Elsevier

Surgery

Volume 171, Issue 3, March 2022, Pages 628-634
Surgery

GI Surgery
Impedance planimetry (EndoFLIP) measurements persist long term after anti-reflux surgery

https://doi.org/10.1016/j.surg.2021.08.065Get rights and content

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.

Introduction

Laparoscopic Anti-Reflux Surgery (LARS) includes Nissen Fundoplication, Toupet Fundoplication, and recently Magnetic Sphincter Augmentation (MSA). The durability of each operation is typically assessed through patient-reported outcomes unless severe symptoms recur leading to additional evaluation. This would include an esophagram, endoscopy, acid monitoring, or manometry. New technology such as impedance planimetry based on the functional lumen imaging probe (FLIP) can provide geometric measurements of the gastroesophageal junction and quantify the tightness of a sphincter. Tightness, calculated as the distensibility index through FLIP during LARS, has been shown to predict patient outcomes.1,2 Collecting FLIP values during postoperative endoscopy present a unique opportunity to examine the durability of sphincter augmentation over time. We aim to describe our institutional experience in performing FLIP during postoperative esophagogastroduodenoscopy (EGD) after LARS.

Section snippets

Data collection

All patients who had postoperative EGD with FLIP between March 2018 and June 2021 were included. Patients had their index LARS from November 2003 to February 2020 meaning a portion of this cohort did not undergo intraoperative FLIP evaluation because we started using FLIP in 2013 for fundoplication and 2016 for MSA. Dedicated research fellows perform the FLIP evaluation in the operating room and collect data during each case. The surgeon (M.B.U.) performs FLIP evaluation in the procedure suite

Patient demographics and QOL questionnaire responses

Fifty-eight patients had primary LARS (Nissen fundoplication 35%, Toupet fundoplication 41%, LINX 24%) from November 2003 to February 2020, this includes 5 patients who had their index operation at an outside hospital. Postoperative EGD with FLIP was performed at a median (Q1-Q3) 16 (11−31) months after surgery from March 2018 to June 2021. Reason for EGD included Barrett’s Esophagus Surveillance, dysphagia, symptomatic GERD, or no symptoms (routine GERD surveillance). Symptomatic GERD was the

Discussion

The surgical management of GERD includes restoring the native anti-reflux barriers of the gastroesophageal junction. This can be done through Nissen fundoplication, Toupet fundoplication, or Magnetic Sphincter Augmentation. Patients are hesitant to commit to surgical management, because of fearful side effects such as dysphagia and gas-bloat syndrome. Surgeons evolved their techniques to reduce these side effects, which include shortening the length of fundoplication, increasing bougie

Funding/Support

None.

Conflict of interest/Disclosure

John Linn is a lecturer for Gore. Michael B. Ujiki is a board member for Boston Scientific, is a paid consultant for Olympus and Cook, and is a lecturer for Medtronic, Erbe, and Gore.

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