harry J Wong
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Department of Surgery, University of Chicago, IL
| | - Mikhail Attaar
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Department of Surgery, University of Chicago, IL
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | - John G Linn
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | | | - Woody Denham
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
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15
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Desprez C, Roman S, Leroi AM, Gourcerol G. The use of impedance planimetry (Endoscopic Functional Lumen Imaging Probe, EndoFLIP ® ) in the gastrointestinal tract: A systematic review. Neurogastroenterol Motil 2020; 32:e13980. [PMID: 32856765 DOI: 10.1111/nmo.13980] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE The EndoFLIP® system is a method of delineating impedance and was first designed to investigate the characteristics of the esophago-gastric junction. In the last decade, its use was widened to investigate other sphincteric and non-sphincteric systems of the gastrointestinal tract. The objective of the present systematic review was to summarize the available data in literature on the use of the EndoFLIP® system in the gastrointestinal tract, including sphincteric and non-sphincteric regions. We performed a systematic review in accordance with recommendations for systematic review using PRISMA guidelines without date restriction, until June 2020, using MEDLINE-PubMed, Cochrane Library, and Google Scholar databases. Only articles written in English were included in the present review. Five hundred and six unique citations were identified from all database combined. Of those, 95 met the inclusion criteria. There was a lack of standardization among studies in terms of anesthetic drugs use, probe placement, and inflation protocol. In most cases, only small cohorts of patients were included. Most studies investigated the EGJ, with a potential use of the EndoFLIP® to identify a subgroup of patients with achalasia and for intraoperative assessment of treatment efficacy in achalasia. However, the use of EndoFLIP® in the esophageal body (esophageal panometry), other esophageal diseases (gastro-esophageal reflux disease, eosinophilic esophagitis), and other sphincter regions (anal canal, pylorus) will need further confirmatory studies. The EndoFLIP® system provides detailed geometric data of the gastrointestinal lumen but further works are needed to determine its use in clinical practice.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
| | - Sabine Roman
- Digestive Physiology Department, Hospices Civils de Lyon, Hopital H Herriot, Lyon, France
| | - Anne Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
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16
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Nwokedi U, Nguyen DT, Meisenbach LM, Chihara R, Chan EY, Graviss EA, Kim MP. Short-term outcome of routine use of EndoFLIP during hiatal hernia repair. Surg Endosc 2020; 35:3840-3849. [PMID: 32661713 DOI: 10.1007/s00464-020-07788-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Endoluminal functional lumen imaging probe (EndoFLIP) technology is a tool that can be used to provide intraoperative objective real-time feedback during hiatal hernia repair. We wanted to determine the implication of initial distensibility index (DI) after mobilization of hiatus and final DI after creation of barrier in short-term clinical outcomes. METHODS We performed a retrospective analysis of prospectively collected data on the intraoperative use of EndoFLIP during hiatal hernia repair at a single institution from 2017 to 2019. We analyzed the initial DI and final DI with the short-term clinical outcomes. RESULTS There were 163 patients who had Nissen (n = 16), Toupet (n = 79) or magnetic sphincter augmentation (n = 68) with (n = 158) or without (n = 5) hiatal hernia repair with median initial DI was 3.2 mm2/mmHg. We used 3 mm2/mmHg as the cutoff for low (n = 84) vs. high (n = 79) initial DI group. There was no difference in DeMeester score (p = 0.76), the peristalsis on manometry (p = 0.13), type of hiatal hernia (p = 0.98), and GERD-HRQL score prior to surgery (p = 0.73) between the groups. There was significantly higher final DI in the high initial DI group compared to low initial DI group; however, there was no significant difference in the GERD-HRQL score at 1-3 months (p = 0.28). All of the patients had a final DI > 0.5 mm2/mmHg at the end of the case with median final DI of 1.6 mm2/mmHg. None of these patients required steroids (0%) and only one patient (0.6%) required EGD and dilatation as well as re-operation for dysphagia within 3 months. CONCLUSIONS The initial DI was associated with final DI, but it did not correlate with improvement in short-term GERD-HRQL score. Final DI maintained above the cutoff value led to most of the patients not to require intervention for dysphagia. Use of the EndoFLIP can provide objective data during the operation and prevent severe dysphagia after repair.
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Affiliation(s)
- Ugoeze Nwokedi
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Leonora M Meisenbach
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA.
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
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Experience-based expert consensus on the intra-operative usage of the Endoflip impedance planimetry system. Surg Endosc 2020; 35:2731-2742. [DOI: 10.1007/s00464-020-07704-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 02/06/2023]
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