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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1033_Библиотеки_им_академика_М_И_Перельмана
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11 High-Resolution Esophageal Manometry with and…
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20. Wang YT, Yazaki E, Sifrim D.High-resolution manometry: esophageal
disorders not addressed by the “Chicago classication”. J
Neurogastroenterol Motil. 2012;18:365.
21. Ghoshal UC, Kumar S, Saraswat VA, Aggarwal R, Misra A, Choudhuri
G. Long-term follow-up after pneumatic dilation for achalasia cardia:
factors associated with treatment failure and recurrence. Am J
Gastroenterol. 2004;99:2304.
22. Stoikes N, Drapekin J, Kushnir V, Shaker A, Brunt LM, Gyawali CP.The
value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireux surgery. Surg Endosc. 2012;26:3401.
23. Yadlapati R, Kahrilas PJ, Fox MR, etal. Esophageal motility disorders on
high-resolution manometry: Chicago classication version 4.0©.
Neurogastroenterol Motil. 2021;33(1):e14058. https://doi.org/10.1111/
nmo.14058.
24. Shaker A, Stoikes N, Drapekin J, etal. Multiple rapid swallow responses
during esophageal high-resolution manometry reect esophageal body
peristaltic reserve. Am J Gastroenterol. 2013;108(11):1706–12. https://
doi.org/10.1038/ajg.2013.289.
25. Ang D, Hollenstein M, Misselwitz B, etal. Rapid drink challenge in highresolution manometry: an adjunctive test for detection of esophageal
motility disorders. Neurogastroenterol Motil. 2017;29(1):e12902. https://
doi.org/10.1111/nmo.12902.
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Impedance Planimetry:
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EndoFLIP
MichelleCampbell andMichaelUjiki
Background
Impedance planimetry has been used since the late 1980s to measure compliance and cross-sectional area (CSA) of luminal organs
and sphincters [1]. Over the next 20years, it was rened for use in
all hollow organs but found particular utility in the lumen of the
esophagus [2, 3]. In 2004, a new probe was developed allowing
simultaneous measurement of multiple luminal CSAs [4] and was
quickly adopted for use at the esophagogastric junction (EGJ) [5].
The new method, known as functional lumen imaging probe
(FLIP), was validated in 2005 as a quantitative method for assessing the EGJ in diseases such as achalasia and GERD [6].
12
M. Campbell
University of Chicago Medical Center, Chicago, IL, USA
M. Ujiki (*)
NorthShore University HealthSystem, Evanston, IL, USA
e-mail: mujiki@northshore.org
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_12
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M. Campbell and M. Ujiki
Denition
FLIP is an endoscopic catheter-based device that utilizes highresolution impedance planimetry to measure luminal CSA and
pressure allowing for calculation of distensibility, compliance,
and depiction of luminal geometry [7]. The distal end of the
72-cm exible catheter carries impedance electrodes within a distensible polyester urethane balloon, impermeable to body uids
and electrical current [6]. The FDA has approved FLIP in two
available congurations: 8-cm balloon with 16 paired sensors
spaced 0.5cm apart (EF-325) utilized for evaluation of esophagogastric junction (EGJ) or 16-cm balloon with 16 paired sensors
spaced 1cm apart (EF-322) utilized for esophageal body in addition to EGJ.The catheter is most often placed transorally into the
esophagus with the most distal few sensors in the stomach, thereby
spanning the EGJ (Fig.12.1). Transnasal placement is also possible; however, most existing data is based on transoral placement.
Using a mechanical pump within the attached FLIP machine,
the balloon is distended at controlled speed to a target ll volume
with proprietary electrolyte solution of known conductance [7]. A
continuous low electric current is emitted by electrodes at either
end of the balloon and the voltage across paired electrodes measured. Making use of Ohm’s law (voltage=current x resistance),
the electrical resistance (impedance) of the uid is proportional to
CSA.The original FLIP 1.0 module, available for use with either
catheter, displays the calculated CSA measurements in a 3D
depiction of the lumen (Fig.12.1). More recently, the FLIP 2.0
panometry module was released for use with the 16cm balloon
catheter which topographically depicts diameter-pressure changes
across space-time continuum representing contraction and distension of the esophageal lumen.
Clinical Role The FLIP system’s primary utility is in evaluating
the biophysical and motor properties of the esophagus and lower
esophageal sphincter (LES), although theoretically its use can be
expanded to any gastrointestinal sphincter, including the anal
Fli
r
Time: seconds
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175
pTM Device: Placement
16-cm EGJ
Stomach
FlipTM 1.0
Time: Instant
Impedance planimetry channels : 1-cm spacing
Pressure
0 sec 100 sec 200 sec 300 sec
TM
Flip
2.0 Panometry
Diamete
(mm)
Esophageal body
-30
Anatomic location
-25
-20
-15
-10
EGJ
-5
Stomach
40 mmHg
20 mmHg
1
Fig. 12.1 Left: FLIP device position at the EGJ. Center: correlating FLIP
1.0 images. Right: FLIP 2.0 panometry topography representing diameter
changes that represent contraction and distention of the esophageal lumen.
EGJ esophagogastric junction, FLIP functional lumen imaging probe
canal [8–11]. Reported metrics obtained during FLIP evaluation
include minimum diameter (mm), CSA (mm2), intra-balloon
pressure (mmHg), distensibility index (mm2/mmHg), and compliance. Of these, distensibility index (DI), dened as the narrowest
CSA divided by the corresponding pressure, is the most widely
studied with the greatest clinical utility. Normal values for DI at
the EGJ range from 3.1 to 9.0mm2/mmHg [12].
Achalasia andMotility Disorders
FLIP may be considered as a diagnostic adjunct to endoscopy,
manometry, and cross-sectional imaging in the evaluation of suspected mechanical or motor obstruction at the EGJ. Highresolution manometry (HRM) is considered the gold standard in
diagnosis of motility disorders, including achalasia in which integrated relaxation pressure (IRP) of the LES is >15 mmHg and
peristalsis is absent. FLIP analysis reliably detects major esophageal motility disorders and achalasia when compared to HRM
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M. Campbell and M. Ujiki
[13]. In treatment-naïve achalasia patients, the EGJ demonstrates
impaired distensibility with DI <1.0 mm2/mmHg [14–17].
Moreover, FLIP may show a slight advantage over HRM, having
been shown to detect impaired EGJ distensibility despite normal
IRP on manometry in a subgroup of patients with typical achalasia symptoms and abnormal peristalsis [18]. Volumetric distension within the esophagus during FLIP analysis triggers secondary
peristalsis [19]. The second iteration of the FLIP system, FLIP 2.0
panometry, allows serial measurements of luminal diameters plotted as a function of time in topographic fashion using interpolation to depict peristalsis in the esophagus akin to high-resolution
manometry. This has led to an expanded role for FLIP 2.0 panometry in accurately identifying achalasia subtypes or other motility
disorders using distension-induced contractility mapping [20].
FLIP panometry which is discordant from HRM may be useful in
clarifying equivocal or undetected abnormalities on manometry.
The esophagus responds to distention by a bolus with contractions. Similar to a food bolus, FLIP distends the esophagus and
induces contractions that are repetitive and antegrade in patients
with normal motility. In patients with achalasia, FILP panometry
or topography can be used to identify the different achalasia
classes. All three classes present with a low distensibility index at
the lower esophageal sphincter, but vary in the contractile
response. A patient with type I achalasia will have an absent contractile response. Those with type II achalasia will have decreased
and disordered contractions. A patient with type III achalasia will
have a topography pattern with abnormal retrograde and often,
rapid contractions (Fig. 12.2). (ref: Donnan EN, Pandolno
JE. EndoFLIP in the esophagus: assessing sphincter function,
wall stiffness, and motility to guide treatment. Gastroenterol Clin
North Am. 2020 Sep;49 [3]:427–435.)
In addition to diagnostic utility, FLIP has shown excellent
advantage in the assessment of treatment efcacy for achalasia.
FLIP measurements obtained following pneumodilation, laparoscopic Heller myotomy, or per oral endoscopic myotomy (POEM)
Diamete
FLIP topography: Contractile patterns
cd
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Repetitive, ANTEGRADE
contractions (RACs)
ab
Pressure
(mmHg)
150
120
90
60
30
0
r
(mm)
30
25
20
15
10
5
Absent
contractility
Contractility,
No RACs or RRCs
RETROGRADE
contractions
177
Repetitive,
(RRCs)
Fig. 12.2 Motility patterns in response to volumetric distention. The top
panel is the high-resolution manometry image, and the bottom panel is the
FLIP topography image of the representative patient. Panel (a) is a normal
subject with a RAC pattern. Panel (b) is a patient with type I achalasia, and
the FLIP depicts an absent contractile response and a poorly relaxing sphincter. Panel (c) is type II achalasia, and the FLIP suggests that there are disordered non-occluding contractions in the body of the esophagus and the
sphincter does not open. Panel (d) is a patient with type III achalasia, and the
FLIP topography reveals an abnormal pattern where the contractions are retrograde and rapid in terms of the rate of contractions. Courtesy of the Esophageal Center at Northwestern, Chicago, IL
have been shown to have signicant association with treatment
success as reported by Eckardt scores [17, 21] and in fact show
greater association when compared to manometric measurement
of LES pressure [14]. Achieving an optimal DI range (4.5–
8.5mm2/mmHg) can successfully alleviate achalasia symptoms
while minimizing risk of GERD [22]. Therefore, FLIP is now
used with increasing frequency intraoperatively to assess extent
and completeness of myotomy during laparoscopic Heller myotomy or per oral endoscopic myotomy (POEM) [15, 23, 24].
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M. Campbell and M. Ujiki
GERD
Although there was initially early excitement at the prospect of
utilizing FLIP technology to diagnose and stratify GERD patients
for management planning [25], FLIP has since proven to be a
poor diagnostic study for GERD with distensibility and CSA
showing poor correlation to clinical symptoms or pH testing [26,
27]. However, FLIP does have an important role in the intraopera-
tive setting in guiding adequacy of fundoplication during reux
procedures. Hiatus repair and fundoplication result in a signicant
reduction in distensibility of the EGJ during reux surgery [28–
30]. These distensibility changes can be measured by FLIP in real
time in the operating room at intervals throughout the procedure
(e.g., initial, following hiatal dissection and hernia reduction, following crural closure, and following fundoplication) [28]. Toupet
fundoplication results in a more distensible EGJ than Nissen fundoplication [29]. FLIP can be used to provide objective measurement of distensibility when performing fundoplication with early
evidence suggesting that maintaining a DI between 2.0 and
3.5mm2/mmHg alleviates reux symptoms while limiting risk of
gas bloat from an overly tight wrap [30]. Similarly, using additional metrics provided by FLIP, a decrease in minimum EGJ
diameter of 0.15mm or less, or a decrease in CSA of 1.5mm2 or
less from initial to post-fundoplication results in greater association with severe heartburn in the postoperative period [31].
Gastroparesis
FLIP has also found utility in evaluating the pylorus in the setting
of gastroparesis. Patients with diabetic and idiopathic gastroparesis show decreased sphincter diameter and CSA which correlate
inversely with presence of symptoms of early satiety and postprandial fullness [32]. Similar to achalasia and GERD treatments,
FLIP can be used in evaluating the efcacy of interventions
including gastric peroral endoscopic myotomy (G-POEM).
Following G-POEM, FLIP has shown higher CSA and DI in those
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who achieve clinical relief of symptoms and improvement on gastric emptying scan [33]. Further studies are yet to be performed to
better characterize the predictive value of FLIP in gastroparesis,
as well as the potential role for tailoring intervention such as with
POEM in the achalasia population.
Summary
EndoFLIP is a novel technique with rapidly expanding clinical
use in diagnostics and treatment guidance in achalasia, GERD,
gastroparesis, and other motility disorders of the foregut and
beyond. It is an excellent diagnostic tool in esophageal motility
disorders including achalasia, serving currently as an adjunct to
manometry with potential to replace HRM as further renement is
made to diagnostic parameters. While not as useful in the diagnosis of GERD, FLIP serves as a valuable tool in the intervention of
both achalasia and GERD by allowing the foregut surgeon or
interventional endoscopist to guide the POEM or fundoplication
procedure in real time for greater treatment efcacy. Application
of FLIP to other foregut disorders such as gastroparesis diagnosis
and management shows similar promise. As FLIP analysis is
more widely adopted, we anticipate a corresponding increase in
the availability of both normative data and in-depth applications
to the study of foregut pathophysiology and beyond.
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