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LIMITATION AND POTENTIAL OF GASTROESOPHAGEAL JUNCTION INTRAOPERATIVE LUMINAL IMAGING DURING LAPAROSCOPIC FUNDOPLICATION
Herbert M. Hedberg*1,2, Tyler Hall2, JoAnn Carbray2, Michael Ujiki2,1
1Surgery, University of Chicago, Chicago, IL; 2Surgery, NorthShore University HealthSystems, Chicago, IL
Background
Laparoscopic fundoplication (FP) is regularly performed for medically refractory GERD. A Functional Luminal Imaging Probe (FLIP) is a novel balloon-catheter device used for real-time monitoring of lower esophageal sphincter (LES) distensibility as a function of LES diameter and pressure. Changes in distensibility at different intraoperative time points have been previously reported, but the clinical significance of FLIP metrics before and after FP have not been established. This study sought correlation among intraop FLIP measurements, preop patient characteristics, and postop symptomatology.
Methods
A retrospective review of a prospectively collected database was performed. Queried patients underwent Nissen FP by a single surgeon during the years 2009-2016 for GERD and/or symptomatic hiatal hernia and had intraop FLIP metrics recorded. A 54-60 Fr bougie was used when constructing the FP. Patients completed validated symptom based and quality of life surveys (Reflux Severity Index, GERD-HRQL, Dysphagia Score, SF36) preop and were invited to repeat the surveys at three weeks, six months, and annually postop. Student’s t-test was used to analyze pre and post FP FLIP data for the entire cohort, as well as sub-groups defined by pre FP LES diameter ≥9mm and <9mm. Correlations were sought among intraop FLIP metrics, preop characteristics, and postop symptoms.
Results
Fifty-nine patients were included in the analysis. There was no significant change in pre to post FP diameter (9.3±3.2mm vs 8.5±1.8mm, p=0.15). No significant correlations were found between post FP FLIP metrics and postop symptoms or quality of life. The <9mm and ≥9mm sub-groups (n=26 vs n=33) were significantly different pre FP (6.7±3.2mm vs 11.3±2.7mm, p<0.001) but not post FP (8.3±1.7mm vs 8.7±1.8mm, p=0.48). The ≥9mm group had a higher proportion of patients reporting heartburn preop (26% difference ±22% 95% CI), and had higher resting LES pressure on preop high resolution manometry (20.9±15.4 vs 13.0±11.9, p=0.03). No significant differences between postop symptoms or quality of life were found between the two groups.
Conclusion
No significant change was found between FLIP measured diameter pre to post FP. Prior studies reporting significant LES diameter change pre to post FP did not exchange the FLIP device for a bougie when constructing the FP. The convergence of post FP diameters between the <9mm and ≥9mm groups (6.7mm to 8.3mm and 11.3mm to 8.7mm) was unexpected, and may reflect a dilation effect of the bougie on smaller diameter LES’s. Use of a bougie may be a confounding element that limits the clinical usefulness of post FP FLIP measurements. Pre FP diameter <9mm and ≥9mm did correlate with preop heartburn and manometry, and may be a useful metric to help choose between full or partial FP for individual patients.
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