Pyloric Functional Lumen Imaging Probe Measurements Are Dependent on Balloon Position.

Background/Aims: The functional lumen imaging probe (FLIP) device has been used to assess pyloric dysfunction in patients with gastroparesis. We aim to investigate whether varying FLIP catheter positions affect pyloric FLIP measurements. Methods: Patients undergoing endoscopy for chronic unexplained nausea and vomiting (CUNV) or gastroparesis were prospectively enrolled. FLIP balloon was adjusted for 3 positions within the pylorus: (1) proximal position, 75% of FLIP balloon in the duodenum and 25% in the antrum; (2) middle position, 50% in the duodenum and 50% in the antrum; and (3) distal position, 25% in the duodenum and 75% in the antrum. Pylorus cross-sectional area (CSA), intra-bag pressure (P), and distensibility indices (DI) were measured for 30, 40, and 50-mL balloon volumes. Fluoroscopic images were obtained to confirm FLIP balloon geometry. Data was analyzed separately using FLIP Analytic and customized MATLAB software. Results: Twenty-two patients with CUNV (n = 4) and gastroparesis (n = 18) were enrolled. Pressures were significantly higher in the proximal position compared to the middle and distal positions. CSA measurements were significantly higher at the proximal and middle positions for 30-mL and 40-mL volume compared to the distal position values. DI values were significantly lower at the proximal positions for 40-mL and 50-mL distensions when compared to the middle and distal positions. Fluoroscopic images confirmed increased balloon bending when placed mostly in the duodenum. Conclusions: FLIP balloon position within the pylorus directly affects balloon geometry which significantly affects P, CSA, and DI measurements. Standardized pyloric FLIP protocols and balloon design adjustments are needed for the continued application of this technology to the pylorus.

Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a prospective single-center experience with mid-term follow-up (with video).

BACKGROUND AND AIMS: Gastroparesis (GP) is a multifactorial disease associated with a large burden on the health care systems. Pyloric-directed therapies including gastric peroral endoscopic myotomy (G-POEM) can be effective in improving patient quality of life and symptom severity. We report on the safety and efficacy of G-POEM and its impact on the quality of life of patients managed at a large referral center. METHODS: Consecutive patients with confirmed GP referred for G-POEM due to failure of medical therapy were included. All patients were assessed at baseline and then at 1, 3, 6, and 12 and 24 months after G-POEM using validated symptom and quality of life instruments, including the Gastroparesis Cardinal Symptom Index (GCSI), Patient Assessment of Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM), and 36-Item Short Form Survey (SF-36). Patients were evaluated before and 6 months after the procedure with EGD, 4-hour scintigraphy, and pyloric EndoFLIP. Technical success was defined as the ability to perform full-thickness pyloromyotomy. Clinical response was defined as an improvement of ≥1 point on GCSI. RESULTS: Fifty-two patients (median age, 48 years; range, 25-80 years, 88% female) underwent G-POEM between February 2018 and September 2020 for the following phenotypes: vomiting-predominant (n=30), dyspepsia-predominant (n=16), and regurgitation-predominant (n=6) GP. The technical success rate was 100%. Adverse events were noted in 3 of 52 patients (5.77%), and were all managed successfully endoscopically. Clinical response was achieved in 68%, 58%, and 48% of patients at 1-month, 6-month, and 12-month follow-up (P < .001, P < .001, and P < .01, respectively). When classified by the cause of GP, the clinical response rates were diabetic GP 64% (11 of 17), postsurgical GP 67% (6 of 9), and idiopathic GP 72% (13 of 18). A statistically significant improvement in PAGI-SYM scores was observed at 1, 3, 6, 12, and 24 months, in addition to significant improvement in several domains of SF-36. Mean 4-hour gastric emptying was reduced 6 months after G-POEM (10.2%) compared with baseline (36.5%, P < .001). We report a significant reduction in the number of emergency department visits and days spent in the hospital up to 24 months after G-POEM. CONCLUSIONS: G-POEM appears to be a safe and feasible treatment alternative for refractory GP with significant short-term and mid-term improvements in overall symptoms, quality of life scores, and health care utilization.

Poor Outcomes in Hepatic Amyloidosis: A Report of 2 Cases.

Hepatic amyloidosis is a rare disease entity that results from insoluble amyloid protein deposition in the liver. The disease often presents with vague, nonspecific clinical features. Currently, there is little literature describing treatment outcomes for biopsy-proven hepatic amyloidosis and current treatment guidelines recommend that patients enroll in a clinical trial due to insufficient evidence to suggest an optimal treatment regimen. Here, we present two cases of hepatic amyloidosis at an academic medical center and describe their presentation, treatment, and outcomes. These cases highlight the poor outcomes and difficult management of hepatic amyloidosis. Further understanding and investigation of this rare disease are warranted.

The four phases of esophageal bolus transit defined by high-resolution impedance manometry and fluoroscopy.

We aimed to model esophageal bolus transit based on esophageal pressure topography (EPT) landmarks, concurrent intrabolus pressure (IBP), and esophageal diameter as defined with fluoroscopy. Ten healthy subjects were studied with high-resolution impedance manometry and videofluoroscopy. Data from four 5-ml barium swallows (2 upright, 2 supine) in each subject were analyzed. EPT landmarks were utilized to divide bolus transit into four phases: phase I, upper esophageal sphincter (UES) opening; phase II, UES closure to the transition zone (TZ); phase III, TZ to contractile deceleration point (CDP); and phase IV, CDP to completion of bolus emptying. IBP and esophageal diameter were analyzed to define functional differences among phases. IBP exhibited distinct changes during the four phases of bolus transit. Phase I was associated with filling via passive dilatation of the esophagus and IBP reflective of intrathoracic pressure. Phase II was associated with auxotonic relaxation and compartmentalization of the bolus distal to the TZ. During phase III, IBP exhibited a slow increase with loss of volume related to peristalsis (auxotonic contraction) and passive dilatation in the distal esophagus. Phase IV was associated with the highest IBP and exhibited isometric contraction during periods of nonemptying and auxotonic contraction during emptying. IBP may be used as a marker of esophageal wall state during the four phases of esophageal bolus transit. Thus abnormalities in IBP may identify subtypes of esophageal disease attributable to abnormal distensibility or neuromuscular dysfunction.

Flow time through esophagogastric junction derived during high-resolution impedance-manometry studies: a novel parameter for assessing esophageal bolus transit.

This study aimed to develop and validate a method to measure bolus flow time (BFT) through the esophagogastric junction (EGJ) using a high-resolution impedance-manometry (HRIM) sleeve. Ten healthy subjects were studied with concurrent HRIM and videofluoroscopy; another 15 controls were studied with HRIM alone. HRIM studies were performed using a 4.2-mm-outer diameter assembly with 36 pressure sensors at 1-cm intervals and 18 impedance segments at 2-cm intervals (Given Imaging, Los Angeles, CA). HRIM and fluoroscopic data from four barium swallows, two in the supine and two in the upright position, were analyzed to create a customized MATLAB program to calculate BFT using a HRIM sleeve comprising three sensors positioned at the crural diaphragm. Bolus transit through the EGJ measured during blinded review of fluoroscopy was almost identical to BFT calculated with the HRIM sleeve, with the nadir impedance deflection point used as the signature of bolus presence. Good correlation existed between videofluoroscopy for measurement of upper sphincter relaxation to beginning of flow [R = 0.97, P < 0.001 (supine) and R = 0.77, P < 0.01 (upright)] and time to end of flow [R = 0.95, P < 0.001 (supine) and R = 0.82, P < 0.01 (upright)]. The medians and interquartile ranges (IQR) of flow time though the EGJ in 15 healthy subjects calculated using the virtual sleeve were 3.5 s (IQR 2.3-3.9 s) in the supine position and 3.2 s (IQR 2.3-3.6 s) in the upright position. BFT is a new metric that provides important information about bolus transit through the EGJ. An assessment of BFT will determine when the EGJ is open and will also provide a useful method to accurately assess trans-EGJ pressure gradients during flow.