Aaron N Sachs, MD, Howard M Mccollister, MD, Timothy P Lemieur, MD, Shawn A Roberts, MD, Lea M Carlson, RNC, Paul A Severson, MD. Minnesota Institute for Minimally Invasive Surgery
INTRODUCTION: Objective, intraoperative measurement of anti-reflux surgery is not standardized and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP) has the potential to serve this purpose. There is no discrete guidance for surgeons on what constitutes a "tight" crural repair or sufficiently “floppy” fundoplication. The EndoFLIP device gives real time, intraoperative measurements, and at our institution is used to calibrate crural closure, fundoplication, and placement of LINX Magnetic Sphincter Augmentation devices. In order to begin standardizing operative technique, we need to determine typical intraoperative diameter of the lower esophageal sphincter (LES), distensibility index (DI), and pressure values during these procedures. Standardization for measurement technique is evolving.
METHODS AND PROCEDURES: Four surgeons at two institutions performed laparoscopic anti-reflux operations during 2017-2018 with the assistance of the EndoFLIP device. Measurements were taken with intraabdominal pressures of 15 and 6 mmHg, with and without respirations. LES, DI, and balloon pressures were recorded at three key intraoperative events: 1) post-dissection, 2) post-crural repair, 3) post-fundoplication or LINX placement. A retrospective review of prospectively collected data was conducted. Statistical analysis was categorized based on the operation performed.
RESULTS: 40 patients were included: 14 Nissens, 14 Toupets, 6 LINX, and 6 revisions. Table 1 attached demonstrates the mean measurements. By dropping the intraabdominal pressure to 6 mmHg and suspending respirations, the DI increased by 21-111%, with an average increase of 47%.
CONCLUSIONS: EndoFLIP utilization during anti-reflux surgery offers advantages over traditional techniques performed with or without bougies: 1) the inflation of the EndoFLIP soft balloon functions as a safe bougie, 2) the location of the LES becomes easily visible to the surgeon, eliminating improper placement of the fundoplication or LINX, 3) calibration of both cruroplasty and the anti-reflux procedure is now possible. The increased intra-abdominal pressure associated with pneumoperitoneum elevates balloon pressure and lowers DI. In order to allow correlation between preoperative diagnostic EndoFLIP and intraoperative EndoFLIP, measurements should be taken at normal intraabdominal pressures. Consequently, this study demonstrates the importance of lowering pneumoperitoneum to 6 mmHg. Our EndoFLIP results show that DI and LES diameter decrease as the repair is completed. Similarly, balloon pressures increase. These changes match what would be expected for an appropriately tight fundoplication. We are able to avoid GEJ outflow obstruction by adjusting “on-the-fly” if LES diameter or DI are too low, potentially avoiding postoperative dysphagia. Thus standardization by performing an objective, calibrated anti-reflux procedure is now possible.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94424
Program Number: S041
Presentation Session: Foregut II – Physiology
Presentation Type: Podium