Consistency and effect of body position change on measurement of upper and lower esophageal sphincter geometry using impedance planimetry in a canine model

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

Swallowing impairment is a highly prevalent and clinically significant problem affecting people and dogs. There are myriad causes of swallowing impairment of which gastroesophageal reflux is the most common in both species. Similarities in anatomy and physiology between humans and canines results in analogous swallowing disorders including cricopharyngeus muscle achalasia, esophageal achalasia, hiatal herniation, and gastroesophageal reflux with secondary esophagitis and esophageal dysmotility. Accordingly, the diagnostic approach to human and canine patients with swallowing impairment is similar. Diagnostic procedures such as swallowing fluoroscopy, high-resolution manometry, pH/impedance monitoring, and endolumenal functional luminal imaging probe can be performed in both species; however, nasofacial conformation, increased esophageal length, and the difficulty of completing several of these procedures in awake dogs are inherent challenges that need to be considered. Human patients can convey their symptoms and respond to verbal cues, whereas veterinarians must rely on clinical histories narrated by pet owners followed by comprehensive physical examination and observation of the animal eating different food consistencies and drinking water. Dogs may also be unwilling to drink or eat in the hospital setting and may be resistant to physical restraint during diagnostic procedures. Despite the species differences and diagnostic challenges, dogs are a natural animal model for many oropharyngeal and esophageal disorders affecting people, which presents a tremendous opportunity for shared learnings. This manuscript reviews the comparative aspects of esophageal anatomy and physiology between humans and canines, summarizes the diagnostic assessment of swallowing impairment in both species, and discusses future considerations for collaborative medicine and translational research.

Clinical and videofluoroscopic outcomes of laparoscopic treatment for sliding hiatal hernia and associated gastroesophageal reflux in brachycephalic dogs

OBJECTIVE

To describe a laparoscopic technique for treatment of sliding hiatal hernia (SHH) and associated gastroesophageal reflux (GER) in brachycephalic dogs and document clinical and videofluoroscopic outcomes postoperatively.

STUDY DESIGN

Prospective clinical trial.

ANIMALS

Eighteen client-owned dogs.

METHODS

A three-port laparoscopic approach was used. Intracorporeal suturing was used for hiatal plication and esophagopexy, and left-sided laparoscopic or laparoscopic-assisted gastropexy was performed. A standardized canine dysphagia assessment tool (CDAT) questionnaire was completed by owners pre- and postoperatively. Videofluoroscopic swallow studies (VFSS) were used to evaluate esophageal function, and impedance planimetry was used to assess lower esophageal sphincter geometry preoperatively and in a subset of dogs postoperatively.

RESULTS

Median age was 27.5 (range 5-84) months. Conversion to open surgery was necessary in 1 (5.5%) of 18 dogs. Regurgitation after eating, and associated with activity/exercise, improved significantly when comparing pre- and postoperative CDAT assessments. Hiatal hernia and GER severity scores improved significantly between pre- and postoperative VFSS assessments, whereas SHH and GER frequency scores did not. One dog developed pneumothorax intraoperatively, underwent cardiopulmonary arrest, and died. Minor complications included splenic (n = 6) and hepatic lacerations (n = 3) that did not require specific therapy.

CONCLUSION

A laparoscopic approach to treatment of SHH and GER led to improvements in clinical and VFSS indices in the majority of brachycephalic dogs. However, a subset of dogs still demonstrated some clinical signs postoperatively.

CLINICAL RELEVANCE

In experienced hands, laparoscopic treatment of SHH and GER offers a minimally invasive alternative to open surgery.

[Intraoperative Aspiration]

术中误吸是外科手术中常见的肺部并发症，麻醉和体位是导致术中误吸的主要因素。近年来，围手术期肺保护已受到外科和麻醉医师的广泛关注，如何加速术后康复进程，减少相关并发症发生，显著改善患者预后已成为当前外科治疗的主要目标。本文将以术中误吸为重点，从解剖、病理生理、表现、诊断、处理和预防等方面展开综述。

Flip Technology for Assessing Esophageal Structural and Motor Disorders: a Skeptic's View

PURPOSE OF REVIEW

Functional lumen impedance (FLIP) technology has become commercially available to assess structural and motor abnormalities of the esophagus. Increasing numbers of papers have described novel findings with this technology. This review examines the validity of the FLIP technique, how it compares with existing diagnostic modalities, and evidence to date on diagnostic accuracy.

RECENT FINDINGS

FLIP studies require deep sedation at the time of endoscopy to complete. They assess a simulated state of esophageal obstruction in only a distal part of the esophagus rather than deglutitive motor function of the entire esophagus. The available normative dataset is small and not matched to the older age of patients typically being evaluated. The test-retest agreement in health and disease is unknown, as is the operator dependence on performing and interpreting findings. Studies to date have largely excluded patients with structural disorders, which FLIP cannot reliably distinguish from motor disorders. FLIP is an expensive technology that has been made clinically available without its true utility being established. For FLIP to be deemed a device ready for widespread clinical use, additional studies on validity, diagnostic accuracy, and outcomes need to be performed. Prospective clinical studies need to include all patients and assess the incremental cost-effectiveness of FLIP over more innovative use of existing technology, such as high-resolution manometry with provocative challenges.

Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video)

BACKGROUND AND AIMS

Endoluminal functional luminal imaging probe (EndoFLIP) is an imaging tool that measures the physiologic characteristics of GI sphincters. In this study, we used EndoFLIP to evaluate the association between the pyloric physiologic measurements and the clinical outcomes of gastric peroral endoscopic myotomy (G-POEM) in patients with refractory gastroparesis.

METHODS

Thirty-seven patients from 5 centers who underwent G-POEM for management of refractory gastroparesis and had EndoFLIP measurements were evaluated. Cross-sectional area (CSA), balloon pressure, and the distensibility index (DI) of the pylorus were evaluated by EndoFLIP at 40 mL and 50 mL balloon fills before and after G-POEM. One-year clinical success and change in gastric emptying study 3 months after the G-POEM procedure were compared with the EndoFLIP measurements.

RESULTS

Clinical success was achieved in 26 (70%) patients. Post-G-POEM CSA and DI were significantly higher in the clinical success group with both 40-mL volume distension (CSA: 89.9 ± 64.8 vs 172.5 ± 71.9 mm², P =.003; DI: 5.8 ± 4.4 vs 8.8 ± 6.1 mm²/mm Hg, P =.043) and 50-mL volume distention (CSA: 140.1 ± 89.9 vs 237.5 ± 80.3 mm², P =.003; DI: 5.6 ± 3.3 vs 9.9 ± 6.6 mm²/mm Hg, P =.049). CSA using 40-mL volume distention with an area under the curve of 0.83 yielded a specificity of 91% and a sensitivity of 71% at a cutoff point of 154 mm².

CONCLUSIONS

Post-G-POEM CSA of the pylorus is associated with clinical success and improvement in a gastric emptying scan after G-POEM. EndoFLIP measurements of the pylorus have the potential to be used as a tool to predict the clinical outcome of G-POEM.

Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia

BACKGROUND

The functional luminal imaging probe (FLIP) can evaluate esophagogastric junction (EGJ) distensibility and esophageal peristalsis in real time. FLIP measurements performed during diagnostic endoscopy can accurately discriminate between healthy controls and patients with achalasia based on EGJ-distensibility and distinct motility patterns termed repetitive antegrade contractions (RACs) and repetitive retrograde contractions (RRCs). We sought to evaluate real-time motility changes in patients undergoing surgical myotomy for achalasia.

METHODS

FLIP measurements using a stepwise volumetric distention protocol were performed at three time points during assessment and performance of laparoscopic Heller myotomy and POEM: (1) During preoperative outpatient endoscopy, (2) Intraoperatively following induction of anesthesia, and (3) Intraoperatively after myotomy completion. EGJ-distensibility, contractility, RACs, and RRCs were measured.

RESULTS

FLIP measurements were performed in 32 patients. The EGJ-distensibility index was similar between the preoperative and initial operative measurements (1.1 vs 1.4 mm²/mmHg, p = NS). There was a significant increase in distensibility following surgical myotomy (1.4 to 4.7 mm²/mmHg, p < 0.01). Intraoperative contractile patterns varied between achalasia subtypes. Contractility was seen in < 20% of assessments in patients with types I and II achalasia. Type III patients demonstrated contractility in 100% of assessments, with 70% exhibiting RRCs and 60% RACs. There was a reduction in the frequency of RRC presence (70% to 20%), and contractile vigor (80% to 0% of patients with lumen occluding contractions) in type III patients following surgical myotomy.

CONCLUSIONS

This first report of real-time intraoperative measurement of esophageal motility using FLIP demonstrates the feasibility of such assessments during surgical myotomy for achalasia. Patients with type I and II achalasia exhibited rare intraoperative contractility, while the presence of motility was the norm in those with type III. Patients with type III achalasia demonstrated an immediate reduction in repetitive contraction motility patterns and contractile vigor following myotomy.