Intraoperative Assessment of Esophagogastric Junction Distensibility During Laparoscopic Fundoplication with Endoluminal Functional Lumen Imaging Probe Device (EndoFLIP)

Elizabeth A Schoenfeldt1, Matthew J Frelich, MS2, Reece K DeHaan, BA2, Jon C Gould, MD2. 1UW-Madison, 2Medical College of Wisconsin

Background: The goal in antireflux surgery is to re-establish a competent barrier to prevent excessive reflux of gastric contents into the esophagus. We sought to characterize the changes in esophagogastric junction distensibility that occurs in patients during the various stages of antireflux surgery.

Methods and Procedures: This is a retrospective review of prospectively maintained data. All patients underwent laparoscopic fundoplication at the Medical College of Wisconsin between September 2013 and August 2014. A novel functional luminal imaging probe, EndoFLIP®, which uses impedance planimetry with 16 electrodes at 5 mm increments within a bag that can be filled with varying amounts of saline solution was used for intraoperative measurements. Minimum esophageal diameter (Dmin), cross-sectional areas (CSA) and EGJ distensibility index (DI) were measured at 30mL and 40mL distension volumes prior to abdominal insufflation, after complete dissection at the esophageal hiatus, and after completion of the fundoplication using EndoFLIP. DI is defined as the narrowest CSA and the corresponding pressure expressed in mm2/mmHg. A Wilcoxon-Signed rank test was performed to assess significance.

Results: A total of 28 patients underwent fundoplication during the study interval [11 primary Nissen (39%), 1 primary Toupet partial fundoplication (4%), and 16 reoperative fundoplications (57%). Mean age was 56.4 years (±13.0) and mean BMI was 28.6 kg/m2 (±5.0). Overall, Dmin and CSA decreased from prior to surgery to completion of the fundoplication. Intrabag pressure at a given volume increased following fundoplication. The distensibility index decreased significantly with the addition of the fundoplication.

Measurement Dmin (mm) CSA (mm2) Intrabag Pressure (mmHg) DI (mm2/mmHg)

Pre-insufflation (30 mL)

7.1 (1.6) 40.2 (16.9) 25.0 (11.4) 2.0 (1.6)
Takedown Hiatus (30 mL) 7.6 (2.7) 48.5 (26.5) 29.1 (14.6) 1.8 (1.2)
Post fundoplication (30 mL) 7.0 (1.4)** 38.3 (14.4)** *32.7 (11.1) *1.3 (0.8)**
Pre-insufflation (40 mL) 9.8 (2.1) 76.0 (30.5) 31.5 (12.1) 2.9 (2.1)
Takedown Hiatus (40 mL) 10.7 (3.2) 91.1 (45.6) 35.4 (14.2) 2.9 (2.4)
Post fundoplication (40 mL) 9.5 (2.2)** 69.6 (21.7)** *41.6 (9.3)** *1.8 (0.9)**

Table: EndoFLIP® variables reported as mean ± (SD). * indicates p<0.05 for Post-fundoplication compared to pre-insufflation. ** indicates p<0.05 for Takedown Hiatus compared to Post-fundoplication.

Conclusions: Laparoscopic fundoplication results in a decrease in EGJ distensibility in patients with GERD. Long-term follow-up with the addition of symptomatic outcomes may ultimately allow surgeons to tailor the fundoplication based on objective, intraoperative feedback in a manner than minimizes post-operative side effects such as dysphagia, bloating, and difficulty belching.

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