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Wang TN, Underhill J, Tamer R, Perry KA, Haisley KR. Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery. Surg Endosc 2024; 38:377-383. [PMID: 37803186 DOI: 10.1007/s00464-023-10418-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/29/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study. METHODS Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant. RESULTS Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3 kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001). CONCLUSION Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD.
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Affiliation(s)
- Theresa N Wang
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA.
| | - Jennifer Underhill
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA
| | - Robert Tamer
- Department of Surgery, Center for Surgical Health Assessment, Research and Policy, The Ohio State University, Columbus, OH, USA
| | - Kyle A Perry
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA
| | - Kelly R Haisley
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, Columbus, OH, USA
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Vackova Z, Levenfus I, Pohl D. Interventional functional diagnostics in gastrointestinal endoscopy: Combining diagnostic and therapeutic tools in the endoscopy suite with the functional lumen imaging probe. Curr Opin Pharmacol 2023; 73:102414. [PMID: 38029641 DOI: 10.1016/j.coph.2023.102414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
With technical progress of gastrointestinal functional testing, there has been a demand for more comprehensive examination of esophageal physiology and pathophysiology beyond high-resolution manometry. A new interventional technology based on impedance planimetry, the functional lumen imaging probe (FLIP), enables intraluminal measurement of distensibility and compliance of hollow organs. EndoFLIP uses balloon catheters to measure diameter and distension pressure to calculate cross-sectional area and distensibility in different organs (mostly esophagus, stomach, anorectal region) and can be used in wide variety of indications (diagnostics, pre- and post-treatment evaluation) and currently serves as a helpful adjunctive tool in ambiguous clinical cases. EsoFLIP is a therapeutic variation that uses a stiffer balloon catheter allowing for dilation. The trend to simplify the clinical process from diagnosis to treatment tends to a one-session procedure combining diagnostics and therapeutic interventions. In specified conditions like e.g. achalasia or gastroparesis, a combination of EndoFLIP and EsoFLIP procedures may therefore be useful. The aim of this narrative review is to introduce the clinical use of FLIP and its potential benefit in combined diagnostic-therapeutic procedures.
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Affiliation(s)
- Zuzana Vackova
- Department of Gastrointestinal Endoscopy, Department of Medicine, Military University Hospital Prague, Czech Republic.
| | - Ian Levenfus
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
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Halder S, Pandolfino JE, Kahrilas PJ, Koop A, Schauer J, Araujo IK, Elisha G, Kou W, Patankar NA, Carlson DA. Assessing mechanical function of peristalsis with functional lumen imaging probe panometry: Contraction power and displaced volume. Neurogastroenterol Motil 2023; 35:e14692. [PMID: 37845833 DOI: 10.1111/nmo.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND AIMS The distal contractile integral (DCI) quantifies the contractile vigor of primary peristalsis on high-resolution manometry (HRM), whereas no such metric exists for secondary peristalsis on functional lumen imaging probe (FLIP) panometry. This study aimed to evaluate novel FLIP metrics of contraction power and displaced volume in asymptomatic controls and a patient cohort. METHODS Thirty-five asymptomatic controls and adult patients (with normal esophagogastric junction outflow/opening and without spasm) who completed HRM and FLIP panometry were included. The patient group also completed timed barium esophagram (TBE). Contraction power (estimate of esophageal work over time) and displaced volume (estimate of contraction-associated fluid flow) were computed from FLIP. HRM was analyzed per Chicago Classification v4.0. KEY RESULTS In controls, median (5th-95th percentile) contraction power was 27 mW (10-44) and displaced volume was 43 mL (17-66). 95 patients were included: 72% with normal motility on HRM, 17% with ineffective esophageal motility (IEM), and 12% with absent contractility. Among patients, DCI was significantly correlated with both contraction power (rho = 0.499) and displaced volume (rho = 0.342); p values < 0.001. Both contraction power and displaced volume were greater in patients with normal motility versus IEM or absent contractility, complete versus incomplete bolus transit, and normal versus abnormal retention on TBE; p values < 0.02. CONCLUSIONS FLIP panometry metrics of contraction power and displaced volume appeared to effectively quantify peristaltic vigor. These novel metrics may enhance evaluation of esophageal motility with FLIP panometry and provide a reliable surrogate to DCI on HRM.
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Affiliation(s)
- Sourav Halder
- Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andree Koop
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Jacob Schauer
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Isis K Araujo
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Guy Elisha
- Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Wenjun Kou
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Neelesh A Patankar
- Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
- Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Casabona Francés S, Ruiz de León San Juan A, Sanz García A, Ortega Rabbione GJ, Majano P, Pérez Fernández MT, Lucendo AJ, Santander C. Esophageal biomechanics assessed by impedance planimetry (EndoFLIPTM) in healthy subjects and in patients with eosinophilic esophagitis. Normality values. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:693-699. [PMID: 37449498 DOI: 10.17235/reed.2023.9560/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND active eosinophilic esophagitis is associated with esophageal caliber, distensibility and motility changes that may be reversed with treatment. OBJECTIVES to study esophageal diameter, distensibility and contractility in healthy subjects compared to patients with eosinophilic esophagitis, both before and after treatment. METHODS a quasi-experimental study, EndoFLIP™, was used to analyze the esophageal body and esophago-gastric junction (EGJ) in all three groups, and a program was designed to obtain esophageal diameter, distensibility and contractility values. RESULTS ten healthy volunteers (24-61 years, six men) and nine patients with eosinophilic esophagitis (21-52 years, seven men) were included. The esophagogastric junction distensibility index was 5.07 mm2/Hg in the control subjects, 2.40 mm2/Hg in the subjects with eosinophilic esophagitis before treatment and 2.46 mm2/Hg after treatment. The distensibility plateau was 20.02 mm, 15.43 mm and 17.41 mm, respectively, and the diameter was 21.90 mm, 17.73 mm and 18.30 mm, showing significant differences (p < 0.05), except between control subjects and patients after treatment (p = 0.079). Repetitive antegrade contractions developed in 90 % of control subjects, 66.7 % of eosinophilic esophagitis patients before treatment and 88.9 % of the latter after treatment (p > 0.05). CONCLUSIONS esophago-gastric junction distensibility index, distensibility plateau and diameter values were higher in controls than in patients, although six weeks of treatment seems a short period to observe significant changes in esophageal biomechanics. Repetitive antegrade contractions are the predominant pattern in healthy subjects and eosinophilic esophagitis. We provide normality values for esophageal biomechanics, measured by impedance planimetry in our setting.
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Affiliation(s)
| | | | - Ancor Sanz García
- Unidad de Análisis de Datos, Instituto de Investigación Sanitaria Princesa (IIS-IP)
| | | | - Pedro Majano
- Aparato Digestivo, Hospital Universitario de La Princesa
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Wakim El-Khoury J, Pandolfino JE, Kahrilas PJ, Godo B, Farina DA, Kou W, Carlson DA. Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry. Neurogastroenterol Motil 2023; 35:e14663. [PMID: 37691556 DOI: 10.1111/nmo.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension. METHODS Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0). KEY RESULTS Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM. CONCLUSIONS AND INFERENCES This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.
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Affiliation(s)
- Jeanine Wakim El-Khoury
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bidemi Godo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Blonski W, Slone S, Richter JE. Update on the Diagnosis and Treatment of Achalasia. Dysphagia 2023; 38:596-608. [PMID: 35585208 DOI: 10.1007/s00455-022-10435-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 03/04/2022] [Indexed: 12/23/2022]
Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
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Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Carlson DA, Kahrilas PJ. The Case for Functional Lumen Imaging Probe Panometry in Clinical Practice. Gastroenterology 2023; 164:702-703. [PMID: 36402193 DOI: 10.1053/j.gastro.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ellison A, Nguyen AD, Zhang J, Mendoza R, Davis D, Podgaetz E, Ward M, Reddy C, Souza R, Spechler SJ, Konda VJA. The broad impact of functional lumen imaging probe panometry in addition to high-resolution manometry in an esophageal clinical practice. Dis Esophagus 2023; 36:6705376. [PMID: 36125222 DOI: 10.1093/dote/doac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 12/11/2022]
Abstract
High-resolution manometry (HRM) with the Chicago Classification (CC) is the standard paradigm to define esophageal motility disorders. Functional lumen imaging probe (FLIP) panometry utilizes impedance planimetry to characterize esophageal compliance and secondary peristalsis. The aim of this study was to explore the clinical impact of FLIP panometry in addition to HRM. A retrospective chart review was performed on FLIP panometry cases utilizing the 322N catheter. Cases with prior foregut surgeries or botulinum injection within 6 months of FLIP panometry were excluded. EGJ-diameter and distensibility index (DI) and secondary contraction patterns at increasing balloon volumes were recorded. An EGJ-DI of ≥2.8 mm2/mm Hg at 60 mL was considered as a normal EGJ distensibility. CC diagnosis, Eckhardt score, Brief Esophageal Dysphagia Questionnaire, and clinical outcomes were obtained for each FLIP case. A total of 186 cases were included. Absent contractility and achalasia types 1 and 2 showed predominantly absent secondary contraction patterns, while type 3 had a variety of secondary contractile patterns on FLIP panometry. Among 77 cases with EGJ outflow obstruction (EGJOO), 60% had a low EGJ-DI. Among those with no motility disorder or ineffective esophageal motility on HRM, 27% had a low DI and 47% had sustained contractions on FLIP, raising concern for an esophageal dysmotility process along the achalasia and/or spastic spectrum. FLIP panometry often confirmed findings on HRM in achalasia and absent contractility. FLIP panometry is useful in characterizing EGJOO cases. Spastic features on FLIP panometry may raise concern for a motility disorder on the spastic spectrum not captured by HRM. Further studies are needed on FLIP panometry to determine how to proceed with discrepancy with HRM and explore diagnoses beyond the CC.
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Affiliation(s)
- Ashton Ellison
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Anh D Nguyen
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Jesse Zhang
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Roseann Mendoza
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Daniel Davis
- Department of Surgery, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Eitan Podgaetz
- Department of Thoracic Surgery, Baylor University Medical Center, pa rt of Baylor Scott & White, Dallas, TX, USA
| | - Marc Ward
- Department of Surgery, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Chanakyaram Reddy
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Rhonda Souza
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Stuart J Spechler
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
| | - Vani J A Konda
- Center for Esophageal Diseases, Baylor University Medical Center, part of Baylor Scott & White, Dallas, TX, USA
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Vespa E, Farina DA, Kahrilas PJ, Kou W, Low EE, Yadlapati R, Pandolfino JE, Carlson DA. Identifying spastic variant of type II achalasia after treatment with high-resolution manometry and FLIP Panometry. Neurogastroenterol Motil 2023:e14552. [PMID: 36807659 DOI: 10.1111/nmo.14552] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Panesophageal pressurization (PEP) defines type II achalasia on high-resolution-manometry (HRM) but some patients exhibit spasm after treatment. The Chicago Classification (CC) v4.0 proposed high PEP values as predictor of embedded spasm, yet supportive evidence is lacking. METHODS Fifty seven type II achalasia patients (47 ± 18 years, 54% males) with HRM and LIP Panometry before and after treatment were retrospectively identified. Baseline HRM and FLIP studies were analyzed to identify factors associated with post-treatment spasm, defined on HRM per CC v4.0. RESULTS Seven patients (12%) had spasm following treatment (peroral endoscopic myotomy 47%; pneumatic dilation [PD] 37%; laparoscopic Heller myotomy 16%). At baseline, greater median maximum PEP pressure (MaxPEP) values on HRM (77 vs 55 mmHg, p = 0.045) and spastic-reactive contractile response pattern on FLIP (43% vs 8%, p = 0.033) were more common in patients with post-treatment spasm while absent contractile response on FLIP was more common in patients without spasm (14% vs 66%, p = 0.014). The strongest predictor of post-treatment spasm was the percentage of swallows with MaxPEP ≥70 mmHg (best cut-off: ≥30%), with AUROC of 0.78. A combination of MaxPEP <70 mmHg and FLIP 60 mL pressure < 40 mmHg identified patients with lower rates of post-treatment spasm (3% overall, 0% post-PD) compared to those with values above these thresholds (33% overall, 83% post-PD). CONCLUSIONS High maximum PEP values, high FLIP 60 mL pressures and contractile response pattern on FLIP Panometry prior to treatment identified type II achalasia patients more likely to exhibit post-treatment spasm. Evaluating these features may guide personalized patient management.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy.,Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eric E Low
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kou W, Soni P, Klug MW, Etemadi M, Kahrilas PJ, Pandolfino JE, Carlson DA. An artificial intelligence platform provides an accurate interpretation of esophageal motility from Functional Lumen Imaging Probe Panometry studies. Neurogastroenterol Motil 2023:e14549. [PMID: 36808777 DOI: 10.1111/nmo.14549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/18/2023] [Accepted: 01/30/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Functional lumen imaging probe (FLIP) Panometry is performed at the time of sedated endoscopy and evaluates esophageal motility in response to distension. This study aimed to develop and test an automated artificial intelligence (AI) platform that could interpret FLIP Panometry studies. METHODS The study cohort included 678 consecutive patients and 35 asymptomatic controls that completed FLIP Panometry during endoscopy and high-resolution manometry (HRM). "True" study labels for model training and testing were assigned by experienced esophagologists per a hierarchical classification scheme. The supervised, deep learning, AI model generated FLIP Panometry heatmaps from raw FLIP data and based on convolutional neural networks assigned esophageal motility labels using a two-stage prediction model. Model performance was tested on a 15% held-out test set (n = 103); the remainder of the studies were utilized for model training (n = 610). KEY RESULTS "True" FLIP labels across the entire cohort included 190 (27%) "normal," 265 (37%) "not normal/not achalasia," and 258 (36%) "achalasia." On the test set, both the Normal/Not normal and the achalasia/not achalasia models achieved an accuracy of 89% (with 89%/88% recall, 90%/89% precision, respectively). Of 28 patients with achalasia (per HRM) in the test set, 0 were predicted as "normal" and 93% as "achalasia" by the AI model. CONCLUSIONS An AI platform provided accurate interpretation of FLIP Panometry esophageal motility studies from a single center compared with the impression of experienced FLIP Panometry interpreters. This platform may provide useful clinical decision support for esophageal motility diagnosis from FLIP Panometry studies performed at the time of endoscopy.
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Affiliation(s)
- Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Priyanka Soni
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew W Klug
- Department of Information Services, Northwestern Medicine, Chicago, Illinois, USA
| | - Mozziyar Etemadi
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Information Services, Northwestern Medicine, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Carlson DA, Kahrilas PJ, Simlote A, Vespa E, Teitelbaum E, Hungness E, Kou W, Pandolfino JE. Identifying hiatal hernia with impedance planimetry during esophageal distension testing. Neurogastroenterol Motil 2023; 35:e14470. [PMID: 36168153 PMCID: PMC10078178 DOI: 10.1111/nmo.14470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/29/2022] [Accepted: 09/12/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Functional luminal imaging probe (FLIP) Panometry evaluates the esophageal response to distension involving biomechanics and motility. We have observed that hiatus hernia (HH) is evident during FLIP studies as a separation between the crural diaphragm (CD) and lower esophageal sphincter (LES) like what is seen with high-resolution manometry (HRM). The aim of this study was to compare FLIP findings to endoscopy and HRM in the detection of HH. METHODS A total of 100 consecutive patients that completed FLIP during sedated endoscopy and HRM were included. LES-CD separation was assessed on FLIP and HRM with the presence of HH defined as LES-CD ≥1 cm. The agreement was evaluated using the kappa (κ) statistic. RESULTS Hiatal hernia was detected in 32% of patients on HRM and 44% of patients on FLIP with a substantial agreement between studies (84% agreement; κ = 0.667). On FLIP, a 'new' HH (i.e. HH not observed on HRM) occurred in 14 patients and an "enlarged" HH (i.e., LES-CD ≥2 cm larger than on HRM) occurred in 11 patients. Among patients that also completed, timed barium esophagogram (TBE), delayed esophageal emptying on TBE was more common in patients with new or enlarged HH on FLIP than those without: 7/11 (64%) versus 2/12 (17%); p = 0.017. CONCLUSION FLIP can detect HH with a substantial agreement with HRM, though esophageal distension with FLIP testing appeared to elicit and/or enlarge a HH in an additional 25% of patients. Although this unique response to esophageal distension may represent a mechanism of dysphagia or susceptibility to reflux, additional study is needed to clarify its significance.
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Affiliation(s)
- Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aditi Simlote
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Vespa
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Ezra Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eric Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Carlson DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. Functional Lumen Imaging Probe Panometry Helps Identify Clinically Relevant Esophagogastric Junction Outflow Obstruction per Chicago Classification v4.0. Am J Gastroenterol 2023; 118:77-86. [PMID: 36002925 PMCID: PMC9822847 DOI: 10.14309/ajg.0000000000001980] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/10/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Esophagogastric junction (EGJ) outflow obstruction (EGJOO) per Chicago Classification v4.0 (CCv4.0) represents a high-resolution manometry (HRM) diagnosis with uncertain clinical significance. This study aimed to evaluate functional lumen imaging probe (FLIP) panometry among patients with EGJOO on HRM/CCv4.0 to assess clinical/manometric associations and treatment outcomes. METHODS An observational cohort study was performed on patients who completed FLIP during endoscopy and had an HRM/CCv4.0 diagnosis of EGJOO, i.e., HRM-EGJOO (inconclusive). Abnormal FLIP panometry motility classifications were applied to identify FLIP-confirmed conclusive EGJOO. Rapid drink challenge on HRM and timed barium esophagram were also assessed. Clinical management plan was determined by treating physicians and assessed through chart review. Clinical outcome was defined using the Eckardt score (ES) during follow-up evaluation: ES < 3 was considered a good outcome. RESULTS Of 139 adult patients with manometric EGJOO (inconclusive per CCv4.0), a treatment outcome ES was obtained in 55 after achalasia-type treatment (i.e., pneumatic dilation, peroral endoscopic myotomy, laparoscopic Heller myotomy, or botulinum toxin injection) and 36 patients after other nonachalasia-type treatment. Among patients with conclusive EGJOO by HRM-FLIP complementary impression, 77% (33/43) had a good outcome after achalasia-type treatment, whereas 0% (0/12) of patients had a good outcome after nonachalasia-type treatment. Of patients with normal EGJ opening on FLIP, one-third of patients treated with achalasia-type treatment had a good outcome, while 9 of the 10 treated conservatively had a good outcome. DISCUSSION FLIP panometry provides a useful complement to clarify the clinical significance of an HRM/CCv4.0 EGJOO diagnosis and help direct management decisions.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jacob M. Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
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13
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Jung KW. The Clinical Usefulness of Functional Luminal Imaging Probe in Esophageal Dysmotility Disorder. J Neurogastroenterol Motil 2022; 28:509-511. [PMID: 36250356 PMCID: PMC9577584 DOI: 10.5056/jnm22135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/07/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Schauer JM, Kou W, Prescott JE, Kahrilas PJ, Pandolfino JE, Carlson DA. Estimating Probability for Esophageal Obstruction: A Diagnostic Decision Support Tool Applying Machine Learning to Functional Lumen Imaging Probe Panometry. J Neurogastroenterol Motil 2022; 28:572-579. [PMID: 36250364 PMCID: PMC9577577 DOI: 10.5056/jnm21239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/24/2022] [Accepted: 04/04/2022] [Indexed: 12/21/2022] Open
Abstract
Background/Aims This 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). Methods Five 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. Results Per 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, open-source tool to calculate probability for EGJ obstruction using FLIP metrics is available at https://www.wklytics.com/nmgi/prob_flip.html. Conclusions Application 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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Affiliation(s)
- Jacob M Schauer
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline E Prescott
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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15
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Goyal RK. EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus. Gastroenterology 2022; 163:552-555. [PMID: 35643171 DOI: 10.1053/j.gastro.2022.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Raj K Goyal
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts; Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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16
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Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction. Curr Opin Gastroenterol 2022; 38:388-394. [PMID: 35762698 DOI: 10.1097/mog.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Esophagogastric 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 FINDINGS FLIP 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. SUMMARY FLIP 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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17
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Carlson DA, Prescott JE, Germond E, Brenner D, Carns M, Correia CS, Tetreault MP, McMahan ZH, Hinchcliff M, Kou W, Kahrilas PJ, Perlman HR, Pandolfino JE. Heterogeneity of primary and secondary peristalsis in systemic sclerosis: A new model of "scleroderma esophagus". Neurogastroenterol Motil 2022; 34:e14284. [PMID: 34709690 PMCID: PMC9046463 DOI: 10.1111/nmo.14284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/27/2021] [Accepted: 10/12/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Although esophageal dysmotility is common in systemic sclerosis (SSc)/scleroderma, little is known regarding the pathophysiology of motor abnormalities driving reflux severity and dysphagia. This study aimed to assess primary and secondary peristalsis in SSc using a comprehensive esophageal motility assessment applying high-resolution manometry (HRM) and functional luminal imaging probe (FLIP) Panometry. METHODS A total of 32 patients with scleroderma (28 female; ages 38-77; 20 limited SSc, 12 diffuse SSc) completed FLIP Panometry and HRM. Secondary peristalsis, i.e., contractile responses (CR), was classified on FLIP Panometry by pattern of contractility as normal (NCR), borderline (BCR), impaired/disordered (IDCR), or absent (ACR). Primary peristalsis on HRM was assessed according to the Chicago classification. RESULTS The manometric diagnoses were 56% (n = 18) absent contractility, 22% (n = 7) ineffective esophageal motility (IEM), and 22% (n = 7) normal motility. Secondary peristalsis (CRs) included 38% (n = 12) ACR, 38% (n = 12) IDCR, 19% (n = 6) BCR, and 15% (n = 5) NCR. The median (IQR) esophagogastric junction (EGJ) distensibility index (DI) was 5.8 mm2 /mmHg (4.8-10.1) mm2 /mmHg; EGJ-DI was >8.0 mm2 /mmHg in 31%, and >2.0 mm2 /mmHg in 100% of patients. Among 18 patients with absent contractility on HRM, 11 had ACR, 5 had IDCR, and 2 had BCR. Among 7 patients with IEM, 1 had ACR, 5 had IDCR, and 1 NCR. All of the patients with normal peristalsis had NCR or BCR. CONCLUSIONS This was the first study assessing combined HRM and FLIP Panometry in a cohort of SSc patients, which demonstrated heterogeneity in primary and secondary peristalsis. This complementary approach facilitates characterizing esophageal function in SSc, although future study to examine clinical outcomes remains necessary.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline E Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emma Germond
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Darren Brenner
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mary Carns
- Department of Medicine, Division of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Chase S. Correia
- Department of Medicine, Division of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Marie-Pier Tetreault
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zsuzsanna H. McMahan
- Department of Medicine, Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Monique Hinchcliff
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, CT, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Harris R. Perlman
- Department of Medicine, Division of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Nguyen AD, Ellison A, Reddy CA, Mendoza R, Podgaetz E, Ward MA, Souza RF, Spechler SJ, Konda VJA. Spastic secondary contractile patterns identified by FLIP panometry in symptomatic patients with unremarkable high-resolution manometry. Neurogastroenterol Motil 2022; 34:e14321. [PMID: 35075734 DOI: 10.1111/nmo.14321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Functional lumen imaging probe (FLIP) panometry can show spastic secondary contractile patterns of unclear significance in symptomatic patients who have no esophageal obstructive disorders, and no motility disorders on high-resolution manometry (HRM). METHODS We retrospectively analyzed non-obstructed, symptomatic patients with HRM findings of no motility disorder or ineffective esophageal motility (IEM) for whom spastic secondary contractile patterns identified by FLIP panometry were used to guide treatment. Symptoms were scored using the Brief Esophageal Dysphagia Questionnaire (BEDQ). KEY RESULTS We identified ten symptomatic patients treated at our medical center who met inclusion criteria (seven women; mean age 56 years; eight no motility disorder, two IEM). On FLIP panometry, seven had spastic secondary contractions at 60 ml, two at 40 ml, and one at both 40 ml and 60 ml balloon volumes. Eight patients (80%) had improvement in BEDQ scores with therapies that targeted the spastic secondary contractile patterns identified by FLIP (five botulinum toxin injection, two Esoflip dilation, and one Heller myotomy). Interestingly, review of HRM tracings revealed that all patients had a novel HRM finding of mid-vertical pressurization in at least 20% swallows, with seven exhibiting this finding in >50% of swallows. CONCLUSIONS This case series demonstrates that treatments targeting spastic secondary contractions identified by FLIP panometry can result in symptomatic improvement in patients with no obstructive disorder and no diagnostic motility disorder on HRM. In such patients, we have identified the novel HRM finding of mid-vertical pressurization, which might be the manometric manifestation of spasm limited to the mid-esophagus.
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Affiliation(s)
- Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Eitan Podgaetz
- Department of Surgery, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Marc A Ward
- Department of Surgery, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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Ullal TV, Marks SL, Belafsky PC, Conklin JL, Pandolfino JE. A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans. Front Vet Sci 2022; 9:889331. [PMID: 35754550 PMCID: PMC9228035 DOI: 10.3389/fvets.2022.889331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Tarini V Ullal
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Stanley L Marks
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Peter C Belafsky
- Department of Otolaryngology, Center for Voice and Swallowing, School of Medicine, University of California, Davis, Davis, CA, United States
| | - Jeffrey L Conklin
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, UCLA Robert G. Kardashian Center for Esophageal Health, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Carlson DA, Prescott JE, Baumann AJ, Schauer JM, Krause A, Donnan EN, Kou W, Kahrilas PJ, Pandolfino JE. Validation of Clinically Relevant Thresholds of Esophagogastric Junction Obstruction Using FLIP Panometry. Clin Gastroenterol Hepatol 2022; 20:e1250-e1262. [PMID: 34216821 PMCID: PMC8716679 DOI: 10.1016/j.cgh.2021.06.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS This study aimed to assess the accuracy of functional luminal imaging probe (FLIP) panometry to detect esophagogastric junction (EGJ) obstruction assigned by high-resolution manometry (HRM) and the Chicago Classification version 4.0 (CCv4.0). METHODS Six hundred eighty-seven adult patients who completed FLIP and HRM for primary esophageal motility evaluation and 35 asymptomatic volunteers (controls) were included. EGJ opening was evaluated with 16-cm FLIP during sedated endoscopy via EGJ-distensibility index (DI) and maximum EGJ diameter. HRM was classified according to CCv4.0 and focused on studies with a conclusive disorder of EGJ outflow (ie, achalasia subtypes I, II, or III; or EGJ outflow obstruction with abnormal timed barium esophagogram) or normal EGJ outflow. RESULTS All 35 controls had EGJ-DI >3.0 mm2/mmHg and maximum EGJ diameter >16 mm. Per HRM and CCv4.0, 245 patients had a conclusive disorder of EGJ outflow, and 314 patients had normal EGJ outflow. Among the 241 patients with reduced EGJ opening (EGJ-DI <2.0 mm2/mmHg and maximum EGJ diameter <12 mm) on FLIP panometry, 86% had a conclusive disorder of EGJ outflow per CCv4.0. Among the 203 patients with normal EGJ opening (EGJ-DI ≥2.0 mm2/mmHg and maximum EGJ diameter ≥16 mm) on FLIP panometry, 99% had normal EGJ outflow per CCv4.0. CONCLUSIONS FLIP panometry accurately identified clinically relevant conclusive EGJ obstruction as defined by CCv4.0 in patients evaluated for esophageal motor disorders. Thus, FLIP panometry is a valuable tool for both independent and complementary evaluation of esophageal motility.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline E Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alexandra J. Baumann
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacob M. Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amanda Krause
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Makamson LM, Holm TE, Jenkins HN, Mehaffey NA, Mansour EA, Coleman TP, Norton CH, Walker SC, McClain JE, Parker AC, Brousse BR, Schaefer DC, Kutcher ME, Moremen JR. Impedance Planimetry and the Changing Paradigm of Esophageal Dysphagia. Am Surg 2022; 88:1805-1808. [PMID: 35387505 DOI: 10.1177/00031348221084088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Patients presenting with dysphagia can encounter a pathway to therapy and relief that is expensive and frustrating. High resolution impedance planimetry (HRIP) is a new mechanism for enhancing and possibly hastening that process. A balloon with integrated pressure sensors is utilized to measure luminal geometry and pressure by volume-controlled distention. Esophagogastric junction (EGJ) distensibility and body contractility are assessed at the time of other endoscopic procedures. Here we describe a single-center experience utilizing HRIP in the endoscopic evaluation of patients presenting with dysphagia. METHODS A prospectively maintained registry of patients undergoing impedance planimetry assessments at an academic medical center was queried for demographics, procedural details, and patient-reported outcomes. RESULTS Data was reviewed for 122 procedures performed by two providers. HRIP was performed in 63 (52%) patients for initial dysphagia assessment, 36 (30%) for follow-up assessment, and 20 (16%) as a procedural adjunct at the time of other planned procedures. HRIP contractile response was characterized as normal in 36%, absent in 32%, and diminished/disorganized in 14%. These results motivated clinical planning for surgical referral in 7 (5%) patients, 31 (26%) additional testing, and 82 (68%) continued medical management and follow-up. DISCUSSION HRIP is an emerging endoscopic modality which can streamline diagnostic work-up and therapeutic planning for patients with symptomatic dysphagia. Using functional esophageal assessment at the time of other diagnostic and therapeutic procedures, HRIP may expedite care and lead to improved patient satisfaction and clinical outcomes.
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Affiliation(s)
- Luci M Makamson
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Tyler E Holm
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Niall A Mehaffey
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Emily A Mansour
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Thomas P Coleman
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Christian H Norton
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Savannah C Walker
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Jessica E McClain
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Adam C Parker
- School of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Brandon R Brousse
- Department of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - David C Schaefer
- Department of Medicine, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Matthew E Kutcher
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
| | - Jacob R Moremen
- Department of Surgery, 21693University of Mississippi Medical Center, Jackson, MS, USA
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Ribolsi M, Ghisa M, Savarino E. Nonachalasic esophageal motor disorders, from diagnosis to therapy. Expert Rev Gastroenterol Hepatol 2022; 16:205-216. [PMID: 35220870 DOI: 10.1080/17474124.2022.2047648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Investigations conducted using conventional manometry and, recently, using high-resolution manometry (HRM), allowed us to explore the field of esophageal motility and understand the potential link between motor features and gastroesophageal reflux disease (GERD) pathogenesis. The management of patients with nonachalasic esophageal motor disorders is often challenging, due to the clinical heterogeneous presentation and the multifactorial nature of the mechanisms underlying symptoms. AREAS COVERED Several studies, carried out using HRM, have better interpreted the esophageal motor function in patients with esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypertensive esophagus, and hypomotility disorders. Moreover, HRM studies have shown a direct correlation between reduced esophageal motility, disruption of the esophagogastric junction, and gastroesophageal reflux burden. EXPERT OPINION Pathogenesis, clinical presentation, diagnosis, and treatment of nonachalasic esophageal motor disorders still represent a challenging area, requiring future evaluation by multicenter outcome studies carried out in a large cohort of patients and asymptomatic subjects. However, we believe that an accurate clinical, endoscopic, and HRM evaluation is, nowadays, helpful in addressing patients with nonachalasic esophageal motor disorders to optimal treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Matteo Ghisa
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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Carlson DA, Baumann AJ, Prescott JE, Donnan EN, Yadlapati R, Khan A, Gyawali CP, Kou W, Kahrilas PJ, Pandolfino JE. Validation of secondary peristalsis classification using FLIP panometry in 741 subjects undergoing manometry. Neurogastroenterol Motil 2022; 34:e14192. [PMID: 34120383 PMCID: PMC8666463 DOI: 10.1111/nmo.14192] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/05/2021] [Accepted: 05/13/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS This study aimed to systematically evaluate a classification scheme of secondary peristalsis using functional luminal imaging probe (FLIP) panometry through comparison with primary peristalsis on high-resolution manometry (HRM). METHODS 706 adult patients that completed FLIP and HRM for primary esophageal motility evaluation and 35 asymptomatic volunteers ("controls") were included. Secondary peristalsis, that is, contractile responses (CRs), was classified on FLIP panometry by the presence and pattern of contractility as normal (NCR), borderline (BCR), impaired/disordered (IDCR), absent (ACR), or spastic-reactive (SRCR). Primary peristalsis on HRM was assessed according to the Chicago Classification. RESULTS All 35 of the controls had antegrade contractions on FLIP panometry with either NCR (89%) or BCR (11%). The average percentages of normal swallows on HRM varied across contractile response patterns from 84% in NCR, 68% in BCR, 39% in IDCR, to 11% in ACR, as did the percentage of failed swallows on HRM: 4% in NCR, 12% in BCR, 36% in IDCR, and 79% in ACR. SRCR on FLIP panometry was observed in 18/57 (32%) patients with type III achalasia, 4/15 (27%) with distal esophageal spasm, and 7/15 (47%) with hypercontractile esophagus on HRM. CONCLUSIONS The FLIP panometry contractile response patterns reflect a pathophysiologic transition from normal to abnormal esophageal peristaltic function with shared features with primary peristaltic function/dysfunction on HRM. Thus, these patterns of the contractile response to distension can facilitate the evaluation of esophageal motility using FLIP panometry.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alexandra J. Baumann
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline E Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Abraham Khan
- Division of Gastroenterology, New York University School of Medicine, New York, NY, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Pannala R, Krishnan K, Watson RR, Vela MF, Abu Dayyeh BK, Bhatt A, Bhutani MS, Bucobo JC, Chandrasekhara V, Copland AP, Jirapinyo P, Kumta NA, Law RJ, Maple JT, Melson J, Parsi MA, Rahimi EF, Saumoy M, Sethi A, Trikudanathan G, Trindade AJ, Yang J, Lichtenstein DR. Devices for esophageal function testing. VideoGIE 2022; 7:1-20. [PMID: 35059533 PMCID: PMC8755458 DOI: 10.1016/j.vgie.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California
| | - Marcelo F Vela
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juan Carlos Bucobo
- Division of Gastroenterology and Hepatology, Stony Brook Medicine, Stony Brook, New York
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health Systems, Charlottesville, Virginia
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Mansour A Parsi
- Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Erik F Rahimi
- Department of Gastroenterology, Baylor Scott & White Health, Lakeway, Texas
| | - Monica Saumoy
- Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amrita Sethi
- Department of Digestive and Liver Diseases, New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Abstract
Among recent advances in diagnostics for dysphagia and esophageal motility disorders is the update to the Chicago Classification (version 4.0) for interpretation of high-resolution manometry (HRM) and diagnosis of esophageal motility disorders. The update incorporates application of complementary testing strategies during HRM, such as provocative HRM maneuvers, and recommendation for barium esophagram or functional luminal imaging probe (FLIP) panometry to help clarify inconclusive HRM findings. FLIP panometry also represents an emerging technology for evaluation of esophageal distensibility and motility at the time of endoscopy.
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Classifying Esophageal Motility by FLIP Panometry: A Study of 722 Subjects With Manometry. Am J Gastroenterol 2021; 116:2357-2366. [PMID: 34668487 PMCID: PMC8825704 DOI: 10.14309/ajg.0000000000001532] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Functional luminal imaging probe (FLIP) panometry can evaluate esophageal motility in response to sustained esophageal distension at the time of sedated endoscopy. This study aimed to describe a classification of esophageal motility using FLIP panometry and evaluate it against high-resolution manometry (HRM) and Chicago Classification v4.0 (CCv4.0). METHODS Five hundred thirty-nine adult patients who completed FLIP and HRM with a conclusive CCv4.0 diagnosis were included in the primary analysis. Thirty-five asymptomatic volunteers ("controls") and 148 patients with an inconclusive CCv4.0 diagnosis or systemic sclerosis were also described. Esophagogastric junction (EGJ) opening and the contractile response (CR) to distension (i.e., secondary peristalsis) were evaluated with a 16-cm FLIP during sedated endoscopy and analyzed using a customized software program. HRM was classified according to CCv4.0. RESULTS In the primary analysis, 156 patients (29%) had normal motility on FLIP panometry, defined by normal EGJ opening and a normal or borderline CR; 95% of these patients had normal motility or ineffective esophageal motility on HRM. Two hundred two patients (37%) had obstruction with weak CR, defined as reduced EGJ opening and absent CR or impaired/disordered CR, on FLIP panometry; 92% of these patients had a disorder of EGJ outflow per CCv4.0. DISCUSSION Classifying esophageal motility in response to sustained distension with FLIP panometry parallels the swallow-associated motility evaluation provided with HRM and CCv4.0. Thus, FLIP panometry serves as a well-tolerated method that can complement, or in some cases be an alternative to HRM, for evaluating esophageal motility disorders.
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Prediction of Esophageal Retention: A Study Comparing High-Resolution Manometry and Functional Luminal Imaging Probe Panometry. Am J Gastroenterol 2021; 116:2032-2041. [PMID: 34388142 PMCID: PMC8852837 DOI: 10.14309/ajg.0000000000001402] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION High-resolution manometry (HRM) is generally considered the primary method to evaluate esophageal motility; functional luminal imaging probe (FLIP) panometry represents a novel method to do so and is completed during sedated endoscopy. This study aimed to compare HRM and FLIP panometry in predicting esophageal retention on timed barium esophagram (TBE). METHODS A total of 329 adult patients who completed FLIP, HRM, and TBE for primary esophageal motility evaluation were included. An abnormal TBE was defined by a 1-minute column height >5 cm or impaction of a 12.5-mm barium tablet. The integrated relaxation pressure (IRP) on HRM was assessed in the supine and upright patient positions. Esophagogastric junction (EGJ) opening was evaluated with 16-cm FLIP performed during sedated endoscopy through EGJ-distensibility index and maximum EGJ diameter. RESULTS Receiver operating characteristic curves to identify an abnormal TBE demonstrated AUC (95% confidence interval) of 0.79 (0.75-0.84) for supine IRP, 0.79 (0.76-0.86) for upright IRP, 0.84 (0.79-0.88) for EGJ-distensibility index, and 0.88 (0.85-0.92) for maximum EGJ diameter. Logistic regression to predict abnormal TBE showed odds ratios (95% confidence interval) of 1.8 (0.84-3.7) for consistent IRP elevation and 39.7 (16.4-96.2) for reduced EGJ opening on FLIP panometry. Of 40 patients with HRM-FLIP panometry discordance, HRM-IRP was consistent with TBE in 23% while FLIP panometry was consistent with TBE in 78%. DISCUSSION FLIP panometry provided superior detection of esophageal retention over IRP on HRM. However, application of a complementary evaluation involving FLIP panometry, HRM, and TBE may be necessary to accurately diagnose esophageal motility disorders.
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28
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Carlson DA, Baumann AJ, Donnan EN, Krause A, Kou W, Pandolfino JE. Evaluating esophageal motility beyond primary peristalsis: Assessing esophagogastric junction opening mechanics and secondary peristalsis in patients with normal manometry. Neurogastroenterol Motil 2021; 33:e14116. [PMID: 33705590 PMCID: PMC8433263 DOI: 10.1111/nmo.14116] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Functional luminal imaging probe (FLIP) Panometry assesses the esophageal response to distention and may complement the assessment of primary peristalsis on high-resolution manometry (HRM). We aimed to investigate whether FLIP Panometry provides complementary information in patients with normal esophageal motility on HRM. METHODS Adult patients that completed FLIP and had an HRM classification of normal motility were retrospectively identified for inclusion. 16-cm FLIP studies performed during endoscopy were evaluated to assess EGJ distensibility, secondary peristalsis, and identify an abnormal response to distention involving sustained LES contraction (sLESC). Clinical characteristics and esophagram were assessed when available. KEY RESULTS Of 164 patients included (mean(SD) age 48(16) years, 75% female), 111 (68%) had normal Panometry with EGJ-distensibility index (DI) ≥2.0 mm2 /mmHg, maximum EGJ diameter ≥16mm and antegrade contractions. Abnormal EGJ distensibility was observed in 44/164 (27%), and 38/164 (23%) had an abnormal contractile response to distension. sLESC was observed in 11/164 (7%). Among 68 patients that completed esophagram, abnormal EGJ distensibility was more frequently observed with an abnormal esophagram than normal EGJ opening: 14/23 (61%) vs 10/45 (22%); P=0.003. Epiphrenic diverticula were present in 3/164 patients: 2/3 had sLESC. CONCLUSIONS & INFERENCES Symptomatic patients with normal esophageal motility on HRM predominantly have normal FLIP Panometry; however, abnormal FLIP findings can be observed. While abnormal Panometry findings appear clinically relevant via an association with abnormal bolus retention, complementary tests, such as provocative maneuvers with HRM and timed barium esophagram, are useful to determine clinical context.
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Affiliation(s)
| | | | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amanda Krause
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Acharya S, Halder S, Carlson DA, Kou W, Kahrilas PJ, Pandolfino JE, Patankar NA. Estimation of mechanical work done to open the esophagogastric junction using functional lumen imaging probe panometry. Am J Physiol Gastrointest Liver Physiol 2021; 320:G780-G790. [PMID: 33655760 PMCID: PMC8202198 DOI: 10.1152/ajpgi.00032.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In this study, we quantify the work done by the esophagus to open the esophagogastric junction (EGJ) and create a passage for bolus flow into the stomach. Work done on the EGJ was computed using functional lumen imaging probe (FLIP) panometry. Eighty-five individuals underwent FLIP panometry with a 16-cm catheter during sedated endoscopy including asymptomatic controls (n = 14), 45 patients with achalasia (n = 15 each, three subtypes), those with gastroesophageal reflux disease (GERD; n = 13), those with eosinophilic esophagitis (EoE; n = 8), and those with systemic sclerosis (SSc; n = 5). Luminal cross-sectional area (CSA) and pressure were measured by the FLIP catheter positioned across the EGJ. Work done on the EGJ (EGJW) was computed (millijoules, mJ) at 40-mL distension. Additionally, a separate method was developed to estimate the "work required" to fully open the EGJ (EGJROW) when it did not open during the procedure. EGJW for controls had a median [interquartile range (IQR)] value of 75 (56-141) mJ. All achalasia subtypes showed low EGJW compared with controls (P < 0.001). Subjects with GERD and EoE had EGJW 54.1 (6.9-96.3) and 65.9 (10.8-102.3) mJ, similar to controls (P < 0.08 and P < 0.4, respectively). The scleroderma group showed low values of EGJW, 12 mJ (P < 0.001). For patients with achalasia, EGJROW was the greatest and had a value of 210.4 (115.2-375.4) mJ. Disease groups with minimal or absent EGJ opening showed low values of EGJW. For patients with achalasia, EGJROW significantly exceeded EGJW values of all other groups, highlighting its unique pathophysiology. Balancing the relationship between EGJW and EGJROW is potentially useful for calibrating achalasia treatments and evaluating treatment response.NEW & NOTEWORTHY Changes in pressure and diameter occur at the EGJ during esophageal emptying. Similar changes can be observed during FLIP panometry. Data from healthy and diseased individuals were used to estimate the mechanical work done on the EGJ during distension-induced relaxation or, in instances of failed opening, work required to open the EGJ. Quantifying these parameters is potentially valuable to calibrate treatments and gauge treatment efficacy for subjects with disorders of EGJ function, especially achalasia.
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Affiliation(s)
- Shashank Acharya
- 1Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Sourav Halder
- 2Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Dustin A. Carlson
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Wenjun Kou
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J. Kahrilas
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E. Pandolfino
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Neelesh A. Patankar
- 1Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois,2Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, Illinois
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30
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Carlson DA, Kou W, Rooney KP, Baumann AJ, Donnan E, Triggs JR, Teitelbaum EN, Holmstrom A, Hungness E, Sethi S, Kahrilas PJ, Pandolfino JE. Achalasia subtypes can be identified with functional luminal imaging probe (FLIP) panometry using a supervised machine learning process. Neurogastroenterol Motil 2021; 33:e13932. [PMID: 32608147 PMCID: PMC7775338 DOI: 10.1111/nmo.13932] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/28/2020] [Accepted: 06/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achalasia subtypes on high-resolution manometry (HRM) prognosticate treatment response and help direct management plan. We aimed to utilize parameters of distension-induced contractility and pressurization on functional luminal imaging probe (FLIP) panometry and machine learning to predict HRM achalasia subtypes. METHODS One hundred eighty adult patients with treatment-naïve achalasia defined by HRM per Chicago Classification (40 type I, 99 type II, 41 type III achalasia) who underwent FLIP panometry were included: 140 patients were used as the training cohort and 40 patients as the test cohort. FLIP panometry studies performed with 16-cm FLIP assemblies were retrospectively analyzed to assess distensive pressure and distension-induced esophageal contractility. Correlation analysis, single tree, and random forest were adopted to develop classification trees to identify achalasia subtypes. KEY RESULTS Intra-balloon pressure at 60 mL fill volume, and proportions of patients with absent contractile response, repetitive retrograde contractile pattern, occluding contractions, sustained occluding contractions (SOC), contraction-associated pressure changes >10 mm Hg all differed between HRM achalasia subtypes and were used to build the decision tree-based classification model. The model identified spastic (type III) vs non-spastic (types I and II) achalasia with 90% and 78% accuracy in the train and test cohorts, respectively. Achalasia subtypes I, II, and III were identified with 71% and 55% accuracy in the train and test cohorts, respectively. CONCLUSIONS AND INFERENCES Using a supervised machine learning process, a preliminary model was developed that distinguished type III achalasia from non-spastic achalasia with FLIP panometry. Further refinement of the measurements and more experience (data) may improve its ability for clinically relevant application.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Katharine P. Rooney
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alexandra J. Baumann
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ezra N. Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amy Holmstrom
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sajiv Sethi
- Department of Medicine, Division of Gastroenterology, University of South Florida, Tampa, FL, USA
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Cha B, Jung KW. [Diagnosis of Dysphagia: High Resolution Manometry & EndoFLIP]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:64-70. [PMID: 33632996 DOI: 10.4166/kjg.2021.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 12/27/2022]
Abstract
Esophageal motility disorders were re-defined when high-resolution manometry was employed to better understand their pathogenesis. Newly developed parameters including integrated relaxation pressure (IRP), distal contractile integral, and distal latency showed better diagnostic yield compared with previously used conventional parameters. Therefore, Chicago classification was formulated, and its diagnostic cascade begins by assessing the IRP value. However, IRP showed limitation due to its inconsistency, and other studies have tried to overcome this. Recent studies showed that provocative tests, supplementing the conventional esophageal manometry protocol, have improved the diagnostic yield of the esophageal motility disorders. Therefore, position change from supine to upright, solid or semi-solid swallowing, multiple rapid swallows, and the rapid drink challenge were newly added to the manometry protocol in the revised Chicago classification version 4.0. Impedance planimetry enables measurement of bag cross-sectional area at various locations. The functional lumen imaging probe (FLIP) has been applied to assess luminal distensibility. This probe can also measure pressure, serial cross-sectional areas, and tension-strain relationship. The esophagogastric junction's distensibility is decreased in achalasia. Therefore, EndoFLIP can be used to assess contractility and distensibility of the esophagus in the patients with achalasia, including repetitive antegrade or retrograde contractions. EndoFLIP can detect achalasia patients with relatively low IRP, which was difficult to diagnose using the current high-resolution manometry. EndoFLIP also provides information on the contractile activity and distensibility of the esophageal body in patients with achalasia. The use of provocative tests, newly added in Chicago classification 4.0 version, and EndoFLIP can expand understanding of esophageal motility disorders.
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Affiliation(s)
- Boram Cha
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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Acharya S, Halder S, Carlson DA, Kou W, Kahrilas PJ, Pandolfino JE, Patankar NA. Assessment of esophageal body peristaltic work using functional lumen imaging probe panometry. Am J Physiol Gastrointest Liver Physiol 2021; 320:G217-G226. [PMID: 33174457 PMCID: PMC7948118 DOI: 10.1152/ajpgi.00324.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The goal of this study was to conceptualize and compute measures of "mechanical work" done by the esophagus using data generated during functional lumen imaging probe (FLIP) panometry and compare work done during secondary peristalsis among patients and controls. Eighty-five individuals were evaluated with a 16-cm FLIP during sedated endoscopy, including asymptomatic controls (n = 14) and those with achalasia subtypes I, II, and III (n = 15, each); gastroesophageal reflux disease (GERD; n = 13); eosinophilic esophagitis (EoE; n = 9); and systemic sclerosis (SSc; n = 5). The FLIP catheter was positioned to have its distal segment straddling the esophagogastric junction (EGJ) during stepwise distension. Two metrics of work were assessed: "active work" (during bag volumes ≤ 40 mL where contractility generates substantial changes in lumen area) and "work capacity" (for bag volumes ≥ 60 mL when contractility cannot substantially alter the lumen area). Controls showed median [interquartile range (IQR)] of 7.3 (3.6-9.2) mJ of active work and 268.6 (225.2-332.3) mJ of work capacity. Patients with all achalasia subtypes, GERD, and SSc showed lower active work done than controls (P ≤ 0.003). Patients with achalasia subtypes I and II, GERD, and SSc had lower work capacity compared with controls (P < 0.001, 0.004, 0.04, and 0.001, respectively). Work capacity was similar between controls and patients with achalasia type III and EoE. Mechanical work of the esophagus differs between healthy controls and patient groups with achalasia, EoE, SSc, and GERD. Further studies are needed to fully explore the utility of this approach, but these work metrics would be valuable for device design (artificial esophagus), to measure the efficacy of peristalsis, to gauge the physiological state of the esophagus, and to comment on its pumping effectiveness.NEW & NOTEWORTHY Functional lumen imaging probe (FLIP) panometry assesses esophageal response to distension and provides a simultaneous assessment of pressure and dimension during contractility. This enables an objective assessment of "mechanical work" done by the esophagus. Eighty-five individuals were evaluated, and two work metrics were computed for each subject. Controls showed greater values of work compared with individuals with achalasia, gastroesophageal reflux disease (GERD), and systemic sclerosis (SSc). These values can quantify the mechanical behavior of the distal esophagus and assist in the estimation of muscular integrity.
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Affiliation(s)
- Shashank Acharya
- 1Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Sourav Halder
- 2Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Dustin A. Carlson
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Wenjun Kou
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J. Kahrilas
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E. Pandolfino
- 3Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Neelesh A. Patankar
- 1Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois,2Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, Illinois
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Baumann AJ, Donnan EN, Triggs JR, Kou W, Prescott J, Decorrevont A, Dorian E, Kahrilas PJ, Pandolfino JE, Carlson DA. Normal Functional Luminal Imaging Probe Panometry Findings Associate With Lack of Major Esophageal Motility Disorder on High-Resolution Manometry. Clin Gastroenterol Hepatol 2021; 19:259-268.e1. [PMID: 32205217 PMCID: PMC7502471 DOI: 10.1016/j.cgh.2020.03.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/19/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A normal esophageal response to distension on functional luminal imaging probe (FLIP) panometry during endoscopy might indicate normal esophageal motor function. We aimed to investigate the correlation of normal FLIP panometry findings with esophageal high-resolution manometry (HRM) and outcomes of discrepant patients. METHODS We performed a retrospective study using data from a registry of patients who completed FLIP during sedated endoscopy. We identified 111 patients with normal FLIP panometry findings (mean age, 42 y; 69% female) and corresponding HRM data. A normal FLIP panometry was defined as an esophagogastric junction (EGJ) distensibility index greater than 3.0 mm2/mm Hg, an absence of repetitive retrograde contractions, and a repetitive antegrade contraction pattern that met the Rule-of-6s: ≥6 consecutive antegrade contractions of ≥6-cm in length, at a rate of 6 ± 3 contractions per minute. HRM findings were classified by the Chicago classification system version 3.0. RESULTS HRM results were classified as normal motility in 78 patients (70%), ineffective esophageal motility in 10 patients (9%), EGJ outflow obstruction in 20 patients (18%), and 3 patients (3%) as other. In patients with EGJ outflow obstruction based on HRM, the integrated relaxation pressure normalized on adjunctive swallows in 16 of 20 patients (80%), and in 8 of 9 patients (88%) who completed a barium esophagram and had normal barium clearance. Thus, although 23 of 111 patients (21%) with normal FLIP panometry had abnormal HRM findings, these HRMs often were considered to be false-positive or equivocal results. All patients with an abnormal result from HRM were treated conservatively. CONCLUSIONS In a retrospective cohort study, we found that patients with normal FLIP panometry results did not have a clinical impression of a major esophageal motor disorder. Normal FLIP panometry results can exclude esophageal motility disorders at the time of endoscopy, possibly negating the need for HRM in select patients.
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Affiliation(s)
- Alexandra J. Baumann
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex Decorrevont
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emily Dorian
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Kou W, Carlson DA, Patankar NA, Kahrilas PJ, Pandolfino JE. Four-dimensional impedance manometry derived from esophageal high-resolution impedance-manometry studies: a novel analysis paradigm. Therap Adv Gastroenterol 2020; 13:1756284820969050. [PMID: 33178334 PMCID: PMC7592175 DOI: 10.1177/1756284820969050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/24/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND This study aimed to introduce a novel analysis paradigm, referred to as 4-dimensional (4D) manometry based on biophysical analysis; 4D manometry enables the visualization of luminal geometry of the esophagus and esophagogastric junction (EGJ) using high-resolution-impedance-manometry (HRIM) data. METHODS HRIM studies from two asymptomatic controls and one type-I achalasia patient were analyzed. Concomitant fluoroscopy images from one control subject were used to validate the calculated temporal-spatial luminal radius and time-history of intraluminal bolus volume and movement. EGJ analysis computed diameter threshold for emptying, emptying time, flow rate, and distensibility index (DI), which were compared with bolus flow time (BFT) analysis. RESULTS For normal control, calculated volumes for 5 ml swallows were 4.1 ml-6.7 ml; for 30 ml swallows 21.3 ml-21.8 ml. With type-I achalasia, >4 ml of intraesophageal bolus residual was present both pre- and post-swallow. The four phases of bolus transit were clearly illustrated on the time-history of bolus movement, correlating well with the fluoroscopic images. In the control subjects, the EGJ diameter threshold for emptying was 8 mm for 5 ml swallows and 10 mm for 30 ml swallows; emptying time was 1.2-2.2 s for 5 ml swallows (BFT was 0.3-3 s) and 3.25-3.75 s for 30 ml swallows; DI was 2.4-3.4 mm2/mmHg for 5 ml swallows and 4.2-4.6 mm2/mmHg for 30 ml swallows. CONCLUSIONS The 4D manometry system facilitates a comprehensive characterization of dynamic esophageal bolus transit with concurrent luminal morphology and pressure from conventional HRIM measurements. Calculations of flow rate and wall distensibility provide novel measures of EGJ functionality.
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Affiliation(s)
| | - Dustin A. Carlson
- Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA
| | - Neelesh A. Patankar
- Department of Mechanical Engineering,
Northwestern University, Evanston, IL, USA
| | - Peter J. Kahrilas
- Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA
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Carlson DA, Kou W, Masihi M, Acharya S, Baumann AJ, Donnan EN, Kahrilas PJ, Pandolfino JE. Repetitive Antegrade Contractions: A novel response to sustained esophageal distension is modulated by cholinergic influence. Am J Physiol Gastrointest Liver Physiol 2020; 319:G696-G702. [PMID: 33026823 DOI: 10.1152/ajpgi.00305.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND & AIMS A unique motor response to sustained esophageal distension, repetitive antegrade contractions (RACs), is observed using functional luminal imaging probe (FLIP) panometry. However, physiologic mechanisms related to this response are unexplored. This study aimed to evaluate the impact of cholinergic inhibition with atropine on the esophageal contractile response to sustained distention, including RACs, among healthy volunteers. METHODS 8 asymptomatic volunteers (ages 22-45) were evaluated in a crossover study design with 16-cm FLIP positioned across the esophagogastric junction and distal esophagus during sedated upper endoscopy. The FLIP study involving stepwise volumetric distension was performed twice in each subject, at baseline and again after atropine (15 mcg/kg) was administered intravenously. FLIP panometry was analyzed to assess the contractile response to distension. RESULTS Antegrade contractions, lumen-occluding contractions, and a RAC pattern were observed in 8/8, 8/8, and 7/8(88%) subjects, respectively, at baseline and in 5/8 (63%), 2/8 (25%) and 2/8 (25%) subjects after atropine. The rate of contractions in the RAC pattern was similar (6-7 contractions per minute) before and after atropine. Compared with the baseline study, distension-induced contractility was triggered at higher fill volumes after atropine. FLIP pressures were lower in response to volumetric filling after atropine than at baseline. CONCLUSIONS The vigor and triggering of the esophageal contractile response to distension is reduced by cholinergic inhibition in asymptomatic controls. The observation that the rate of contractions did not change when patients developed repetitive contractile responses suggests that this rate is not modified by cholinergic inhibition once contractility is triggered.
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Affiliation(s)
| | - Wenjun Kou
- Medicine, Northwestern University, United States
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Lazarescu A, Chan WW, Gyawali CP, Lee YY, Xiao Y, Wu P. Updates on diagnostic modalities for esophageal dysphagia. Ann N Y Acad Sci 2020; 1481:108-116. [PMID: 32875574 DOI: 10.1111/nyas.14453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.
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Affiliation(s)
- Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, PR China
| | - Peter Wu
- Department of Gastroenterology and Hepatology, St. George Hospital, Kogarah, New South Wales, Australia
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Donnan EN, Pandolfino JE. EndoFLIP in the Esophagus: Assessing Sphincter Function, Wall Stiffness, and Motility to Guide Treatment. Gastroenterol Clin North Am 2020; 49:427-435. [PMID: 32718562 PMCID: PMC7387752 DOI: 10.1016/j.gtc.2020.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. Literature surrounding use of FLIP has demonstrated its clinical utility as a diagnostic tool and as a device to guide and measure response to therapy. FLIP can assess and guide treatments for esophageal disease states including gastroesophageal reflux disease, achalasia, and eosinophilic esophagitis. FLIP may become the initial test for patients with undifferentiated dysphagia at their index endoscopy. This article summarizes use of FLIP in assessing sphincter function, wall stiffness, and motility to guide treatments.
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Affiliation(s)
- Erica N Donnan
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; NMH/Arkes Family Pavilion, Suite 1400, 676 North Saint Clair, Chicago, IL 60611, USA.
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; NMH/Arkes Family Pavilion, Suite 1400, 676 North Saint Clair, Chicago, IL 60611, USA
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Desprez C, Roman S, Leroi AM, Gourcerol G. The use of impedance planimetry (Endoscopic Functional Lumen Imaging Probe, EndoFLIP ® ) in the gastrointestinal tract: A systematic review. Neurogastroenterol Motil 2020; 32:e13980. [PMID: 32856765 DOI: 10.1111/nmo.13980] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE The EndoFLIP® system is a method of delineating impedance and was first designed to investigate the characteristics of the esophago-gastric junction. In the last decade, its use was widened to investigate other sphincteric and non-sphincteric systems of the gastrointestinal tract. The objective of the present systematic review was to summarize the available data in literature on the use of the EndoFLIP® system in the gastrointestinal tract, including sphincteric and non-sphincteric regions. We performed a systematic review in accordance with recommendations for systematic review using PRISMA guidelines without date restriction, until June 2020, using MEDLINE-PubMed, Cochrane Library, and Google Scholar databases. Only articles written in English were included in the present review. Five hundred and six unique citations were identified from all database combined. Of those, 95 met the inclusion criteria. There was a lack of standardization among studies in terms of anesthetic drugs use, probe placement, and inflation protocol. In most cases, only small cohorts of patients were included. Most studies investigated the EGJ, with a potential use of the EndoFLIP® to identify a subgroup of patients with achalasia and for intraoperative assessment of treatment efficacy in achalasia. However, the use of EndoFLIP® in the esophageal body (esophageal panometry), other esophageal diseases (gastro-esophageal reflux disease, eosinophilic esophagitis), and other sphincter regions (anal canal, pylorus) will need further confirmatory studies. The EndoFLIP® system provides detailed geometric data of the gastrointestinal lumen but further works are needed to determine its use in clinical practice.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
| | - Sabine Roman
- Digestive Physiology Department, Hospices Civils de Lyon, Hopital H Herriot, Lyon, France
| | - Anne Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
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Clarke JO, Ahuja NK, Fernandez-Becker NQ, Gregersen H, Kamal AN, Khan A, Lynch KL, Vela MF. The functional lumen imaging probe in gastrointestinal disorders: the past, present, and future. Ann N Y Acad Sci 2020; 1482:16-25. [PMID: 32814368 DOI: 10.1111/nyas.14463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 12/14/2022]
Abstract
The functional lumen imaging probe (FLIP) is a diagnostic tool that utilizes impedance planimetry to allow the assessment of luminal diameter and distensibility. It has been used primarily in esophageal diseases, in particular, in the assessment of achalasia, esophagogastric junction outflow obstruction, and eosinophilic esophagitis (EoE). The usage and publications have increased over the past decade and it is now an essential tool in the armamentarium of the esophagologist. Indications are emerging outside of the esophagus, in particular with regard to gastroparesis. Our paper will review the history of FLIP, optimal current usage, data for key esophageal disorders (including achalasia, reflux, and EoE), data for nonesophageal disorders, and our sense as to whether FLIP is ready for prime time, as well as gaps in evidence and suggestions for future research.
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Affiliation(s)
- John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Hong Kong, China
| | - Afrin N Kamal
- Department of Medicine, Stanford University, Redwood City, California
| | - Abraham Khan
- Department of Medicine, New York University, New York, New York
| | - Kristie L Lynch
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcelo F Vela
- Gastroenterology Division, The Mayo Clinic, Scottsdale, Arizona
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Nwokedi U, Nguyen DT, Meisenbach LM, Chihara R, Chan EY, Graviss EA, Kim MP. Short-term outcome of routine use of EndoFLIP during hiatal hernia repair. Surg Endosc 2020; 35:3840-3849. [PMID: 32661713 DOI: 10.1007/s00464-020-07788-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Endoluminal functional lumen imaging probe (EndoFLIP) technology is a tool that can be used to provide intraoperative objective real-time feedback during hiatal hernia repair. We wanted to determine the implication of initial distensibility index (DI) after mobilization of hiatus and final DI after creation of barrier in short-term clinical outcomes. METHODS We performed a retrospective analysis of prospectively collected data on the intraoperative use of EndoFLIP during hiatal hernia repair at a single institution from 2017 to 2019. We analyzed the initial DI and final DI with the short-term clinical outcomes. RESULTS There were 163 patients who had Nissen (n = 16), Toupet (n = 79) or magnetic sphincter augmentation (n = 68) with (n = 158) or without (n = 5) hiatal hernia repair with median initial DI was 3.2 mm2/mmHg. We used 3 mm2/mmHg as the cutoff for low (n = 84) vs. high (n = 79) initial DI group. There was no difference in DeMeester score (p = 0.76), the peristalsis on manometry (p = 0.13), type of hiatal hernia (p = 0.98), and GERD-HRQL score prior to surgery (p = 0.73) between the groups. There was significantly higher final DI in the high initial DI group compared to low initial DI group; however, there was no significant difference in the GERD-HRQL score at 1-3 months (p = 0.28). All of the patients had a final DI > 0.5 mm2/mmHg at the end of the case with median final DI of 1.6 mm2/mmHg. None of these patients required steroids (0%) and only one patient (0.6%) required EGD and dilatation as well as re-operation for dysphagia within 3 months. CONCLUSIONS The initial DI was associated with final DI, but it did not correlate with improvement in short-term GERD-HRQL score. Final DI maintained above the cutoff value led to most of the patients not to require intervention for dysphagia. Use of the EndoFLIP can provide objective data during the operation and prevent severe dysphagia after repair.
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Affiliation(s)
- Ugoeze Nwokedi
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Leonora M Meisenbach
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA.
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
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42
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Wu PI, Sloan JA, Kuribayashi S, Gregersen H. Impedance in the evaluation of the esophagus. Ann N Y Acad Sci 2020; 1481:139-153. [PMID: 32557676 DOI: 10.1111/nyas.14408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022]
Abstract
The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.
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Affiliation(s)
- Peter I Wu
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Hans Gregersen
- GIOME, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
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Bianca A, Schindler V, Schnurre L, Murray F, Runggaldier D, Gyawali CP, Pohl D. Endoscope presence during endoluminal functional lumen imaging probe (FLIP) influences FLIP metrics in the evaluation of esophageal dysmotility. Neurogastroenterol Motil 2020; 32:e13823. [PMID: 32100389 DOI: 10.1111/nmo.13823] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The functional lumen imaging probe (FLIP) system is an FDA-approved tool for dynamic evaluation of the esophagogastric junction (EGJ). Even though commercially available since 2009, FLIP utilization remains low, partly due to lack of consensus in methodology and interpretation. Therefore, we aimed to analyze the influence of concurrent endoscopy on FLIP measurements. METHODS In this single-center study, we reviewed data from 93 patients undergoing FLIP for symptomatic esophageal motility disorders between 2016 and 2018. During sedated endoscopy, we measured luminal values (distensibility, cross-sectional area (CSA), and balloon pressure) at the EGJ and distal esophagus using 30, 40, and 50 mL distension volumes, with and without concurrent endoscope presence. All recorded values were compared at the various distension volumes between the two measurements using a Wilcoxon rank sum test. KEY RESULTS There was a significant difference in distensibility and CSA with index distension volume (40 mL) at the EGJ comparing the two measurements: Lower median distensibility was 2.1 mm2 mm Hg-1 in the group with concurrent inserted endoscope, respectively, 3.4 mm2 mm Hg-1 without endoscope (P < .001), and median CSA was 86.0 resp. 110.0 mm2 (P < .001). No significant difference could be found in the measurements of the distal esophagus. CONCLUSIONS & INFERENCES Our results show a significant difference in FLIP measurements with and without endoscope presence. This underlines the importance of establishing a consensus of a standardized FLIP protocol to define normal luminal values and guiding future FLIP diagnostic studies.
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Affiliation(s)
- Amanda Bianca
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valeria Schindler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Division of Internal Medicine, Stadtspital Triemli, Zurich, Switzerland
| | - Larissa Schnurre
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fritz Murray
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Runggaldier
- Department of Otorhinolaryngology, University Hospital of Zurich, Zurich, Switzerland
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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Carlson DA, Kou W, Pandolfino JE. The rhythm and rate of distension-induced esophageal contractility: A physiomarker of esophageal function. Neurogastroenterol Motil 2020; 32:e13794. [PMID: 31919949 PMCID: PMC7182495 DOI: 10.1111/nmo.13794] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/03/2019] [Accepted: 12/13/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Distention of the esophagus elicits a unique pattern of repetitive contractions in healthy controls. We aimed to assess the rhythm and rate of distension-induced contractile patterns between achalasia and controls and identify factors that distinguish the normal contractile response to distension. METHODS Twenty asymptomatic controls and 140 adult patients with treatment-naïve achalasia defined by HRM (29 type I, 81 type II, 30 type III) were prospectively evaluated with functional luminal imaging probe (FLIP) during sedated endoscopy. 16-cm FLIP balloons were positioned within the distal esophagus during stepwise balloon distension. Functional luminal imaging probe panometry studies were retrospectively analyzed using a customized program. KEY RESULTS All controls had contractility in a repetitive antegrade contraction (RAC) pattern with a rate of mean (10-90th) 6 (4-8) contractions per minute. 19/20 controls had > 6 consecutive antegrade contractions (ACs), that is, duration > 6 ACs, >6 cm in length, at a rate of 6 ± 3 contractions per minute (met the "Rule-of-6s"). 50 achalasia patients had repetitive contractions that occurred at a rates of 11 (7 - 15) ACs per minute; P < .001 compared with controls, or 12 (8-15) repetitive retrograde contractions per minute. Only 1/140 achalasia patients had a contractile response that met the "Rule-of-6s." CONCLUSION The normal contractile response to sustained distention is associated with > 6 RACs with a consistent rate of 6 ± 3 per minute, which was exceptionally rare in achalasia. These findings support that the RAC pattern is disrupted in achalasia and the faster rate may be a manifestation of abnormal inhibition and/or a reduced refractory period.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine Division of Gastroenterology and Hepatology Feinberg School of Medicine Northwestern University Chicago IL USA
| | - Wenjun Kou
- Department of Medicine Division of Gastroenterology and Hepatology Feinberg School of Medicine Northwestern University Chicago IL USA
| | - John E. Pandolfino
- Department of Medicine Division of Gastroenterology and Hepatology Feinberg School of Medicine Northwestern University Chicago IL USA
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45
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Abstract
PURPOSE OF REVIEW The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. The goal of this review is to summarize the most recent advances in applying the (FLIP) to esophageal disorders. RECENT FINDINGS The FLIP has been studied in esophageal disease states including gastroesophageal reflux disease (GERD), achalasia, and eosinophilic esophagitis. It has also been used in the investigation of dysphagia. The FLIP is a valuable tool for the diagnosis of esophageal diseases as well as guiding treatments and predicting treatment response. As further research is done, the FLIP may become the initial test for the patient with undifferentiated dysphagia at the time of their index endoscopy.
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Affiliation(s)
- Erica N Donnan
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, NMH/Arkes Family Pavilion Suite 1400, 676 N Saint Clair, Chicago, IL, 60611, USA.
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, NMH/Arkes Family Pavilion Suite 1400, 676 N Saint Clair, Chicago, IL, 60611, USA
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Carlson DA, Gyawali CP, Kahrilas PJ, Triggs JR, Falmagne S, Prescott J, Dorian E, Kou W, Lin Z, Pandolfino JE. Esophageal motility classification can be established at the time of endoscopy: a study evaluating real-time functional luminal imaging probe panometry. Gastrointest Endosc 2019; 90:915-923.e1. [PMID: 31279625 PMCID: PMC6875629 DOI: 10.1016/j.gie.2019.06.039] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/17/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A novel device that provides real-time depiction of functional luminal image probe (FLIP) panometry (ie, esophagogastric junction [EGJ] distensibility and distension-induced contractility) was evaluated. We aimed to compare real-time FLIP panometry interpretation at the time of sedated endoscopy with high-resolution manometry (HRM) in evaluating esophageal motility. METHODS Forty consecutive patients (aged 24-81 years; 60% women) referred for endoscopy with a plan for future HRM from 2 centers were prospectively evaluated with real-time FLIP panometry during sedated upper endoscopy. The EGJ distensibility index and contractility profile were applied to derive a FLIP panometry classification at the time of endoscopy and again (post-hoc) using a customized program. HRM was classified according to the Chicago classification. RESULTS Real-time FLIP panometry motility classification was abnormal in 29 patients (73%), 19 (66%) of whom had a subsequent major motility disorder on HRM. All 9 patients with an HRM diagnosis of achalasia had abnormal real-time FLIP panometry classifications. Eleven patients (33%) had normal motility on real-time FLIP panometry and 8 (73%) had a subsequent HRM without a major motility disorder. There was excellent agreement (κ = .939) between real-time and post-hoc FLIP panometry interpretation of abnormal motility. CONCLUSIONS This prospective, multicentered study demonstrated that real-time FLIP panometry could detect abnormal esophageal motility, including achalasia, at the endoscopic encounter. Additionally, normal motility on FLIP panometry was predictive of a benign HRM. Thus, real-time FLIP panometry incorporated with endoscopy appears to provide a suitable and well-tolerated point-of-care esophageal motility assessment.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sophia Falmagne
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emily Dorian
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zhiyue Lin
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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47
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Chen HM, Li BW, Li LY, Xia L, Chen XB, Shah R, Abdelfatah MM, Jain A, Cassani L, Massaad J, Keilin S, Cai Q. Functional lumen imaging probe in gastrointestinal motility diseases. J Dig Dis 2019; 20:572-577. [PMID: 31498966 DOI: 10.1111/1751-2980.12818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/19/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022]
Abstract
Dysfunction of gastrointestinal (GI) sphincters, including the lower esophageal sphincter (LES) at the esophagogastric junction (EGJ) and the pyloric sphincter, plays a vital role in GI motility disorders, such as achalasia, gastroesophageal reflux disease (GERD), gastroparesis, and fecal incontinence. Using multi-detector high-resolution impedance planimetry, the functional luminal imaging probe (FLIP) system measures simultaneous data on tissue distensibility and luminal geometry changes in the sphincter in a real-time manner. In this review we focus on the emerging data on FLIP, which can be used as an innovative diagnostic method during endoscopic or surgical procedures in GI motility disorders. Subsequent large, prospective, standardizing studies are needed to validate these findings before it can be put to routine clinical use.
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Affiliation(s)
- Hui Min Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bai Wen Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lian Yong Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, The People's Liberation Army 306th Hospital, Beijing, China
| | - Liang Xia
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xiang Bo Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Endoscopy, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian Province, China
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohamed M Abdelfatah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Jain
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Lisa Cassani
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Division of Digestive Diseases, Department of Medicine, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
| | - Julia Massaad
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steve Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
The literal definition of dysphagia is "disturbed eating". However, it is more accurately described in clinical practice as a sensation of food or liquid being stuck in the esophagus or chest. If this sensation is associated with pain, it is labeled odynophagia, and if it is associated with persistent obstruction and bolus retention, it is categorized as a food impaction. Through research and technological advances, we continue to expand our understanding of the etiologies and underlying pathophysiology relating to this complaint. However, for now, our clinical algorithms focus on endoscopy and manometry to break down dysphagia into three categories: obstructive dysphagia, esophageal motility disorders, and functional dysphagia. Here, we review some critical pitfalls in our current clinical diagnoses, new proposed underlying mechanisms of esophageal motor disorders, and developing technologies to aid in diagnosis and treatment.
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Affiliation(s)
- Joseph Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
| | - John Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
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Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia. Surg Endosc 2019; 34:2593-2600. [PMID: 31376012 DOI: 10.1007/s00464-019-07028-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023]
Abstract
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.
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50
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Carlson DA, Kou W, Lin Z, Hinchcliff M, Thakrar A, Falmagne S, Prescott J, Dorian E, Kahrilas PJ, Pandolfino JE. Normal Values of Esophageal Distensibility and Distension-Induced Contractility Measured by Functional Luminal Imaging Probe Panometry. Clin Gastroenterol Hepatol 2019; 17:674-681.e1. [PMID: 30081222 PMCID: PMC6360138 DOI: 10.1016/j.cgh.2018.07.042] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/19/2018] [Accepted: 07/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Functional luminal imaging probe (FLIP) panometry provides a comprehensive evaluation of esophageal functional at the time of endoscopy, including assessment of esophageal distensibility and distension-induced esophageal contractility. However, the few and inconsistent findings from healthy individuals pose challenges to the application of FLIP to research and clinical practice. We performed FLIP panometry in asymptomatic volunteers. METHODS We performed a prospective study of 20 asymptomatic volunteers (ages, 23-44; 14 women) who were evaluated with 16-cm FLIP positioned across the esophagogastric junction (EGJ) and distal esophagus (and in 8 subjects also repositioned at the proximal esophagus) during sedated upper endoscopy. FLIP data were analyzed with a customized program that generated FLIP panometry plots and calculated the EGJ-distensibility index (DI) and distensibility plateaus (DP) of distal and proximal esophageal body. Distension-induced esophageal contractility was also assessed. RESULTS The median EGJ-DI was 5.8 mm2/mm Hg (interquartile range [IQR], 4.9-6.7 mm2/mm Hg); all 20 subjects had an EGJ-DI greater than 2.8 mm2/mm Hg. The median DP values from all subjects tested were 20.2 mm (IQR, 19.8-20.8 mm) at the distal body, 21.1 mm (IQR, 20.3-22.9 mm) at the proximal body, and greater than 18 mm at both locations. Repetitive antegrade contractions (RACs) were observed in all 20 subjects; in 19 of 20 (95%) subjects, the RAC pattern persisted for 10 or more consecutive antegrade contractions. CONCLUSIONS Normal parameters of FLIP panometry are EGJ-DI greater than 2.8 mm2/mm Hg, DP greater than 18 mm, and antegrade contractions that occur in a repetitive pattern (RACs)-these can be used as normal findings for esophageal distensibility and distension-induced contractility. These values can be used in comparative studies of esophageal diseases, such as achalasia and eosinophilic esophagitis, and will facilitate application of FLIP panometry to clinical practice.
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Affiliation(s)
- Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Zhiyue Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Monique Hinchcliff
- Division of Rheumatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anjali Thakrar
- Division of Rheumatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sophia Falmagne
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jacqueline Prescott
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emily Dorian
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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