Intraoperative impedance planimetry for assessment of pyloric function in minimally invasive esophagectomy

Pyloric management during esophagectomy remains controversial. Routine drainage may improve conduit emptying in some patients but exposes others to potential long-term symptoms including dumping syndrome and bile reflux. Conversely, omission of drainage avoids routine intervention but leaves a subset of patients requiring postoperative endoscopic treatment for delayed gastric emptying. The central problem is the lack of a validated method to identify, at the time of operation, which patients are likely to benefit from pyloric intervention. We describe early lessons from incorporating intraoperative impedance planimetry using EndoFLIP into minimally invasive esophagectomy. The assessment was performed as an incremental addition to routine on-table endoscopy after gastric conduit reconstruction. In 20 consecutive patients, pyloric distensibility index and diameter were measured at 30, 40, and 50 mL balloon fill volumes. Assessment was completed in all patients, added less than 10 minutes to operative time, and caused no device-related complications. Nine patients subsequently underwent postoperative pyloric dilation, most commonly for symptomatic delayed gastric emptying. These patients had lower intraoperative pyloric distensibility at 40 and 50 mL, whereas pyloric diameter did not differ between groups. Several lessons emerged: intraoperative pyloric impedance planimetry is feasible when intraoperative endoscopy is already part of routine workflow. Distensibility appears more informative than static diameter. Higher balloon fill volumes may better reveal clinically relevant differences. Finally, postoperative dilation is a pragmatic but imperfect endpoint because it is partly influenced by surgeon judgment and institutional practice. These observations support further prospective evaluation of intraoperative pyloric distensibility as a potential basis for selective, physiology-guided pyloric management.