Amundson Julia R, Kuchta Kristine, Zimmermann Christopher J, VanDruff Vanessa N, Joseph Stephanie, Che Simon, Ishii Shun, Hedberg H Mason, Ujiki Michael B
Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
Surg Endosc. 2023 Nov;37(11):8670-8681. doi: 10.1007/s00464-023-10301-9. Epub 2023 Jul 27.
Impedance planimetry (FLIP) provides objective feedback to optimize fundoplication outcomes. Ideal FLIP ranges for differing wraps and bougies have not yet been established. We report FLIP measurements during fundoplication grouped by choice of wrap and bougie with associated outcomes.
A retrospective review of a prospective gastroesophageal database was performed for all Nissen or Toupet fundoplication with intraoperative FLIP using an 8-cm catheter, 30-mL and/or 40-mL fill and/or 16-cm catheter, 60-mL fill. Surgeons used no bougie, the FLIP balloon as bougie, or a hard bougie. Outcomes included perioperative data, Reflux Symptom Index, GERD-HRQL, Dysphagia scores, need for dilation, postoperative EGD findings, and hernia recurrence. Group comparisons were made using two-tailed Kruskal-Wallis and Fisher's exact tests.
Between 2016 and 2022, 333 patients underwent fundoplication and intraoperative FLIP. Procedures included Toupet with hard bougie (TFHB, N = 147), Toupet with FLIP bougie (TFFB, N = 69), Toupet without bougie (TFNB, N = 78), Nissen with hard bougie (NFHB, n = 20), or Nissen with FLIP bougie (NFFB, N = 19). FLIP measurements at 30-mL/40-mL fills varied significantly between groups, notably distensibility index at crural closure (CCDI) and post-fundoplication (FDI). No significant differences in FLIP measurements were seen between those who developed poor postoperative outcomes and those who did not, including when grouping by choice of wrap and bougie. At a 40-mL fill, abnormal motility patients with CCDI > 3.5 mm/mmHg developed zero postoperative dysphagia. TFFB abnormal motility patients with CCDI > 3.5 mm/mmHg or FDI > 3.6 mm/mmHg developed zero postoperative dysphagia.
Intraoperative FLIP measurements vary by fundoplication and bougie choice. A CCDI > 3.5 mm/mmHg (40 mL fill) should be sought in abnormal motility patients, regardless of wrap or bougie, to avoid postoperative dysphagia. TFFB abnormal motility patients with FDI > 3.6 mm/mmHg (40 mL fill) also developed zero postoperative dysphagia. FDI > 6.2 mm/mmHg (40 mL fill) was seen in all postoperative hernia recurrences.
阻抗平面测量法（FLIP）可提供客观反馈以优化胃底折叠术的效果。不同包绕方式和探条下理想的FLIP范围尚未确定。我们报告了在胃底折叠术期间，根据包绕方式和探条的选择进行分组的FLIP测量结果及相关结局。
对一个前瞻性胃食管数据库进行回顾性分析，纳入所有接受Nissen或Toupet胃底折叠术且术中使用8厘米导管、30毫升和/或40毫升填充液和/或16厘米导管、60毫升填充液进行FLIP测量的患者。外科医生未使用探条、将FLIP球囊用作探条或使用硬探条。结局指标包括围手术期数据、反流症状指数、GERD-HRQL、吞咽困难评分、扩张需求、术后内镜检查结果和疝复发情况。采用双尾Kruskal-Wallis检验和Fisher精确检验进行组间比较。
2016年至2022年期间，333例患者接受了胃底折叠术及术中FLIP测量。手术方式包括使用硬探条的Toupet术（TFHB，N = 147）、使用FLIP探条的Toupet术（TFFB，N = 69）、未使用探条的Toupet术（TFNB，N = 78）、使用硬探条的Nissen术（NFHB，n = 20）或使用FLIP探条的Nissen术（NFFB，N = 19）。30毫升/40毫升填充量时的FLIP测量结果在各组间差异显著，尤其是在膈脚闭合时的扩张指数（CCDI）和胃底折叠术后（FDI）。术后结局不佳者与结局良好者之间在FLIP测量上无显著差异，按包绕方式和探条选择分组时亦是如此。在40毫升填充量时，CCDI > 3.5毫米/毫米汞柱的异常动力患者术后吞咽困难发生率为零。CCDI > 3.5毫米/毫米汞柱或FDI > 3.6毫米/毫米汞柱的TFFB异常动力患者术后吞咽困难发生率为零。
术中FLIP测量结果因胃底折叠术方式和探条选择而异。对于异常动力患者，无论采用何种包绕方式或探条，均应寻求CCDI > 3.5毫米/毫米汞柱（40毫升填充量）以避免术后吞咽困难。CCDI > 毫米汞柱或FDI > 3.6毫米/毫米汞柱（40毫升填充量）的TFFB异常动力患者术后吞咽困难发生率也为零。所有术后疝复发患者的FDI均 > 6.2毫米/毫米汞柱（40毫升填充量）。
