Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication

Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti-reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF-325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross-sectional area and distensibility within a balloon-tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty-second median cross-sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre-extubation. Postoperatively, patients continued on protocol and were discharged after a two-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm(2)/mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm(2)/mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm(2)/mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270 degrees wrap resulting in a change in the DI from 0.65 to 0.89 mm(2)/mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long-term follow up would be beneficial to develop a target range of distensibility associated with good outcome.