Use of Impedance Planimetry (Endoflip) in Foregut Surgery Practice: Experience of More than 400 Cases Bailey Su, MD , Zachary M Callahan, MD , Kristine Kuchta, MS , John G Linn, MD, FACS , Stephen P Haggerty, MD, FACS , Woody Denham, MD, FACS , Michael B Ujiki, MD, FACS BACKGROUND: We provide a comprehensive report of our institution’s experience with the endoluminal functional lumen imaging probe (Endoflip) impedance planimetry system, a device that can be used intraoperatively to objectively evaluate the distensibility of any sphincter of the gastrointestinal tract. We aim to describe the variety of ways in which the Endoflip can be used in a foregut surgeon’s practice. STUDY DESIGN: This is a retrospective review of a prospectively maintained quality database of all patients in which the functional lumen imaging probe (FLIP) system was used between February 2013 and June 2019. RESULTS: During the study period, 402 FLIP cases were performed: 226 fundoplications, 94 peroral endoscopic myotomies, 15 peroral pyloromyotomies, 12 antireflux mucosectomies, 11 mag-netic sphincter augmentations, 9 laparoscopic Heller myotomies, 8 pre-esophagectomy esophagogastroduodenoscopies (EGDs), 4 diagnostic EGDs, 8 endoscopic Zenker’s diver-ticulotomies, 5 post-peroral endoscopic myotomy EGDs, 8 EGDs with dilations, and 2 transoral incisional fundoplications. CONCLUSIONS: Within a foregut surgeon’s practice, the FLIP can be used to measure the upper esoph-ageal sphincter, lower esophageal sphincter, and pylorus in a variety of clinical scenarios and settings. (J Am Coll Surg 2020;231:160 e 171. Ó 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.) Despite its introduction in 2009, there have been few studies describing the use of the endoluminal functional lumen imaging probe (Endoflip) (Medtronic) in an oper-ative setting. These reports have focused individually on Disclosure Information: Dr Ujiki received speaker payments from Med-tronic for instructional courses on the use of Endoflip. Disclosures outside the scope of this work: Drs Linn, Haggerty, and Ujiki receive payment for lectures from Gore. Dr Ujiki is a board member for Boston Scientific, is a paid consultant to Olympus and Apollo, and re-ceives payment for lectures from Apollo. Dr Haggerty received consultant and speaker fees from the renal division of Medtronic for work with peri-toneal dialysis catheters and insertion techniques, development of educa-tional materials, and serving as a lecturer and proctor for hands-on courses. Presented at the Western Surgical Association 127th Scientific Session, Las Vegas, NV, November 2019. Received January 6, 2020; Revised February 3, 2020; Accepted February 4, 2020. From the Department of Surgery, Northshore University HealthSystem, Evanston (Su, Callahan, Kuchta, Linn, Haggerty, Denham, Ujiki) and Department of Surgery, University of Chicago, Chicago (Su), IL. Correspondence address: Bailey Su, MD, Department of Surgery, North-shore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evan-ston, IL 60201. email: bailey.su@uchospitals.edu specific procedures, such as fundoplication, myotomy of the lower esophageal sphincter or myotomy of the pylo-rus. 1-9 There has not been a single comprehensive report describing the multitude of uses for the functional lumen imaging probe (FLIP) in a foregut surgery practice. The FLIP is a balloon-based catheter that uses impedance planimetry technology to evaluate the minimum diameter (D min ), cross-sectional area (CSA), and distensibility of any sphincter in the gastrointestinal tract. There are 17 paired impedance planimetry electrodes and an intrabag pressure transducer housed within a highly compliant bag. Using a specially formulated saline solution, the balloon can be filled with varying volumes, and by measuring the drop in voltage between electrodes, the FLIP is able to calcu-late the luminal CSA and diameter at each electrode. Dividing the minimum CSA by the intrabag pressure pro-vides the distensibility index (DI). A higher distensibility implies a sphincter that is more “open” or “stretchy,” and a lower distensibility indicates a “tighter” or “stiffer” sphincter. Using this technology, the FLIP is able to provide real-time, objective feedback on the geometry of any ª 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved. 160 https://doi.org/10.1016/j.jamcollsurg.2020.02.017 ISSN 1072-7515/20
Journal of the American College of Surgeons July 2020: Page 160
