Original article Clinical endoscopy| Volume 94, ISSUE 3, P509-514, September 2021

Comparison of preoperative, intraoperative, and follow-up functional luminal imaging probe measurements in patients undergoing myotomy for achalasia

Published:March 01, 2021DOI:https://doi.org/10.1016/j.gie.2021.02.031

      Background and Aims

      The functional luminal imaging probe (FLIP) is a novel catheter-based device that measures esophagogastric junction (EGJ) distensibility index (DI) in real time. Previous studies have demonstrated DI to be a predictor of post-treatment clinical outcomes in patients with achalasia. We sought to evaluate EGJ DI in patients with achalasia before, during, and after peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) and to assess the correlation of DI with postoperative outcomes.

      Methods

      DI (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured at 4 time points in patients undergoing surgical myotomy for achalasia: (1) during outpatient preoperative endoscopy (preoperative DI), (2) at the start of each operation after the induction of anesthesia (induction DI), (3) at the conclusion of each operation (postmyotomy DI), and (4) at routine follow-up endoscopy 12 months postoperatively (follow-up DI). Routine Eckardt symptom score, endoscopy, timed barium esophagram, and pH study were obtained 12 months postoperatively.

      Results

      Forty-six patients (35 POEM, 11 LHM) underwent FLIP measurements at all 4 time points. Preoperative and induction mean DI were similar for both groups (POEM, 1 vs .9 mm2/mm Hg; LHM, 1.7 vs 1.5 mm2/mm Hg). POEM resulted in a significant increase in DI (induction .9 vs postmyotomy 7 mm2/mm Hg, P < .001). There was a subsequent decrease in DI in the follow-up period (postmyotomy 7 vs follow-up 4.8 mm2/mm Hg, P < .01), but DI at follow-up was still significantly improved from preoperative values (P < .001). For LHM patients, DI also increased as a result of surgery (induction 1.5 vs postmyotomy 5.9 mm2/mm Hg, P < .001); however, the increase was smaller than in POEM patients (DI increase 4.4 vs 6.2 mm2/mm Hg, P < .05). After LHM, DI also decreased in the follow-up period, but this change was not statistically significant (5.9 vs 4.4 mm2/mm Hg, P = .29). LHM patients with erosive esophagitis on follow-up endoscopy had a significantly higher postmyotomy DI compared with those without esophagitis (9.3 vs 4.8 mm2/mm Hg, P < .05).

      Conclusions

      EGJ DI improved dramatically as a result of both POEM and LHM, with POEM resulting in a larger increase. Mean DI decreased at intermediate follow-up but remained well above previously established thresholds for symptom recurrence. DI at the conclusion of LHM was predictive of erosive esophagitis in the postoperative period, which supports the potential use of FLIP for calibration of partial fundoplication construction during LHM.

      Graphical abstract

      Abbreviations:

      CSA (cross-sectional area), DI (distensibility index), EGJ (esophagogastric junction), FLIP (functional luminal imaging probe), HRM (high-resolution manometry), LES (lower esophageal sphincter), LHM (laparoscopic Heller myotomy), POEM (peroral endoscopic myotomy), TBE (timed barium esophagram)
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      Linked Article

      • Myotomy and EndoFLIP: repeated measurements require a different statistical test
        Gastrointestinal EndoscopyVol. 95Issue 4
        • Preview
          With great interest, we read the study comparing preoperative, intraoperative, and follow-up functional luminal imaging probe measurements in patients undergoing myotomy for achalasia cardia.1 In that study, the esophagogastric junction distensibility index (EGJ-DI) was measured at 4 time points (preoperative, induction, postmyotomy, and follow-up) in patients undergoing peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM). The authors concluded that the preoperative and induction mean EGJ-DIs were similar, with a significant increase in DI after POEM.
        • Full-Text
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      • Functional lumen imaging probe and Heller myotomy: solves the dysphagia issue, but the resulting GERD is still a mystery
        Gastrointestinal EndoscopyVol. 94Issue 3
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          The practice of esophagology has advanced significantly over the past few decades as the now widespread use of high-resolution esophageal manometry (HRM), 24-hour pH-impedance testing, and 48- to 96-hour wireless pH monitoring have transformed the way in which we evaluate patients with esophageal diseases. One of the newest tools used by esophagologists is the functional lumen imaging probe (FLIP), which over the past few years has become (1) increasingly used, especially in academic medical centers, and (2) increasingly investigated to enable a better understanding of all of its potential applications in diagnosing, treating, and monitoring esophageal diseases.
        • Full-Text
        • PDF