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Crafts TD, Seidel H, Hedberg HM, Kuchta K, Carbray J, Anderson DJ, Joseph S, Rwigema JC, Ishii S, Ujiki MB. Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients. Surg Endosc 2024; 38:5239-5245. [PMID: 38992281 DOI: 10.1007/s00464-024-11062-9] [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: 04/24/2024] [Accepted: 07/06/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms and quality of life. As this procedure has only been performed in the United States for the past 4 years, safety and efficacy have not been well established. METHODS This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data, operative intervention, 90-day complications, and response to treatment. Quality of life and patient satisfaction data were collected by phone survey. RESULTS Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65 years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75 min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. CONCLUSIONS POPE is an endoscopic procedure that is efficacious in relieving emptying difficulties for the end-stage esophagus and gastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.
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Affiliation(s)
- Trevor D Crafts
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA.
| | - Henry Seidel
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Herbert M Hedberg
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Kristine Kuchta
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - JoAnn Carbray
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Derrius J Anderson
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Stephanie Joseph
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Jean-Christophe Rwigema
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
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Casabona-Francés S, Sanz-García A, Ortega GJ, Santander C, Perez-Fernandez T, Majano P, Olalla JM, Juárez-Tosina R, Mueller R, Attwood S, Lucendo A. A New Method to Evaluate Lower Esophageal Distension Capacity in Eosinophilic Esophagitis by Using Functional Lumen Imaging Probe (EndoFLIP™). Diagnostics (Basel) 2024; 14:218. [PMID: 38275466 PMCID: PMC10814586 DOI: 10.3390/diagnostics14020218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
Endoluminal functional lumen impedance planimetry (EndoFLIPTM) has become the gold standard to evaluate esophageal distensibility, although the study itself and its analysis present challenges. We propose here a new method to assess lower esophageal distension capacity that overcomes several limitations of prior approaches, including incomplete and corrupted EndoFLIPTM recordings. Esophageal distension capacity was evaluated with a 16-channel EndoFLIPTM in 10 controls and 14 patients with eosinophilic esophagitis (EoE). Controls were evaluated once. EoE patients were evaluated at baseline and after at least six weeks of treatment with orodispersible budesonide tablets, 1 mg bd. Balloon volumes were increased by 5 mL stepwise, either reaching a maximum volume of 60 mL or a maximum balloon pressure of 60 mmHg. Recordings were analyzed with a homemade R script. The mean esophageal diameter at 60 mL, D (60 mL), was calculated or extrapolated depending on whether the 60 mL volume was reached. By fitting a Michaelis-Menten curve across all measured diameters throughout all constant volume steps, the mean D (60 mL) was estimated. For control subjects, the mean ± SD value of D (60 mL) was 17.08 ± 1.69 mm, and for EoE patients at baseline, D (60 mL) was 14.51 ± 2.68 mm. After six weeks of treatment of EoE patients, D (60 mL) significantly increased to 16.22 ± 1.86 mm (paired Wilcoxon signed test: p = 0.0052), although the values for control subjects were not reached. The estimated mean esophageal diameter at 60 mL is a good proxy for esophageal distension capacity, which correlates with clinical outcomes in EoE. The method presented in this study overcomes difficulties encountered during the standard measurement protocol, allowing the analysis of recordings from incomplete and corrupted registries.
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Affiliation(s)
- Sergio Casabona-Francés
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (S.C.-F.); (C.S.); (T.P.-F.); (P.M.)
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain;
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de Investigación, Sanitaria Hospital Universitario de la Princesa, 28006 Madrid, Spain;
| | - Guillermo J. Ortega
- Data Analysis Unit, Instituto de Investigación, Sanitaria Hospital Universitario de la Princesa, 28006 Madrid, Spain;
- Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET, Buenos Aires C1425FQB, Argentina
- Science and Technology Department, National University of Quilmes, Bernal B1876BXD, Argentina
| | - Cecilio Santander
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (S.C.-F.); (C.S.); (T.P.-F.); (P.M.)
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain;
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - Teresa Perez-Fernandez
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (S.C.-F.); (C.S.); (T.P.-F.); (P.M.)
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain;
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - Pedro Majano
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (S.C.-F.); (C.S.); (T.P.-F.); (P.M.)
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain;
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - José Maria Olalla
- Department of Pathology, Hospital General La Mancha Centro, 13600 Alcázar de San Juan, Spain; (J.M.O.); (R.J.-T.)
| | - Rocio Juárez-Tosina
- Department of Pathology, Hospital General La Mancha Centro, 13600 Alcázar de San Juan, Spain; (J.M.O.); (R.J.-T.)
| | - Ralph Mueller
- Department of Clinical Research and Development, Dr. Falk Pharma GmbH, 79108 Freiburg, Germany;
| | - Stephen Attwood
- Department of Health Services Research, Durham University, Durham DH1 3LE, UK;
| | - Alfredo Lucendo
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain;
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
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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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