Esophageal dilation with integrated balloon imaging: initial evaluation in a porcine model

Esophageal dilation with EsoFLIP is faster than CRE balloon dilation combined with EndoFLIP in children

BACKGROUND

Controlled radial expansion (CRE) balloon dilators are traditionally used to dilate esophageal strictures during an esophagogastroduodenoscopy (EGD). EndoFLIP is a diagnostic tool used during an EGD to measure important parameters of the gastrointestinal lumen, capable of assessing treatment before and after dilation. EsoFLIP is a related device that combines a balloon dilator with high-resolution impedance planimetry to provide some of the luminal parameters in real time during dilation. We sought to compare procedure time, fluoroscopy time, and safety profile of esophageal dilation using either CRE balloon dilation combined with EndoFLIP (E + CRE) versus EsoFLIP alone.

METHODS

A single-center retrospective review was performed to identify patients ≤ 21 years of age who underwent an EGD with biopsy and esophageal stricture dilation using E + CRE or EsoFLIP between October 2017 and May 2022.

RESULTS

Twenty-nine EGDs with esophageal stricture dilation were performed in 23 patients (19 E + CRE and 10 EsoFLIP). The two groups did not differ in age, gender, race, chief complaint, type of esophageal stricture, or history of prior gastrointestinal procedures (all p > 0.05). The most common medical history in the E + CRE and EsoFLIP groups were eosinophilic esophagitis and epidermolysis bullosa, respectively. Median procedures times were shorter in the EsoFLIP cohort compared to E + CRE balloon dilation (40.5 min [IQR 23-57 min] for the EsoFLIP group; 64 min [IQR 51-77 min] for the E + CRE group; p < 0.01). Median fluoroscopy times were also shorter for patients who underwent EsoFLIP (0.16 min [IQR 0-0.30 min] for EsoFLIP dilation; 0.30 min [IQR 0.23-0.55] for the E + CRE group; p = 0.003). There were no complications or unplanned hospitalizations in either group.

CONCLUSION

EsoFLIP dilation of esophageal strictures was faster and required less fluoroscopy than CRE balloon dilation combined with EndoFLIP in children, while being equally as safe. Prospective studies are needed to further compare the two modalities.

Treatment experience with a novel 30-mm hydrostatic balloon in esophageal dysmotility: a multicenter retrospective analysis

BACKGROUND AND AIMS

The newest addition in the management of achalasia and esophagogastric junction outflow obstruction (EGJOO) is a 30-mm hydrostatic balloon dilator that uses impedance planimetry technology. It allows for the measurement of the diameter and cross-sectional area to determine effective dilation. We aimed to (1) determine the clinical success (defined as a decrease in Eckardt score to ≤3) in the treatment of esophageal motility disorders and (2) report the safety (rate/severity of adverse events).

METHODS

This retrospective multicenter study involved 4 centers. Patients with esophageal motility disorders who underwent hydrostatic balloon dilation between January 2015 and October 2018 were included.

RESULTS

Fifty-one patients (mean age, 54.1 years; women, 49%) underwent hydrostatic dilation for achalasia (n = 37) or EGJOO (n = 14) during the study period. Forty-seven patients had a median baseline Eckardt score of 5 (range, 3-8; achalasia, n = 35, 6 [range, 3-8]; EGJOO, n = 12, 4 [range, 3.25-6.5]). Clinical success was achieved in 60% of cases (achalasia vs EGJOO: 68.4% vs 33.3%, P = .18). Dilation resulted in a significant decrease in the median Eckardt score from 5 (range, 3-8) to 1.5 (range, 1-4.75; P < .001). Patients with achalasia had a decrease in Eckardt score from 6 (range, 3-8) to 1 (range, 1-4; P < .001), whereas those with EGJOO experienced no significant change. One patient had mild postprocedure chest pain.

CONCLUSIONS

The hydrostatic balloon dilator is a new tool in our armamentarium to treat esophageal motility disorders. This is the first multicenter study showing the device to be safe and moderately efficacious.

EsoFLIP for esophageal dilation: proposed advantages

PURPOSE OF REVIEW

The EsoFLIP integrates impedance planimetry technology into a dilator balloon capable of dilating from diameters between 10 and 30 mm via controlled volumetric distension while providing real-time visualization and objective measurement during the dilation procedure, potentially negating the need for fluoroscopy. This review aims to describe the use and application of EsoFLIP and the potential advantages this novel technology may afford.

RECENT FINDINGS

Small pilot and retrospective studies demonstrate EsoFLIP feasibility and safety, but larger studies are needed to understand its impact on clinical outcomes.

SUMMARY

EsoFLIP is an appealing new technology that offers advantages in therapeutic dilation of the lower esophageal sphincter in achalasia or of esophageal strictures because of previous surgery, gastroesophageal reflux disease, or radiation.

Updated Systematic Review of Achalasia, with a Focus on POEM Therapy

AIM

To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy.

METHODS

Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria.

RESULTS

Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM.

CONCLUSION

This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.

Techniques and principles of endoscopic treatment of benign gastrointestinal strictures

PURPOSE OF REVIEW

The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio.

RECENT FINDINGS

Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition.

SUMMARY

Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.

Measuring mechanical properties of the esophageal wall using impedance planimetry

The mechanical properties of the esophagogastric junction (EGJ) are of major importance for the competence of the EGJ. Although manometry reliably measures sphincter pressure, no information is provided on distensibility, a crucial determinant of flow across the EGJ. Recently, a new technique, impedance planimetry, was introduced allowing accurate measurement of compliance or distensibility. This review discusses the recent advances in this area and highlights the clinical relevance of this new technique evaluating the mechanical properties of the esophageal wall and EGJ.

EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy

BACKGROUND

Peroral endoscopic myotomy (POEM) has been recently introduced in clinical practice for the treatment of achalasia. The endoluminal functional lumen imaging probe (EndoFLIP) system) uses impedance planimetry for the real-time measurement of the diameter of the oesophago-gastric junction.

OBJECTIVE

The aim of this study is to prospectively evaluate the effect of POEM on the oesophago-gastric junction using EndoFLIP.

METHODS

All the patients who underwent POEM in a single centre between April and July 2013 were enrolled in the study. EndoFLIP was used intraoperatively, immediately before and after POEM. During follow-up patients underwent oesophagogastroduodenoscopy, oesophageal pH monitoring and manometry. Clinical outcomes were compared with the diameter of the oesophago-gastric junction after POEM.

RESULTS

In total, 23 patients (12 males, mean age 51.7 years) were enrolled, and 21 underwent POEM successfully. Preoperative mean basal lower oesophageal sphincter pressure was 42.1 mmHg (±17.6). Before POEM, the mean oesophago-gastric junction diameter and cross-sectional area were 6.3 mm (±1.8) and 32.9 mm(2) (±23.1), respectively. After treatment, the mean diameter and cross-sectional area of the oesophago-gastric junction were 11.3 mm (±1.7 SD) and 102.38 mm(2) (±28.2 SD), respectively. No complications occurred during a mean follow-up of 5 months. Median post-operative Eckardt score was 1. Three patients (14.3%) referred heartburn. Follow-up studies revealed gastro-oesophageal reflux disease (GORD) in 57.1% of patients and oesophagitis in 33.3%. No correlations were observed between the diameter of oesophago-gastric junction after POEM and symptoms relief, GORD incidence and lower oesophageal sphincter pressure.

CONCLUSIONS

The diameter of oesophago-gastric junction substantially increases after POEM. EndoFLIP is a reliable method for the intraoperative evaluation of oesophago-gastric junction diameter. However, the real usefulness of this technology after POEM remains controversial.