Validation of Clinically Relevant Thresholds of Esophagogastric Junction Obstruction Using FLIP Panometry

Carlson, Dustin A.; Prescott, Jacqueline; Baumann, Alexandra J.; Schauer, Jacob M.; Krause, Amanda J.; Donnan, Erica; Kou, Wenjun; Kahrilas, Peter J.; Pandolfino, John E.

doi:10.1016/j.cgh.2021.06.040

Cited by 33 publications

(63 citation statements)

References 17 publications

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“…There are no normal data available for diameter in the situation when the EGJ‐DI is between 2–3 mm 2 /mmHg. However, recent work found that in patients with an EGJ‐DI ≥2.0 mm 2 /mmHg and a maximum EGJ diameter ≥16 mm, 99% had a normal EGJ outflow on high resolution manometry 29 . The 5th percentile of the intrabag pressure was 20.7 and 31.3 mmHg at the 40 and 50 ml fill volumes, respectively, which is above the recommended pressure of 20 mmHg threshold indicated at 60 ml 2 …”

Section: Discussionmentioning

confidence: 85%

“…However, recent work found that in patients with an EGJ-DI ≥2.0 mm 2 /mmHg and a maximum EGJ diameter ≥16 mm, 99% had a normal EGJ outflow on high resolution manometry. 29 The 5th percentile of the intrabag Although there is little discussion about the relevance of an abnormally low EGJ-DI, it remains the question if it makes sense to define an upper limit of normality for EGJ-DI. The 95th percentile for upper limit of EGJ-DI from the meta-analysis was 10.95 mm 2 / mmHg at 40 ml balloon filling and 10.66 mm 2 /mmHg at 50 ml balloon filling, relatively close to the value of 9 mm 2 /mmHg that has been suggested in the literature.…”

Section: Discussionmentioning

confidence: 99%

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Normative values for esophageal functional lumen imaging probe measurements: A meta‐analysis

Bredenoord

Rancati

Lin

et al. 2022

Neurogastroenterology Motil

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Background The functional lumen imaging probe (Endoflip™) is increasingly used for evaluation of patients with esophageal symptoms. To improve the interpretation of Endoflip™ in clinical practice, normative values with appropriate cut‐off values are required. Methods Original clinical studies describing Endoflip™ use for measurements of esophageal motility in healthy adults were considered. Meta‐analysis was performed based on published values. Results A total of 17 articles were included in the systematic review, 15 of which were included in the meta‐analysis, representing 154 unique subjects. At 40 ml distention, the 5th–95th and 10th–90th percentiles for esophagogastric junction distensibility index (EGJ‐DI) were 1.96–10.95 mm2/mmHg and 2.36–8.95 mm2/mmHg, respectively. An EGJ‐DI below 2 mm2/mmHg was found in 5.4%, and below 3 mm2/mmHg in 20.1% of healthy subjects. At 50 ml distention, the 5th–95th and 10th–90th percentiles for EGJ‐DI are 2.86–10.66 mm2/mmHg and 3.28–9.12 mm2/mmHg, respectively (below 2 mm2/mmHg: 0.6%, 3 mm2/mmHg: 6.3%). The 5th–95th and 10th–90th percentiles for EGJ‐DI at 60 ml distention were 3.06–8.14 mm2/mmHg and 3.33–7.18 mm2/mmHg, respectively (below 2 mm2/mmHg: 0.0%, 3 mm2/mmHg: 7%). A clear cut‐off for lower values was identified while a large spread in values was observed for upper limits of normal for EGJ‐DI for all filling volumes. Conclusions Given these observations, we recommend using a cut‐off of 2 mm2/mmHg for clinical practice, values below can be considered abnormal. Given that 5.4% of the healthy subjects will have an EGJ‐DI below 2 mm2/mmHg at 40 ml, we recommend using the 50 and 60 ml distention volumes. The clinical use of an upper limit for normality of EGJ‐DI seems questionable.

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Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 99%

Normative values for esophageal functional lumen imaging probe measurements: A meta‐analysis

Bredenoord

Rancati

Lin

et al. 2022

Neurogastroenterology Motil

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“…FLIP panometry findings correlate well with HRM in detecting EGJ obstruction [27 ▪ ], and FLIP can be used to support the manometric diagnosis of EGJOO. One study showed that FLIP revealed an abnormal DI (<2.8 mm 2 /mmHg) in 33 of 38 patients (87%) with EGJOO diagnosed by HRM [22].…”

Section: Functional Luminal Imaging Probe Parameters In Esophagogastr...mentioning

confidence: 75%

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

Ellison

Nguyen²

2022

Current Opinion in Gastroenterology

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Purpose of reviewEsophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO.Recent findingsFLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures.SummaryFLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.

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“…1,2 We recently reported a diagnostic approach to classify EGJ opening (that accurately identified EGJ obstruction as defined by high-resolution manometry (HRM) and the Chicago classification version 4.0 (CCv4.0) applying FLIP panometry metrics: the EGJ distensibility index (DI) and maximum EGJ diameter. 3,4 This approach accurately identified EGJ obstruction, as defined by highresolution manometry (HRM) and the CCv4.0, when the FLIP metrics were both distinctly reduced (ie, reduced EGJ opening [REO]), or both distinctly normal (ie, normal EGJ opening). The promise of the FLIP panometry EGJ opening classification was further demonstrated by outperforming HRM to detect esophageal retention on timed barium esophagram (TBE).…”

Section: Introductionmentioning

confidence: 99%

“… 5 However, the FLIP panometry EGJ opening classification left a “middle-ground” classification of borderline EGJ opening (BEO) when the EGJ-DI or maximum EGJ diameter were reduced, but criteria for REO were not met; this was observed in 23% of the study cohort. 3 The BEO classification was associated with less diagnostic certainty and it was recommended that additional complementary testing should be pursued to facilitate reaching an overall clinical impression.…”

Section: Introductionmentioning

confidence: 99%

Estimating Probability for Esophageal Obstruction: A Diagnostic Decision Support Tool Applying Machine Learning to Functional Lumen Imaging Probe Panometry

Schauer

Kou

Prescott

et al. 2022

J Neurogastroenterol Motil

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Background/AimsThis study aimed to develop a diagnostic tool using machine learning to apply functional luminal imaging probe (FLIP) panometry data to determine the probability of esophagogastric junction (EGJ) obstruction as determined using the Chicago Classification version 4.0 (CCv4.0) and high-resolution manometry (HRM). MethodsFive hundred and fifty-seven adult patients that completed FLIP and HRM (with a conclusive CCv4.0 assessment of EGJ outflow) and 35 asymptomatic volunteers ("controls") were included. EGJ opening was evaluated with 16-cm FLIP performed during sedated endoscopy via EGJ-distensibility index and maximum EGJ diameter. HRM was classified according to the CCv4.0 as conclusive disorders of EGJ outflow or normal EGJ outflow (timed barium esophagram applied when required and available). The probability tool utilized Bayesian additive regression treesBART, which were evaluated using a leave-one-out approach and a holdout test set. ResultsPer HRM and CCv4.0, 243 patients had a conclusive disorder of EGJ outflow while 314 patients (and all 35 controls) had normal EGJ outflow. The model accuracy to predict EGJ obstruction (based on leave-one-out/holdout test set, respectively) was 89%/90%, with 87%/85% sensitivity, 92%/97% specificity, and an area under the receiver operating characteristic curve of 0.95/0.97. A free, opensource tool to calculate probability for EGJ obstruction using FLIP metrics is available at https://www.wklytics.com/nmgi/prob_flip. html. ConclusionsApplication of FLIP metrics utilizing a probabilistic approach incorporates the diagnostic confidence (or uncertainty) into the clinical interpretation of EGJ obstruction. This tool can provide clinical decision support during application of FLIP Panometry for evaluation of esophageal motility disorders.

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Validation of Clinically Relevant Thresholds of Esophagogastric Junction Obstruction Using FLIP Panometry

Cited by 33 publications

References 17 publications

Normative values for esophageal functional lumen imaging probe measurements: A meta‐analysis

Normative values for esophageal functional lumen imaging probe measurements: A meta‐analysis

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

Estimating Probability for Esophageal Obstruction: A Diagnostic Decision Support Tool Applying Machine Learning to Functional Lumen Imaging Probe Panometry

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