Intraoperative use of FLIP is associated with clinical success following POEM for achalasia

Holmstrom, Amy L.; Campagna, Ryan A J; Tudela, Arturo Cirera de; Carlson, Dustin A.; Pandolfino, John E.; Teitelbaum, Ezra N.; Hungness, Eric S.

doi:10.1007/s00464-020-07739-6

Cited by 35 publications

(21 citation statements)

References 20 publications

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“…20 More recently, Triggs et al found that the FLIP identifies achalasia phenotype in some dysphagic patients with normal IRP. 7 Teitenbaum et al and Su et al found that the FLIP distensibility measured intraoperatively after myotomy predicted outcome after myotomy [21][22][23]. Our current study shows that the FLIP DI outperforms HRM metrics in terms of its association with symptoms in treatment-naïve achalasia esophagus and EGJOO patients.…”

supporting

confidence: 52%

Relationship between dysphagia, lower esophageal sphincter relaxation, and esophagogastric junction distensibility

Jain

Allamneni

Kline

et al. 2022

Neurogastroenterology Motil

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Background It is debated whether high‐resolution manometric (HRM) integrated relaxation pressure (IRP) or functional lumen imaging probe (FLIP) distensibility index (DI) is the superior measure of esophagogastric junction (EGJ) opening. We examined the relationship between the DI and IRP and assessed correlations with dysphagia symptoms in patients with achalasia and EGJ outflow obstruction (EGJOO). Methods Patients with achalasia and those with barium tablet retention at the EGJ were grouped as follows: Group 1:Achalasia (IRP ≥ 15 mmHg + complete absence of normal peristalsis); Group 2: Manometric +FLIP EGJOO (IRP ≥ 15 mmHg with some intact peristalsis + DI ≤ 2.8 mm2/mmHg); Group 3: Abnormal DI only (DI ≤ 2.8 mm2/mmHg + IRP <15 mmHg); and Group 4: Normal IRP and DI (IRP ≥ 15 mmHg + DI > 2.8 mm2/mmHg). Correlation between the DI, baseline lower esophageal sphincter pressure (BLESP), IRP, and dysphagia (Eckardt score) was assessed. Multivariable analysis was used to assess variables associated with dysphagia score ≥2. Key Results A total of 79 patients were included: Group 1 (n = 31), Group 2 (n = 33), Group 3 (n = 14), and Group 4 (n = 1). DI did not correlate with BLESP or IRP in the whole sample or subgroups. DI was the only variable associated with dysphagia score ≥2 (p = 0.006). DI < 1.25 mm2/mmHg had sensitivity of 87% and specificity of 52% (p = 0.0003) for dysphagia score ≥2. Conclusions & Inferences DI does not correlate with HRM EGJ measurements and is the metric with the strongest effect on dysphagia severity. The various biological elements that may cause restrictive EGJ function should be the subject of future studies.

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supporting

confidence: 52%

Relationship between dysphagia, lower esophageal sphincter relaxation, and esophagogastric junction distensibility

Jain

Allamneni

Kline

et al. 2022

Neurogastroenterology Motil

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“…Holmstrom et al performed FLIP intraoperatively for 125 patients with achalasia and 17 patients with EGJOO undergoing POEM, demonstrating substantial increases in EGJ-DI after POEM [50]. In another study of 143 patients with achalasia or EGJOO undergoing POEM, Holmstrom et al demonstrated that achalasia patients who underwent intraoperative FLIP-guided myotomy had a higher clinical success rate (defined as Eckardt score ≤3) at 12 months compared to those who did not (93% with FLIP vs. 81% without FLIP, P < 0.05); 65% of the patients who had intraoperative FLIP had additional myotomy performed (during the same POEM procedure) based on FLIP measurements indicating that the initial myotomy did not increase the EGJ-DI adequately [51].…”

Section: Functional Luminal Imaging Probe Panometry Guiding Esophagog...mentioning

confidence: 99%

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

Ellison

Nguyen²

2022

Current Opinion in Gastroenterology

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Purpose of reviewEsophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO.Recent findingsFLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures.SummaryFLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.

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“…A higher percentage of patients in the EndoFLIP group (94 vs. 81%) had clinical success (Eckardt score 3) at 12 months following POEM. 25 Su et al identified two different EndoFLIP parameters that predicted outcomes after myotomy. A CSA > 96.0 mm 2 at 30-mL balloon fill was associated with worse reflux at 2 years.…”

Section: Achalasiamentioning

confidence: 99%

Intraoperative Impedance Planimetry (ENDOFLIP)

Ujiki

2021

Digestive Disease Interventions

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The Endoluminal Functional Imaging Probe (EndoFLIP, Medtronic, Minneapolis, MN) impedance planimetry system provides real-time three-dimensional images of gastrointestinal sphincters of interest, particularly the esophagogastric junction. This allows for real-time objective measurements during the surgical management of foregut diseases such as gastroesophageal reflux and achalasia. Literature continues to grow on how to best utilize this recent technology to improve patient outcomes. This outlines the intraoperative utilization of EndoFLIP.

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Intraoperative use of FLIP is associated with clinical success following POEM for achalasia

Cited by 35 publications

References 20 publications

Relationship between dysphagia, lower esophageal sphincter relaxation, and esophagogastric junction distensibility

Relationship between dysphagia, lower esophageal sphincter relaxation, and esophagogastric junction distensibility

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

Intraoperative Impedance Planimetry (ENDOFLIP)

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