Esophagogastric junction distensibility assessed using the functional lumen imaging probe

Research gap in esophageal achalasia: a narrative review

In recent years, new translational evidence, diagnostic techniques, and innovative therapies have shed new light on esophageal achalasia and revamped the attention on this relatively rare motility disorder. This narrative review aims to highlight the most recent progress and the areas where further research is needed. The four senior authors identified five topics commonly discussed in achalasia management: i.e. pathogenesis, role of functional lumen imaging probe in the diagnostic flow chart of achalasia, how to define the outcome of achalasia treatments, how to manage persistent chest pain after the treatment, and if achalasia patients' may benefit from a regular follow-up. We searched the bibliographic databases to identify systematic reviews, meta-analyses, randomized control trials, and original research articles in English up to December 2023. We provide a summary with the most recent findings in each of the five topics and the critical points where to address future research, such as the immune-genetic patterns of achalasia that might explain the transition among the different phenotypes, the need for a validated clinical definition of treatment success, the use of neuromodulators to manage chest pain, and the need for identifying achalasia patients at risk for cancer and who may benefit of long-term follow-up. Although undoubtedly, progress has been made on the definition and management of achalasia, unmet needs remain. Debated aspects range from mechanistic insights, symptoms, objective measure relationships, and accurate clinical responses to therapeutic interventions. Translational research is eagerly awaited to answer these unresolved questions.

Antireflux mucosectomy for gastroesophageal reflux disease: efficacy and the mechanism of action

BACKGROUND

Previous studies suggested that antireflux mucosectomy (ARMS) is effective in reducing reflux symptoms and total acid exposure, although the mechanism is unknown. Our objective was to investigate the effect of ARMS on reflux parameters and its mechanism of action.

METHODS

Gastroesophageal reflux disease (GERD) patients with insufficient symptom control despite a twice-daily proton pump inhibitor (PPI) underwent a piecemeal multiband mucosectomy of 50% of the circumference of the esophagogastric junction (EGJ), extending 2 cm into the cardia. The primary end point was the total number of reflux episodes during 24-hour pH-impedance studies.

RESULTS

11 patients (8 men; median age 37 [interquartile range (IQR) 32-57] years) were treated, with one patient subsequently lost to follow-up. ARMS reduced the median (IQR) number of total reflux episodes (74 [60-82] vs. 37 [28-66]; P = 0.008) and total acid exposure time (8.7% [6.4%-12.7%] vs. 5.3% [3.5%-6.7%]; P = 0.03). Treatment reduced the median (IQR) number of transient lower esophageal sphincter relaxations (TLESRs) during a 90-minute postprandial period (4 [1-8] vs. 2 [1-4]; P = 0.03) and reflux symptom scores (3.6 [3.6-3.9] vs. 1.6 [0.7-2.7]; P = 0.005). Treatment did not increase the mean (SD) dysphagia scores (8.2 [7.3] vs. 8.5 [6.5]) or change the EGJ distensibility on impedance planimetry (4.4 [2.1] vs. 4.3 [2.2] mm2/mmHg). One delayed post-procedural bleed requiring repeat endoscopy occurred (10%); no strictures developed.

CONCLUSION

ARMS is an effective treatment option in PPI-refractory GERD, reducing acid exposure, reflux episodes, and symptoms. While its working mechanism could not be explained by a difference in distensibility, a reduction in TLESRs might play a role.

Using impedance planimetry to define the end of a peroral endoscopic myotomy

INTRODUCTION

Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic option for management of achalasia. Adequate distal myotomy is necessary for relief of symptoms, but when too long may also increase risk of reflux. The objective of this study is to evaluate clinical outcomes after POEM and final length of gastric myotomy using impedance planimetry (EndoFLIP).

METHODS

A retrospective review of 34 consecutive patients undergoing POEM with EndoFLIP were included. EndoFLIP measurements, including esophagogastric junction distensibility index (DI), minimum diameter (Dmin), and cross-sectional area (CSA) were recorded at 30- and 40-mL balloon-fill pre- and post- myotomy. The myotomy was considered complete when DI ≥ 3.4 mm2/mmHg. Postoperative Eckardt score (ES) was determined at initial postoperative visit and most recent follow-up. Linear and logistic regression were used to evaluate the association between gastric myotomy length and post-myotomy EndoFLIP measurements on postoperative ES and GERD. Wilcoxon rank-sum test was used to compare gastric myotomy lengths and EndoFLIP parameters in relation to clinical success and development of GERD, and paired t-test to compare EndoFLIP measurements and ES pre- and post-myotomy.

RESULTS

Final length of gastric myotomy measured 1 cm in 1 (2.9%), 1.5 cm in 11 (32.4%), 2.0 cm in 19 (55.9%), and 2.5 cm in 3 (8.8%) patients. Mean preoperative ES was 6.6 ± 2.2. All patients achieved ES < 3 postoperatively, which was maintained in 88.5% of patients at a median of 7.5 months of follow-up. Gastric myotomy length and post-myotomy EndoFLIP values were not associated with postoperative Eckardt scores or GERD.

DISCUSSION

Early and late symptom relief was achieved in 100 and 88.5% of patients, respectively, at a gastric myotomy length of 1-2.5 cm. Using EndoFLIP to define a completed myotomy at DI of 3.4 mm2/mmHg yielded variable lengths of gastric myotomy.

Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry

BACKGROUND

The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension.

METHODS

Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0).

KEY RESULTS

Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM.

CONCLUSIONS AND INFERENCES

This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.

Devices for esophageal function testing

BACKGROUND AND AIMS

Esophageal function testing is an integral component of the evaluation of refractory GERD and esophageal motility disorders. This review summarizes the current technologies available for esophageal function testing, including the functional luminal imaging probe (FLIP), high-resolution esophageal manometry (HRM), and multichannel intraluminal impedance (MII) and pH monitoring.

METHODS

We performed a MEDLINE, PubMed, and MAUDE database literature search to identify pertinent clinical studies through March 2021 using the following key words: esophageal manometry, HRM, esophageal impedance, FLIP, MII, and esophageal pH testing. Technical data were gathered from traditional and web-based publications, proprietary publications, and informal communications with pertinent vendors. The report was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy Technology Committee and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

RESULTS

FLIP is a high-resolution impedance planimetry system used for pressure and dimension measurement in the esophagus, pylorus, and anal sphincter. FLIP provides complementary information to HRM for esophageal motility disorders, especially achalasia. The Chicago classification, based on HRM data, is a widely adopted algorithmic scheme used to diagnose esophageal motility disorders. MII detects intraluminal bolus movement and, combined with pH measurement or manometry, provides information on acid and non-acid gastroesophageal reflux and bolus transit in patients with refractory GERD and for preoperative evaluation for anti-reflux procedures.

CONCLUSIONS

Esophageal function testing techniques (FLIP, HRM, and MII-pH) have diagnostic and prognostic value in the evaluation of esophageal motility disorders and refractory GERD. Newer technologies and classification systems have enabled an increased understanding of these diseases.

Predictors of Abnormal Functional Luminal Impedance Planimetry Findings in Non-mechanical Esophagogastric Junction Outflow Obstruction

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is a common but nonspecific motility pattern identified by esophageal high-resolution manometry (HRM). Functional luminal impedance planimetry (FLIP) provides information regarding lower esophageal sphincter (LES) mechanics, which can identify achalasia spectrum disorders and is useful in evaluating EGJOO. However, the relationship between HRM and FLIP parameters in EGJOO is not clearly defined.

AIMS

To identify predictors of abnormal FLIP findings in patients with non-mechanical EGJOO.

METHODS

This is a retrospective cohort study of patients with non-mechanical EGJOO who underwent FLIP between 10/1/16 and 7/1/19. Demographic data including age and gender, examination indication, concomitant medications, HRM parameters, symptom burden, and FLIP metrics of diameter and distensibility index (DI) were collected. DI was categorized as not low (DI > 2.8), borderline low (DI 1.1-2.8), and definitely low (DI ≤ 1). Kruskal-Wallis and Fisher's exact tests were used to assess the relationship between HRM and FLIP parameters and to identify predictors of abnormal FLIP.

RESULTS

Among the 44 patients studied, most were female (n = 33, 75%) and the median age was 63. The median IRP was 18.2, and 10 (23%) patients used chronic narcotics. Lower total heartburn and regurgitation scores, and LES diameter by FLIP are associated with definitely low DI.

CONCLUSIONS

In patients with non-mechanical EGJOO, reflux burden scores and FLIP diameters can aid in predicting DI. These results may provide useful adjunctive data to help in differentiating which patients have meaningful outflow obstruction.

The Usefulness of the Measurement of Esophagogastric Junction Distensibility by EndoFLIP in the Diagnosis of Gastroesophageal Reflux Disease

Background/Aims

Increased esophagogastric junction (EGJ) relaxation is the most important mechanism involved in gastroesophageal reflux disease (GERD). An endoscopic functional luminal imaging probe (EndoFLIP^Ⓡ) is a device used to quantify EGJ distensibility in routine endoscopy. The aim of the current study was to assess the usefulness of EndoFLIP^Ⓡ for the diagnosis of GERD compared to normal controls.

Methods

We analyzed EndoFLIP^Ⓡ data from 204 patients with erosive reflux disease (ERD), 310 patients with nonerosive reflux disease (NERD), and 277 normal subjects. EndoFLIP^Ⓡ uses impedance planimetry to measure 16 cross-sectional areas (CSAs) in conjunction with the corresponding intrabag pressure within a 4.6 cm cylindrical segment of a fluid-filled bag. The EGJ distensibility was assessed using 40 mL volume-controlled distensions.

Results

The mean distensibility index values were 13.98 mm²/mm Hg in ERD patients, 11.42 mm²/mm Hg in NERD patients, and 9.1 mm²/mm Hg in normal subjects. There were significant differences in EGJ distensibility among the three groups (p<0.001). In addition, the CSAs were significantly higher in the ERD (291.03±160.77 mm²) and NERD groups (285.87±155.47 mm²) than in the control group (249.78±144.76 mm², p=0.004). We determined the distensibility index cutoff value of EGJ as 10.95 for the diagnosis of GERD by receiver operating characteristic curve analysis.

Conclusions

The EGJ distensibilities of GERD patients were higher than those of normal subjects, regardless of the presence of reflux esophagitis. Thus, the measurement of EGJ distensibility using the EndoFLIP^Ⓡ system could be useful in the diagnosis of GERD.

European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations

INTRODUCTION

Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care.

METHODS

Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique.

RESULTS

These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk.

CONCLUSION

These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.

Association of Polymorphism in IL-18 Gene with Periodontitis in Uyghur Adults in Xinjiang and Evidence from Six Case-Control Studies with a Comprehensive Analysis

AIM

The aim of the study was to evaluate the association of IL-18 137 G > C, 607 C > A gene polymorphism in Uyghur population with chronic periodontitis (CP) and combine the results with the meta-analysis.

METHODS

In a case-control study, 200 cases with CP and 100 healthy controls were recruited; IL-18 137 G > C, 607 C > A genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). In the meta-analysis, we used electronic databases, including CNKI, Wan Fang, PubMed, EMBASE databases etc.to obtain relevant research published through June 2020. Studies were considered eligible if odds ratios (ORs) and 95% confidence intervals (95% CI) were provided or calculated from the given data. The size of the combined effect was calculated using STATA 15.0.

RESULTS

Our study revealed significant association between CP and IL-18 137 G > C (P = .045, OR = 1.67), 607 C > A (P = .045, OR = 1.67). The overall meta-analysis revealed significant associations between IL-18 137 G > C polymorphism and CP risk in Allele, dominant, co-dominant and recessive genetic models. The subgroup analysis also showed a significant association between the IL-18 137 G > C and risk for periodontitis and aggressive periodontitis in the Asian (GC+ CC VS. GG: P = .047, OR = 1.64,95%CI = 1.01-2.68).

CONCLUSIONS

IL-18 137 G > C, 607 C > A could be associated with susceptibility to periodontitis in Uyghur population. Further case-control of candidate genes studies targeting larger sample sizes and different ethnic groups are needed to arrive more accurate conclusions.

Functional Luminal Imaging Probe Panometry Identifies Achalasia-Type Esophagogastric Junction Outflow Obstruction

BACKGROUND & AIMS

The etiologies of esophagogastric junction outflow obstruction (EGJOO) vary, as do their therapeutic implications. We aimed to identify patients with EGJOO most likely to benefit from achalasia-type treatment, based on findings from functional luminal imaging probe (FLIP) panometry.

METHODS

We performed a retrospective study of 34 patients who received a diagnosis of EGJOO from January 2015 through July 2017. Our analysis included patients who had been evaluated with timed barium esophagram, FLIP, or upper endoscopy.

RESULTS

Among the 34 patients with idiopathic EGJOO, 7 (21%) had a normal esophagogastric junction distensibility index (EGJ-DI), based on FLIP panometry, and all had repetitive antegrade contractions. None of the patients had radiographic evidence of EGJOO (RAD-EGJOO), defined as liquid barium retention and/or barium tablet impaction. On the other hand, all 18 patients with RAD-EGJOO had an EGJ-DI less than 2 mm²/mm Hg. Nine of the 18 patients with RAD-EGJOO and EGJ-DI less than 2 mm²/mm Hg underwent achalasia-type treatment, and 77.8% of these (7 of 9) had improvements in Eckardt score. Of the 6 patients with a normal EGJ-DI (>3 mm²/mm Hg) who were treated conservatively and followed up, 100% had improvements in subsequent Eckardt scores.

CONCLUSIONS

We found that FLIP is useful in identifying patients with EGJOO who are most likely to benefit from achalasia-type therapy. Patients with a low EGJ-DI responded well to achalasia-type treatment, whereas patients with normal results from FLIP panometry had good outcomes from conservative management. FLIP panometry might help select management strategies for this difficult population of patients.

Esophageal Functional Lumen Imaging Probe (FLIP): How Can FLIP Enhance Your Clinical Practice?

Recent innovations in esophageal diagnostic testing have enhanced gastroenterology clinical practice by facilitating more nuanced and advanced evaluation of esophageal symptoms. Among these pivotal advances is the FDA-approved functional lumen imaging probe (FLIP), which utilizes impedance planimetry via volumetric distension of a catheter-mounted balloon at the time of sedated upper endoscopy, to acquire esophageal dimensions and pressures. In real time, FLIP can display cross-sectional areas (CSA) and distensibility indices (ratios of CSA to intra-balloon pressures) throughout the esophagus, most notably at the esophagogastric junction, as well as secondary peristaltic esophageal body contractile patterns. As the use of FLIP has progressively spread and permeated into the practice of clinical gastroenterology since its introduction, increasing data on and experiences with its applications have accumulated to guide its utility in clinical practice. In this current review developed for gastroenterologists and foregut surgeons across clinical practice, we provide an introduction to FLIP technology and metrics and discuss the clinical scenarios in which performance of or referral for FLIP may be helpful in the evaluation and management of patients with commonly encountered esophageal symptoms and disorders. Specifically, we discuss the potential applications and limitations of FLIP as a complementary diagnostic modality in patients with non-obstructive dysphagia, established or suspected achalasia spectrum disorders, eosinophilic esophagitis, gastroesophageal reflux disease and those undergoing esophageal surgery.

Short-term outcome of routine use of EndoFLIP during hiatal hernia repair

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 mm^2/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.

Clinical usefulness of esophagogastric junction distensibility measurement in patients with achalasia before and after peroral endoscopic myotomy

BACKGROUND/AIMS

This study aimed to determine the clinical efficacy of measuring the esophagogastric junction (EGJ) distensibility index (DI) in patients with achalasia before and after peroral endoscopic myotomy (POEM).

MATERIALS AND METHODS

Retrospective data were collected from 195 patients who underwent POEM from November 2014 to November 2017 at our clinic. The Eckardt score, high-resolution manometry, and EGJ distensibility were measured before and six months after POEM. Treatment failure was defined as a postprocedure Eckardt score >3 or patients who underwent repeat POEM.

RESULTS

The DI (mm2/mmHg) before and after POEM was 3.42±3.55 and 11.57±6.64, respectively (p<0.01). There was no difference in the DI between achalasia subtypes I, II, and III (11.45±6.24 versus 15.49±11.53 versus 13.27±9.49, p=0.22) or previous treatment history (15.39±10.85 versus 11.10±7.25, p=0.20). The DI was higher in patients with reflux esophagitis after POEM, but the difference was not significant (13.59±7.15 versus 12.54±10.9, p=0.571).

CONCLUSION

This study showed that EGJ distensibility measurement is useful to assess post-POEM outcomes. These findings suggest that the functional lumen imaging probe may be a useful method for assessing clinical efficacy of POEM in patients with achalasia. However, this is a costly procedure that requires experience.

Functional Luminal Imaging Probe Assessment in Postfundoplication Patients Changes Management Beyond Manometry

OBJECTIVES

Fundoplication is a commonly performed pediatric surgery but the surgery can result in nonspecific symptoms that merit further evaluation. The goal of this study was to determine the utility of Functional Luminal Imaging Probe (FLIP) compared with high-resolution manometry with impedance (HRIM) in the evaluation of fundoplication symptoms.

METHODS

We reviewed the FLIP and HRIM tracings of symptomatic fundoplication patients. We compared FLIP results of fundoplication patients to those of pediatric achalasia and control patients. We also compared the role of FLIP to HRIM in clinical decision-making and clinical outcomes.

RESULTS

EGJ distensibilities of fundoplication patients ranged from 0.6 to 8.2 mm/mmHg. Because of the different pediatric patient sizes (8.9--73.5 kg), balloon size inflations varied but, after adjusting balloon fill volume by weight, there was a linear relationship between inflation and distensibility. When compared with control patients and achalasia patients, distensibilities of fundoplication patients were lower than control patients and higher than achalasia patients (P = 0.0001). Patients who had an EGJ intervention had a mean EGJ distensibility of 2.3 ± 1.1 mm/mmHg compared with 5.1 ± 1.6 mm/mmHg in medically managed patients (P = 0.0001). Patients who had an esophagogastric junction (EGJ) intervention had a mean IRP of 13.9 ± 6.1 mmHg compared with medically managed patients who had a mean IRP of 9.9 ± 3.9 mmHg (P = 0.3).

CONCLUSIONS

We show FLIP may provide additional insight into EGJ physiology in symptomatic fundoplication patients and complements HRIM.

Endoscope presence during endoluminal functional lumen imaging probe (FLIP) influences FLIP metrics in the evaluation of esophageal dysmotility

BACKGROUND

The functional lumen imaging probe (FLIP) system is an FDA-approved tool for dynamic evaluation of the esophagogastric junction (EGJ). Even though commercially available since 2009, FLIP utilization remains low, partly due to lack of consensus in methodology and interpretation. Therefore, we aimed to analyze the influence of concurrent endoscopy on FLIP measurements.

METHODS

In this single-center study, we reviewed data from 93 patients undergoing FLIP for symptomatic esophageal motility disorders between 2016 and 2018. During sedated endoscopy, we measured luminal values (distensibility, cross-sectional area (CSA), and balloon pressure) at the EGJ and distal esophagus using 30, 40, and 50 mL distension volumes, with and without concurrent endoscope presence. All recorded values were compared at the various distension volumes between the two measurements using a Wilcoxon rank sum test.

KEY RESULTS

There was a significant difference in distensibility and CSA with index distension volume (40 mL) at the EGJ comparing the two measurements: Lower median distensibility was 2.1 mm²  mm Hg^-1 in the group with concurrent inserted endoscope, respectively, 3.4 mm²  mm Hg^-1 without endoscope (P < .001), and median CSA was 86.0 resp. 110.0 mm² (P < .001). No significant difference could be found in the measurements of the distal esophagus.

CONCLUSIONS & INFERENCES

Our results show a significant difference in FLIP measurements with and without endoscope presence. This underlines the importance of establishing a consensus of a standardized FLIP protocol to define normal luminal values and guiding future FLIP diagnostic studies.

A potential simple endoscopic antireflux method, "the Ripple Procedure" to reduce distensibility at the esophagogastric junction in a porcine model

BACKGROUND AND AIMS

Currently available endoscopic or minimally invasive antireflux modalities are not widely accepted due to high procedure cost or inconsistent results. Therefore, a simpler and less technically demanding method is required. We evaluated the feasibility and efficacy of new endoscopic antireflux method (the Ripple Procedure) using functional lumen imaging probe (FLIP).

METHODS

This 5-week survival study included 10 domestic pigs (control, n = 4; experimental [Ripple], n = 6). The procedure includes the following steps: (i) semicircular marking along the lesser curvature of the cardia; (ii) submucosal injection; and (iii) semicircular mucosal incision along the marking. Endoscopic and FLIP evaluations were performed preoperatively and on postoperative days (PODs) 14 and 35. Technical feasibility was evaluated, and FLIP parameters, including the distensibility index (DI) at the esophagogastric junction (EGJ) and histopathological findings, were compared between groups.

RESULTS

The median procedure time was 28 (23.5-33.8) min. There was no significant difference in dysphagia score and body weight between groups. On POD 35, the Ripple group showed significantly lower EGJ DI at 30 mL [2.0 (1.3-2.5) vs 4.9 (2.7-5.0), P = 0.037]. The EGJ DI was significantly reduced at 30 mL, compared with that at the baseline level [- 59.0% (- 68.8% to - 32.1%) vs 27.8% (- 26.3% to 83.1%), P = 0.033]. Histologic evaluation revealed submucosal granulation tissues near the mucosal incision site, with increased intervening fibrosis between lower esophageal sphincter fibers in the Ripple group.

CONCLUSION

The EGJ DI significantly decreased after the Ripple Procedure; hence, the procedure appears to be feasible and effective in this porcine model.

Esophageal Motor Dysfunctions in Gastroesophageal Reflux Disease and Therapeutic Perspectives

Gastroesophageal reflux disease (GERD) is a very common disease, and the prevalence in the general population has recently increased. GERD is a chronic relapsing disease associated with motility disorders of the upper gastrointestinal tract. Several factors are implicated in GERD, including hypotensive lower esophageal sphincter, frequent transient lower esophageal sphincter relaxation, esophageal hypersensitivity, reduced resistance of the esophageal mucosa against the refluxed contents, ineffective esophageal motility, abnormal bolus transport, deficits initiating secondary peristalsis, abnormal response to multiple rapid swallowing, and hiatal hernia. One or more of these mechanisms result in the reflux of stomach contents into the esophagus, delayed clearance of the refluxate, and the development of symptoms and/or complications. New techniques, such as 24-hour pH and multichannel intraluminal impedance monitoring, multichannel intraluminal impedance and esophageal manometry, high-resolution manometry, 3-dimensional high-resolution manometry, enoscopic functional luminal imaging probe, and 24-hour dynamic esophageal manometry, provide more information on esophageal motility and have clarified the pathophysiology of GERD. Proton pump inhibitors remain the preferred pharmaceutical option to treat GERD. The ideal target of GERD treatment is to restore esophageal motility and reconstruct the anti-reflux mechanism. This review focuses on current advances in esophageal motor dysfunction in patients with GERD and the influence of these developments on GERD treatment.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H₂ receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.