Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Gastrointest Endosc. 2021 Sep;94(3):509-514. doi: 10.1016/j.gie.2021.02.031. Epub 2021 Mar 1.
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.
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.
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 mm/mm Hg; LHM, 1.7 vs 1.5 mm/mm Hg). POEM resulted in a significant increase in DI (induction .9 vs postmyotomy 7 mm/mm Hg, P < .001). There was a subsequent decrease in DI in the follow-up period (postmyotomy 7 vs follow-up 4.8 mm/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 mm/mm Hg, P < .001); however, the increase was smaller than in POEM patients (DI increase 4.4 vs 6.2 mm/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 mm/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 mm/mm Hg, P < .05).
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.
功能腔内成像探头（FLIP）是一种新型的基于导管的设备，可实时测量食管胃结合部（EGJ）扩张指数（DI）。先前的研究表明，DI 是贲门失弛缓症患者治疗后临床结局的预测因子。我们旨在评估贲门失弛缓症患者在经口内镜肌切开术（POEM）和腹腔镜 Heller 肌切开术（LHM）前后的 EGJ DI，并评估 DI 与术后结局的相关性。
对接受手术肌切开术治疗贲门失弛缓症的患者在 4 个时间点测量 DI（定义为 EGJ 的最小横截面积除以扩张压力）：（1）门诊术前内镜检查时（术前 DI），（2）麻醉诱导后每次手术开始时（诱导 DI），（3）每次手术结束时（肌切开后 DI），以及（4）术后 12 个月常规内镜随访时（随访 DI）。术后 12 个月常规获得 Eckardt 症状评分、内镜、定时钡餐食管造影和 pH 研究。
46 例患者（35 例 POEM，11 例 LHM）在所有 4 个时间点均进行了 FLIP 测量。两组患者的术前和诱导期平均 DI 相似（POEM：1 与.9mm/mm Hg；LHM：1.7 与 1.5mm/mm Hg）。POEM 导致 DI 显著增加（诱导期.9 与肌切开后 7mm/mm Hg，P<.001）。随后在随访期间 DI 下降（肌切开后 7 与随访 4.8mm/mm Hg，P<.01），但随访时的 DI 仍明显高于术前值（P<.001）。对于 LHM 患者，手术也导致 DI 增加（诱导期 1.5 与肌切开后 5.9mm/mm Hg，P<.001）；然而，增加幅度小于 POEM 患者（DI 增加 4.4 与 6.2mm/mm Hg，P<.05）。LHM 后，DI 在随访期间也下降，但这一变化无统计学意义（5.9 与 4.4mm/mm Hg，P=.29）。在随访内镜检查中存在糜烂性食管炎的 LHM 患者的肌切开后 DI 明显高于无食管炎患者（9.3 与 4.8mm/mm Hg，P<.05）。
POEM 和 LHM 均可显著改善 EGJ DI，POEM 导致的改善更为明显。在中期随访时，平均 DI 下降，但仍远高于先前建立的症状复发阈值。LHM 后 DI 可预测术后糜烂性食管炎，这支持 FLIP 用于校准 LHM 期间部分胃底折叠术的潜在用途。
