Abstract
Objective
We aimed to quantify the contribution of pneumoperitoneum on compliance of the esophagogastric junction (EGJ) during anti-reflux surgery.
Background
Compliance of the EGJ is reduced with anti-reflux surgery. EndoFLIP® planimetry can be used to assess dynamic changes of EGJ compliance intraoperatively. It is unclear how pneumoperitoneum impacts intraoperative measurements by EndoFLIP® and the implications thereof on validity of the results. Therefore, determining variability in EndoFLIP® measurements based on pneumoperitoneum is warranted to establish guidelines to interpret clinical outcomes.
Methods
Primary anti-reflux surgery was performed on 39 consecutive patients with pathologic reflux. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and intrabag pressure were collected using EndoFLIP® at 0, 10, and 15 mmHg of intraperitoneal pressure. Data were acquired pre-procedure, post-hiatal hernia repair, and post-LES augmentation with fundoplications.
Results
Patients underwent Nissen (13.2%), Toupet (68.4%), LINX (10.5%), or Hill-fundoplications (7.9%). There was no difference between 0 and 10 mmHg of pneumoperitoneum in CSA, pressure, or DI measurements pre-procedure; however, there was a difference between 0 and 15 mmHg in pressure (p = 0.016) and DI (p = 0.023) measurements. After LES augmentation, 10 mmHg intraperitoneal pressure reduced DI, though the absolute difference is small (2.0 vs. 1.5 mm2/mmHg, p = 0.002).
Conclusion
Pneumoperitoneum affected EGJ distensibility at 15 mmHg, but not 10 mmHg, of insufflation prior to anti-reflux procedures. After anti-reflux surgery, there was a significant variance between 0 and 10 mmHg of pneumoperitoneum in pressure and distensibility. The change in pressure appears linear and needs to be considered if procedural modifications are performed based on intraoperative findings and when evaluating clinical outcomes.
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References
Kwiatek MA et al (2010) Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc 72(2):272–278
McMahon BP et al (2007) The functional lumen imaging probe (FLIP) for evaluation of the esophagogastric junction. Am J Physiol Gastrointest Liver Physiol 292(1):G377–G384
Pandolfino JE et al (2002) Esophagogastric junction distensibility: a factor contributing to sphincter incompetence. Am J Physiol Gastrointest Liver Physiol 282(6):G1052–G1058
Zheng Z et al (2007) Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology 132(1):87–95
Fei L et al (2009) Hiatal hernia recurrence: surgical complication or disease? Electron microscope findings of the diaphragmatic pillars. J Gastrointest Surg 13(3):459–464
Patti MG (2016) An evidence-based approach to the treatment of gastroesophageal reflux disease. JAMA Surg 151(1):73–78
Moore M et al (2016) Gastroesophageal reflux disease: a review of surgical decision making. World J Gastrointest Surg 8(1):77–83
Richter JE, Rubenstein JH (2018) Presentation and epidemiology of gastroesophageal reflux disease. Gastroenterology 154(2):267–276
Pandolfino JE et al (2005) Restoration of normal distensive characteristics of the esophagogastric junction after fundoplication. Ann Surg 242(1):43–48
Wu W et al (2019) Reflux finding score is associated with gastroesophageal flap valve status in patients with laryngopharyngeal reflux disease: a retrospective study. Sci Rep 9(1):15744
Baumann AJ et al (2021) Normal functional luminal imaging probe panometry findings associate with lack of major esophageal motility disorder on high-resolution manometry. Clin Gastroenterol Hepatol 19(2):259–268
Familiari P et al (2014) EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy. United Eur Gastroenterol J 2(2):77–83
Carlson DA et al (2019) Normal values of esophageal distensibility and distension-induced contractility measured by functional luminal imaging probe panometry. Clin Gastroenterol Hepatol 17(4):674–681
Nathanson LK, Brunott N, Cavallucci D (2012) Adult esophagogastric junction distensibility during general anesthesia assessed with an endoscopic functional luminal imaging probe (EndoFLIP(R)). Surg Endosc 26(4):1051–1055
Su B et al (2020) Using impedance planimetry (EndoFLIP) in the operating room to assess gastroesophageal junction distensibility and predict patient outcomes following fundoplication. Surg Endosc 34(4):1761–1768
Ilczyszyn A, Botha AJ (2014) Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication. Dis Esophagus 27(7):637–644
Elmously A et al (2018) Robotic reoperative anti-reflux surgery: low perioperative morbidity and high symptom resolution. World J Surg 42(12):4014–4021
Stefanova DI et al (2020) Quantifying factors essential to the integrity of the esophagogastric junction during antireflux procedures. Ann Surg 272(3):488–494
Su B et al (2020) Use of impedance planimetry (Endoflip) in foregut surgery practice: experience of more than 400 cases. J Am Coll Surg 231(1):160–171
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Dr. Zarnegar is a consultant for Bard (BD). Dr Katz is a consultant for Medtronic. Drs. Liu, Stefanova, Finnerty, Schnoll-Sussman, and Fahey have no conflicts of interest or financial ties to disclose.
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Liu, M., Stefanova, D.I., Finnerty, B.M. et al. The impact of pneumoperitoneum on esophagogastric junction distensibility during anti-reflux surgery. Surg Endosc 36, 367–374 (2022). https://doi.org/10.1007/s00464-021-08291-7
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DOI: https://doi.org/10.1007/s00464-021-08291-7