Pyloric EndoFlip and Its Clinical Use in Gastroparesis / EndoFLIP pilórico y su utilidad clínica en gastroparesia

Abstract Gastroparesis is a chronic disorder of gastric motility that results in marked impairment of quality of life and significant costs to health care systems. Medical therapies are limited in their management, thus, the reason for a growing enthusiasm for pylorus-targeted therapies. The functional luminal imaging probe (FLIP) is a useful diagnostic tool for assessing pylorus characteristics, especially in refractory cases, which could lead to a better management strategy and, in many cases, predict clinical response.

Resumen La gastroparesia es un trastorno crónico de la motilidad gástrica que genera un deterioro marcado de la calidad de vida y costos significativos en los sistemas de salud. Las terapias médicas son limitadas para su manejo, por lo cual ha surgido un entusiasmo creciente en las terapias dirigidas al píloro. La sonda de imagen luminal funcional (FLIP) ha demostrado ser una herramienta diagnóstica útil para evaluar las características del píloro, especialmente en casos refractarios, en los que podría guiar hacia una mejor estrategia de manejo y, en muchos casos, predecir la respuesta clínica.

EndoFLIP: una nueva tecnología / EndoFLIP: a new technology

Resumen Mediante la distensión de un balón con líquido conductor, la sonda de imagen luminal funcional endoluminal (EndoFLIP) evalúa las propiedades biomecánicas como la distensibilidad, volumen, presión e inclusive diámetros de regiones esfinterianas como la unión gastroesofágica, píloro y ano. La mayor evidencia en la utilidad clínica de la EndoFLIP está en los trastornos de motilidad esofágica, principalmente para identificar acalasia cuando la manometría esofágica de alta resolución y otras imágenes no logran diagnosticarla e inclusive, mediante el programa de FLIP 2.0, caracteriza la acalasia en subtipos a partir de patrones de motilidad del esófago distal en respuesta a la distensión. Se ha demostrado recientemente que la EndoFLIP tiene un rol diagnóstico, pronóstico o terapéutico en otras patologías como la esofagitis eosinofílica, reflujo gastroesofágico, gastroparesia, durante la fundoplicatura y dilatación esofágica.

Abstract EndoFLIP evaluates biomechanical properties such as distensibility, volume, pressure, and even diameters of sphincter regions like the gastroesophageal junction, pylorus, and anus, by distending a balloon with a conductive medium. The best evidence of the clinical utility of EndoFLIP is observed in esophageal motility disorders, mainly when identifying achalasia when high-resolution esophageal manometry and other images fail to diagnose it. Even EndoFLIP 2.0 characterizes achalasia into subtypes based on distal esophageal motility patterns in response to distention. Recently, it has been shown that this system has a diagnostic, prognostic and/or therapeutic role in other diseases such as eosinophilic esophagitis, gastroesophageal reflux, and gastroparesis, and during fundoplication and esophageal dilation.

Pyloric sphincter characteristics using EndoFLIP® in gastroparesis. / Características del esfínter pilórico utilizando EndoFLIP® en gastroparesia.

INTRODUCTION AND AIMS: Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP®) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection. METHODS: EndoFLIP® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12. RESULTS: Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain. CONCLUSIONS: EndoFLIP® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus.

Evaluación intraoperatoria de la distensibilidad de la unión gastroesofágica en fundoplicatura antireflujo / Intraoperative assessment of the distensibility of the gastroesophageal junction in antireflux fundoplication

Introducción: La alteración de la distensibilidad de la unión gastro esofágica (UGE) es un factor etiológico para la enfermedad de reflujo gastroesofágico. El incremento de la distensibilidad permite el reflujo de contenido gástrico incrementa las relajaciones transitorias del esfínter, el número de reflujos y la exposición al ácido. Ha sido descrito que la UGE puede ser calibrada en el acto operatorio utilizando sonda balón, que permite una medida en tiempo real de la capacidad, diámetro y presión de la UGE. Objetivos: evaluar la utilidad de la medida de la distensibilidad de la UGE como predictor de éxito en fundoplicatura laparoscópica (FPL) mediante el uso de la sonda Endoflip ® (Crospon) utilizada intra operatoriamente en pacientes sometidos a FPL como tratamiento anti reflujo practicando mediciones antes y después de la plicatura. Materiales y métodos: La FP se realizó según técnica de Toupet. Se tomaron medidas de distensión del balón con llenado de 40 ml de solución salina 0,2% a) después de la inducción de la anestesia b) después de la reparación de la crura y c) al finalizar el arropado. Los datos fueron analizados por t students. P<0,05 fue considerado significativo. Resultados: Fueron evaluados 9 pacientes, el promedio de edad fue de 45,2; en todos los pacientes existía indicación de cirugía, todos presentaban hernia hiatal. La FPL redujo el promedio de distensibilidad de la UGE de 52,8 mm2/mmHg a 29,8 mm2/mmHg (p=0,0021, (43,5%). Conclusión: Este método permite tomar decisiones en cirugía de la UGE donde el valor objetivo de la distensibilidad puede definir el éxito de la cirugía y evitar eventos adversos post operatorios.

Introduction: The altered distensibility of the gastro esophageal junction (GEJ) is recognized as a primary pathophysiologic factor in the development of gastro esophageal reflux disease (GERD). The increase in GEJ distensibility allows reflux of large volumes of gastric contents into the esophagus, increases transient relaxations of the lower esophageal sphincter and increases the number of reflux and esophageal exposure to acid. Moreover, other pathologies with functional obstruction of the GEJ as achalasia have very little distensibility. Recently was reported that GEJ can be calibrated during surgery using balloon catheter, allowing real-time measurement of capacity, diameter and GEJ pressure during surgery. Objectives: To review the usefulness of the measurement of the distensibility of the GEJ as a predictor of success in laparoscopic fundoplication (LP) using Endoflip® commercial catheter, used intra-operatively in patients undergoing LP anti reflux surgery practicing measurements before and after plication. Material and Methods: The Toupet Fundoplication (TFP) was performed under standard technique, balloon distension measurements were taken, filling with 40 ml of 0.2% saline solution as specified by the manufacturer: a) after induction of anesthesia and once the pneumo peritoneum was stabilized b) After repairing the crura of the diaphragm and c) after the wrapping. Data was analyzed by students t P <0.05 and was considered significant. Results: A total of 9 patients (6 men), age average was 45.2 (32-72), all patients had previous functional and endoscopic studies and surgical indication existed, they all had a diagnosis of hiatal hernia, they all signed informed consent. No patient had postoperative complications. The Toupet Fundoplication (TFP) significantly reduced average GEJ distensibility to 40 ml of 52.8 to 29.8 mm2/mmHg mm2/mmHg (p = 0.0021, which represents a reduction of 43.5%). Conclusion: This method allows the gastro surgical team to make decisions on GEJ surgery in which the target value of distensibility can define the success of the surgery and avoid postoperative adverse events.