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Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia

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Abstract

Background

Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia.

Methods

We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist’s description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm2/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score.

Results

Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7–82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1–88.4%, p = 0.0001).

Conclusions and inferences

Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.

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Acknowledgements

An abstract of this paper was accepted for oral presentation and presented virtually at Digestive Disease Week 2020.

Funding

Funding was provided by a Grant from the Emory University Department of Medicine to Dr. Anand S. Jain. No authors have a financial relationship with Medtronic, the manufacturer or FLIP.

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Authors and Affiliations

  1. Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA

    Salih Samo, Ramzi Mulki, Marie L. Godiers, Chuma G. Obineme, Lucie F. Calderon, John M. Bloch, Joyce J. Kim, Nikrad Shahnavaz, Srikrishna V. Patnana, Field F. Willingham, Steven A. Keilin, Qiang Cai, Jennifer A. Christie, Shanthi Srinivasan & Anand S. Jain

  2. Atlanta VA Medical Center and Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, USA

    Shreya M. Raja

  3. Division of Foregut Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, USA

    Edward Lin & S. Scott Davis Jr.

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  1. Salih Samo
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  2. Ramzi Mulki
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  16. Edward Lin
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  18. Anand S. Jain
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Correspondence to Anand S. Jain.

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Disclosures

Salih Samo, Ramzi Mulki, Marie L. Godiers, Chuma G. Obineme, Lucie F. Calderon, John M. Bloch, Joyce J. Kim, Nikrad Shahnavaz, Shreya M. Raja, Srikrisha V. Patnana, Steven A. Keilin, Qiang Cai, Jennifer A. Christie, Shanthi Srinivasan, S. Scott Davis Jr., Edward Lin and Anand S. Jain have no conflicts of interest or financial ties to disclose. Field F. Willingham: Dr. Willingham reports research grants for clinical trials from Cancer Prevention Pharmaceuticals, Cook Medical, Boston Scientific, and CSA Medical, paid directly to institution. Otherwise, no conflicts of interest or financial ties to disclose.

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Samo, S., Mulki, R., Godiers, M.L. et al. Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia. Surg Endosc 35, 4418–4426 (2021). https://doi.org/10.1007/s00464-020-07941-6

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