Does Measurement of Esophagogastric Junction Distensibility by EndoFLIP Predict Therapy- responsiveness to Endoluminal Fundoplication in Patients With Gastroesophageal Reflux Disease?

Abstract

Background/Aims In patients with gastroesophageal reflux disease (GERD), an increased esophagogastric junction (EGJ) distensibility has been described. Assessment of EGJ distensibility with the endoscopic functional luminal imaging probe (EndoFLIP) technique might identify patients responsive to transoral incisionless fundoplication (TIF), whereas postoperative measurement of EGJ distensibility might provide insight into the antireflux mechanism of TIF. Therefore, we investigated the value of the EndoFLIP technique in GERD patients treated by TIF. Methods Forty-two GERD patients underwent EGJ distensibility measurement before TIF using the EndoFLIP technique. In a subgroup of 25 patients, EndoFLIP measurement was repeated both postoperative and at 6 months follow-up. Treatment outcome was assessed according to esophageal acid exposure time (AET; objective outcome) and symptom scores (clinical outcome) 6 months after TIF. Results Multiple logistic regression analysis showed that preoperative EGJ distensibility (OR, 0.16; 95% CI, 0.03–0.78; P = 0.023) and preoperative AET (OR, 0.62; 95% CI, 0.42–0.90; P = 0.013) were independent predictors for objective treatment outcome but not for clinical outcome after TIF. The best cut-off value for objective outcome was 2.3 mm 2 /mmHg for preoperative EGJ distensibility and 11% for preoperative AET. EGJ distensibility decreased direct postoperative from 2.0 (1.2–3.3) to 1.4 (1.0–2.2) mm 2 /mmHg ( P = 0.014), but increased to 2.2 (1.5–3.0) at 6 months follow-up ( P = 0.925, compared to preoperative). Conclusions Preoperative EGJ distensibility and preoperative AET were independent predictors for objective treatment outcome but not for clinical outcome after TIF. According to our data, the EndoFLIP technique has no added value either in the preoperative diagnostic work-up or in the post-procedure evaluation of endoluminal antireflux therapy.

The relationship between esophageal acid exposure and the esophageal response to volumetric distention

“…6 Another study that evaluated patients treated with trans-oral incisionless fundoplication (TIF) demonstrated that pre-operative EGJ-DI was not correlated with pre-operative AET, nor was EGJ-distensibility at 6month post-TIF follow-up associated with normalization of AET. 7 Similarly, we did not observe a significant correlation of EGJ-DI with AET, nor did we observe a difference in EGJ-DI associated with categorized AET.…”

“…However, a subsequent study assessing patients with FLIP and wireless esophageal pH monitoring found that patients with GERD symptoms actually had lower EGJ‐DI than controls, and EGJ‐DI did not differ between patients with normal (n = 9) or abnormal (n = 9) esophageal acid exposure . Another study that evaluated patients treated with trans‐oral incisionless fundoplication (TIF) demonstrated that pre‐operative EGJ‐DI was not correlated with pre‐operative AET, nor was EGJ‐distensibility at 6‐month post‐TIF follow‐up associated with normalization of AET . Similarly, we did not observe a significant correlation of EGJ‐DI with AET, nor did we observe a difference in EGJ‐DI associated with categorized AET.…”

“…The FLIP is commercially available and can be easily applied during a sedated upper endoscopy, thus it offers the potential to aid clinical characterization of patients presenting with GERD symptoms. Although EGJ‐distensibility was assessed with FLIP in several previous studies, results regarding the association between EGJ‐distensibility and GERD have been inconsistent . Distension‐induced contractility can also be assessed using the FLIP, though this evaluation has not been previously described among patients evaluated for GERD …”

“…Although EGJ-distensibility was assessed with FLIP in several previous studies, results regarding the association between EGJdistensibility and GERD have been inconsistent. [4][5][6][7][8] Distension-induced contractility can also be assessed using the FLIP, though this evaluation has not been previously described among patients evaluated for GERD. 9,10 The role of FLIP for diagnostic evaluation and targeted management in GERD remains appealing, however inconsistent results among prior studies applying FLIP measurement of EGJ-distensibility in GERD limits support of this application.…”

Measurement of Esophagogastric Junction Distensibility May Assist in Selecting Patients for Endoluminal Gastroesophageal Reflux Disease Surgery

“…TO THE EDITOR: I read with interest the study by Smeets et al, 1 who evaluated the association between pre-operative distensibility measurements and objective and clinical outcomes after transoral incisionless fundoplication (TIF) surgery. The study concluded that distensibility measurements have no added value in the pre-operative diagnostic work-up or in the post-procedure evaluation of endoluminal anti-reflux therapy.…”