Improving Functional Esophageal Surgery with a “smart” Bougie: Endoflip®

Introduction: In order to improve the results of functional surgical procedures on the esophagus, the use of intraoperative esophageal manometry has been described to document the ablation of the lower esophageal sphincter (LES) high-pressure zone (HPZ) and to calibrate the pressure of the fundal wrap. An emerging physiology tool, the functional lumen imaging probe (Endoflip®, Crospon Ltd.), combines measurements of the EGJ resistance to distention and provides a geometrical reconstruction of the EGJ. The FLIP therefore represents a promising entirely new method to dynamically profile the EGJ that can show a live modification on EGJ capacity and diameter which would be of particular interest when performing functional operation on the esophagus such as antireflux procedures and Heller myotomy. Here we shows the clinical application of this emerging physiology tool in the surgical tratment of achalasia and GERD.
Methods: The first case is that of a young woman with achalasia undergoing heller myotomy for persistent dysphagia after 2 failed endoscopic dilatation using the Endoflip® to follow the extend of the myotomy. The second case demonstrates its use to assess the configuration and quality of a posterior partial and Nissen fundoplication. In order to do this the EndoFLIP® catheter was placed transorally straddling the esophagogastric junction (EGJ). For the distension protocol the balloon was inflated to 30ml at a rate of 40ml per minute and data on 16 cross-sectional areas and pressure in the balloon was recorded. Two distensions were carried out at each stage of the procedure. Measurements were taken at the key steps of the heller myotomy and total and partial fundoplication .
Results: Before the myotomy pressure in the balloon rose to 15 cmH20 at a cross sectional area (CSA) of 25mm2 indicating that the EGJ is closed and tight. After dissection of the longitudinal muscle and the clasp fibres the pressure only rises to 8 cmH2O and the minimum CSA opens to 34 mm2 indicating that the EGJ is now very compliant and flaccid. After the Heller wrap is complete the junction has become less compliant but it can open at its narrowest point to 35 mm2 at a pressure of 20 cmH2O. This suggests that the EGJ is tight but not as rigid as before so that when a bolus passes through it will stretch and open. The second part of the video demonstrates that the the Endoflip® acts as a “smart bougie” evaluating the orientation and position of a properly constructed floppy Nissen and posterior partial fundoplication.
Conclusions: EndoFLIP can quantify changes in the distensibility of the EGJ. This “smart bougie” could be integrated into the surgical routine of esophageal functional surgery providing a good and immediate physiological visual feed-back of the surgical manoeuvres and could therefore improve outcome and facilitate surgical training and learning curve in this arena.

Session: Podium Video Presentation

Program Number: V001

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