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Esophagogastric Junction Distensibility During Hiatal Hernia Repair

Primary Purpose

Esophagogastric Junction Distensibility, Hiatal Hernia

Status
Recruiting
Phase
Not Applicable
Locations
United States
Study Type
Interventional
Intervention
Surgeon unblinded
EndoFLIP 1.0 System EF-100
Sponsored by
Wake Forest University Health Sciences
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Esophagogastric Junction Distensibility focused on measuring EndoFLIP, Distensibility of the esophagogastric junction, Gastroesophageal Reflux Disease-Health Related Quality of Life survey, Mayo Dysphagia Questionnaire

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Patient undergoing hiatal hernia repair (types I-IV included) and fundoplication
  • Absence of spastic esophageal disorders (i.e. jackhammer esophagus, achalasia types I-III) or esophageal dysmotility (any evidence of ineffective esophageal motility disorder with failed swallows in > 50% of swallows and DCI < 450, or fragmented peristalsis as defined by Chicago Classification) assessed by preoperative high-resolution manometry
  • Adult patients ≥18 years
  • Elective repairs

Exclusion Criteria:

  • Redo hiatal hernia repairs
  • Emergent repairs
  • Patients with contraindication to surgery or endoscopy
  • Patients with esophageal varices
  • Cases with insufficient esophageal length in which fundoplication is unable to be performed or a Collis gastroplasty is required
  • Presence of IEM on Manometry
  • Connective tissue diseases such as scleroderma or lupus

Sites / Locations

  • Atrium Health - Carolinas Medical CenterRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

No Intervention

Experimental

Arm Label

Surgeon blinded

Surgeon unblinded

Arm Description

During blinded cases no adjustment will be made to the surgical procedure based on EndoFLIP results, as the operating surgeon will not be informed of the measured values. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication.

The surgeon will be able to augment the surgical intent based on EndoFLIP measurements, such as adding or removing hiatal sutures or repeating the fundoplication. The data will be evaluated to assess if intraoperative calibration influences postoperative symptoms by comparing the two groups. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication.

Outcomes

Primary Outcome Measures

Change in distensibility index
Change in distensibility index of the esophagogastric junction (EGJ) as measured by EndoFLIP before, during, and after hiatal hernia repair (EndoFLIP distensibility index values range from 0 to 98 with higher numbers indicating a tighter EGJ).

Secondary Outcome Measures

Post-op GERD symptoms
Postoperative symptoms as measured by Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire (GERD-HRQL). The lowest possible score for the GERD-HRQL is 0 and the highest possible score is 75 (higher scores are correlated with worse outcomes).
Post-op dysphagia symptoms
Postoperative symptoms as measured by the Mayo Dysphagia Questionnaire (MDQ-30). The lowest possible score for the MDQ-30 is 0 and the highest score is 100 (higher scores are correlated with worse outcomes).

Full Information

First Posted
June 25, 2020
Last Updated
August 30, 2023
Sponsor
Wake Forest University Health Sciences
Collaborators
Medtronic
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1. Study Identification

Unique Protocol Identification Number
NCT04450628
Brief Title
Esophagogastric Junction Distensibility During Hiatal Hernia Repair
Official Title
Esophagogastric Junction Distensibility During Hiatal Hernia Repair
Study Type
Interventional

2. Study Status

Record Verification Date
August 2023
Overall Recruitment Status
Recruiting
Study Start Date
September 28, 2020 (Actual)
Primary Completion Date
July 2024 (Anticipated)
Study Completion Date
August 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Wake Forest University Health Sciences
Collaborators
Medtronic

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
Yes
Product Manufactured in and Exported from the U.S.
No

5. Study Description

Brief Summary
The investigators aim to ascertain the effects of hiatal hernia repair and fundoplication on the distensibility of the esophagogastric junction (EGJ) as measured by FLIP topography/impedance planimetry. The investigators also aim to assess for any correlation between values of EGJ distensibility and GERD related quality of life (QOL) and dysphagia scores.
Detailed Description
Patients referred for antireflux surgery and/or hiatal hernia repair will be considered for enrollment. Standard preoperative evaluation will include esophagogastroduodenoscopy (EGD) to assess for intraluminal pathology including esophagitis, columnar lined esophagus suggestive of Barrett's esophagus, intraluminal masses, and to measure hernia size. Patients will also undergo preoperative high resolution esophageal manometry testing with impedance as clinically indicated to evaluate esophageal motility as assessed by standardized Chicago Classification V3. Manometry will occasionally be avoided in patients with paraesophageal hernias without substantial dysphagia or those not amenable to manometry, with appropriate upper gastrointestinal radiology imaging (UGI), who will be having partial fundoplications. UGI is also a routine preoperative evaluation. Furthermore, pH testing for evaluation of acid reflux will be performed in patients without LA grade C or D esophagitis, paraesophageal hernia, or pathologic confirmation of Barrett's esophagus. Patients appropriate for enrollment will be consented in the office setting. Preoperative baseline evaluations of symptom severity will be assessed via the GERD-HRQL survey and Mayo Dysphagia Questionnaire. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication. Surgeons will be blinded to EndoFLIP results for half of the cases, with the first 25 cases blinded and the second 25 cases with the surgeons unblinded. There will be interim analysis between the two groups' surgeries. During blinded cases no adjustment will be made to the surgical procedure based on EndoFLIP results, as the operating surgeon will not be informed of the measured values. After the first 25 cases, the surgeons will be unblinded and be able to determine goal impedance planimetry values based on patient postoperative symptom scores. In the following 25 unblinded cases, the surgeon will be able to augment the surgical intent based on EndoFLIP measurements, such as adding or removing hiatal sutures or repeating the fundoplication. Patients will be blinded to the type of procedure (i.e. surgeon blinded or unblinded). The EndoFLIP catheters and generator will be provided by Medtronic, at no cost to the patient. Medtronic will also cover the fees associated with the EndoFLIP procedure (CPT 91040 is used). Postoperative clinical care will proceed as per standard protocol for foregut surgery, with 1 additional office visit. Reports of postoperative symptomatology and QOL will be performed, via GERD-HRQL and Mayo Dysphagia Questionnaire during follow up clinic appointments at 2 weeks and 6 weeks postoperative, and with additional long-term follow-up of at 6 months. Long-term follow-up will again assess for QOL symptoms via GERD-HRQL and the Mayo Dysphagia Questionnaire. The 6 month follow-up visit is not typical practice and the patients cost for this visit will be covered by Medtronic. Per standard clinical care, recurrence of symptoms or dysphagia at any point may lead to additional postoperative testing, including UGI, EGD, pH testing, esophageal manometry, CT scan, or EndoFLIP. Postoperative GERD-HRQL and Mayo Dysphagia score results will be compared to intraoperative EndoFLIP measurements in interim and final analysis.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Esophagogastric Junction Distensibility, Hiatal Hernia
Keywords
EndoFLIP, Distensibility of the esophagogastric junction, Gastroesophageal Reflux Disease-Health Related Quality of Life survey, Mayo Dysphagia Questionnaire

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Model Description
Surgeons will be blinded to EndoFLIP results for half of the cases, with the first 25 cases blinded and the second 25 cases with the surgeons unblinded. There will be interim analysis between the two groups' surgeries. During blinded cases no adjustment will be made to the surgical procedure based on EndoFLIP results, as the operating surgeon will not be informed of the measured values. After the first 25 cases, the surgeons will be unblinded and be able to determine goal impedance planimetry values based on patient postoperative symptom scores.
Masking
ParticipantCare ProviderInvestigator
Masking Description
Surgeons will be blinded to EndoFLIP results for half of the cases, with the first 25 cases blinded and the second 25 cases with the surgeons unblinded. There will be interim analysis between the two groups' surgeries. During blinded cases no adjustment will be made to the surgical procedure based on EndoFLIP results, as the operating surgeon will not be informed of the measured values. After the first 25 cases, the surgeons will be unblinded and be able to determine goal impedance planimetry values based on patient postoperative symptom scores. In the following 25 unblinded cases, the surgeon will be able to augment the surgical intent based on EndoFLIP measurements, such as adding or removing hiatal sutures or repeating the fundoplication . Patients will be blinded to the type of procedure (i.e. surgeon blinded or unblinded).
Allocation
Non-Randomized
Enrollment
50 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Surgeon blinded
Arm Type
No Intervention
Arm Description
During blinded cases no adjustment will be made to the surgical procedure based on EndoFLIP results, as the operating surgeon will not be informed of the measured values. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication.
Arm Title
Surgeon unblinded
Arm Type
Experimental
Arm Description
The surgeon will be able to augment the surgical intent based on EndoFLIP measurements, such as adding or removing hiatal sutures or repeating the fundoplication. The data will be evaluated to assess if intraoperative calibration influences postoperative symptoms by comparing the two groups. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication.
Intervention Type
Procedure
Intervention Name(s)
Surgeon unblinded
Other Intervention Name(s)
EndoFLIP 1.0 System EF-100
Intervention Description
The surgeon will be able to augment the surgical intent based on EndoFLIP measurements, such as adding or removing hiatal sutures or repeating the fundoplication. The data will be evaluated to assess if intraoperative calibration influences postoperative symptoms by comparing the two groups. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication.
Intervention Type
Device
Intervention Name(s)
EndoFLIP 1.0 System EF-100
Intervention Description
The surgeon will be able to augment the surgical intent based on EndoFLIP measurements, such as adding or removing hiatal sutures or repeating the fundoplication. The data will be evaluated to assess if intraoperative calibration influences postoperative symptoms by comparing the two groups. Surgery will be scheduled and patients will undergo intraoperative impedance planimetry with EndoFLIP obtaining measurements of the cross-sectional area, balloon pressure, minimum diameter, compliance, length of high pressure segment, and distensibility index of the EGJ using an 8cm EndoFLIP balloon. Sequential assessments will be performed to 30ml and 40ml for up to a minute for each volume of distension. An initial baseline measurement will be obtained after establishment of pneumoperitoneum. A second measurement will occur following hiatal dissection and mobilization but prior to crural closure. Two additional measurements will be obtained after hiatal closure and after fundoplication.
Primary Outcome Measure Information:
Title
Change in distensibility index
Description
Change in distensibility index of the esophagogastric junction (EGJ) as measured by EndoFLIP before, during, and after hiatal hernia repair (EndoFLIP distensibility index values range from 0 to 98 with higher numbers indicating a tighter EGJ).
Time Frame
6 months
Secondary Outcome Measure Information:
Title
Post-op GERD symptoms
Description
Postoperative symptoms as measured by Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire (GERD-HRQL). The lowest possible score for the GERD-HRQL is 0 and the highest possible score is 75 (higher scores are correlated with worse outcomes).
Time Frame
6 months
Title
Post-op dysphagia symptoms
Description
Postoperative symptoms as measured by the Mayo Dysphagia Questionnaire (MDQ-30). The lowest possible score for the MDQ-30 is 0 and the highest score is 100 (higher scores are correlated with worse outcomes).
Time Frame
6 months

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patient undergoing hiatal hernia repair (types I-IV included) and fundoplication Absence of spastic esophageal disorders (i.e. jackhammer esophagus, achalasia types I-III) or esophageal dysmotility (any evidence of ineffective esophageal motility disorder with failed swallows in > 50% of swallows and DCI < 450, or fragmented peristalsis as defined by Chicago Classification) assessed by preoperative high-resolution manometry Adult patients ≥18 years Elective repairs Exclusion Criteria: Redo hiatal hernia repairs Emergent repairs Patients with contraindication to surgery or endoscopy Patients with esophageal varices Cases with insufficient esophageal length in which fundoplication is unable to be performed or a Collis gastroplasty is required Presence of IEM on Manometry Connective tissue diseases such as scleroderma or lupus
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Greg T Scarola, MS
Phone
704-355-5379
Email
Gregory.Scarola@atriumhealth.org
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Paul D Colavita, MD
Organizational Affiliation
Wake Forest University Health Sciences
Official's Role
Principal Investigator
Facility Information:
Facility Name
Atrium Health - Carolinas Medical Center
City
Charlotte
State/Province
North Carolina
ZIP/Postal Code
28203
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Greg T Scarola, MS
Phone
704-355-5379
Email
Gregory.Scarola@atriumhealth.org
First Name & Middle Initial & Last Name & Degree
Paul D Colavita, MD
First Name & Middle Initial & Last Name & Degree
Todd Heniford, MD
First Name & Middle Initial & Last Name & Degree
Baharak Moshiree, MD

12. IPD Sharing Statement

Learn more about this trial

Esophagogastric Junction Distensibility During Hiatal Hernia Repair

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