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Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia

  • 2019 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The functional luminal imaging probe (FLIP) can evaluate esophagogastric junction (EGJ) distensibility and esophageal peristalsis in real time. FLIP measurements performed during diagnostic endoscopy can accurately discriminate between healthy controls and patients with achalasia based on EGJ-distensibility and distinct motility patterns termed repetitive antegrade contractions (RACs) and repetitive retrograde contractions (RRCs). We sought to evaluate real-time motility changes in patients undergoing surgical myotomy for achalasia.

Methods

FLIP measurements using a stepwise volumetric distention protocol were performed at three time points during assessment and performance of laparoscopic Heller myotomy and POEM: (1) During preoperative outpatient endoscopy, (2) Intraoperatively following induction of anesthesia, and (3) Intraoperatively after myotomy completion. EGJ-distensibility, contractility, RACs, and RRCs were measured.

Results

FLIP measurements were performed in 32 patients. The EGJ-distensibility index was similar between the preoperative and initial operative measurements (1.1 vs 1.4 mm2/mmHg, p = NS). There was a significant increase in distensibility following surgical myotomy (1.4 to 4.7 mm2/mmHg, p < 0.01). Intraoperative contractile patterns varied between achalasia subtypes. Contractility was seen in < 20% of assessments in patients with types I and II achalasia. Type III patients demonstrated contractility in 100% of assessments, with 70% exhibiting RRCs and 60% RACs. There was a reduction in the frequency of RRC presence (70% to 20%), and contractile vigor (80% to 0% of patients with lumen occluding contractions) in type III patients following surgical myotomy.

Conclusions

This first report of real-time intraoperative measurement of esophageal motility using FLIP demonstrates the feasibility of such assessments during surgical myotomy for achalasia. Patients with type I and II achalasia exhibited rare intraoperative contractility, while the presence of motility was the norm in those with type III. Patients with type III achalasia demonstrated an immediate reduction in repetitive contraction motility patterns and contractile vigor following myotomy.

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Funding

This work was supported by R01 DK079902 (JEP) and P01 DK117824 (JEP) from the Public Health service. Ryan A. J. Campagna, MD is supported by T32DK101363 from the National Institutes of Health.

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Authors and Affiliations

  1. Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA

    Ryan A. J. Campagna, Eric S. Hungness, Amy L. Holmstrom, Nathaniel J. Soper & Ezra N. Teitelbaum

  2. Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Dustin A. Carlson & John E. Pandolfino

Authors
  1. Ryan A. J. Campagna
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  2. Dustin A. Carlson
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  3. Eric S. Hungness
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  4. Amy L. Holmstrom
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  5. John E. Pandolfino
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  6. Nathaniel J. Soper
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  7. Ezra N. Teitelbaum
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Corresponding author

Correspondence to Ezra N. Teitelbaum.

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Disclosures

Dr. Carlson: Medtronic, Inc.—speaking, consulting, shared intellectual property rights and ownership surrounding functional luminal imaging probe panometry systems, methods, and apparatus. Dr. Hungness: Cook Medical—consulting; Boston Scientific—consulting. Dr. Pandolfino: Medtronic, Inc.—consulting, grant funding, speaking, consulting, shared intellectual property rights and ownership surrounding functional luminal imaging probe panometry systems, methods, and apparatus; Sandhill Scientific—consulting, speaking; Crospon—stock options; Takeda—speaking; AstraZeneca—speaking. Dr. Soper: Miret Surgical, Inc.—scientific advisory board, stock options; FlexDex, Inc.—scientific advisory board, stock options; MeshSuture, Inc.—scientific advisory board, stock options. Dr. Teitelbaum: Cook Medical—consulting; Boston Scientific—consulting. Drs. Campagna and Holmstrom: None.

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Campagna, R.A.J., Carlson, D.A., Hungness, E.S. et al. Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia. Surg Endosc 34, 2593–2600 (2020). https://doi.org/10.1007/s00464-019-07028-x

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  • DOI: https://doi.org/10.1007/s00464-019-07028-x

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