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New paper proposes optimal intra-operative FLIP values to optimize achalasia surgery outcomes

29th July 2014

A new paper Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes authored by Teitelbaum EN, Soper NJ, Pandolfino JE, Kahrilas PJ, Hirano I, Boris L, Nicodème F, Lin Z, Hungness ES has been published in the journal Surgical Endoscopy. This paper is significant in that it presents what the authors believe to be optimum parameters for GEJ distensibility to be set by a surgeon or endoscopist performing achalasia surgery, in order to not only minimize the risk of post-operative dysphagia, but also to minimize post-operative gastroesophageal reflux. The authors note that patients within this proposed distensibility “sweet spot”  range of 4.5-8.5mm2/Hg were almost twice as likely to have optimal outcomes in terms of achalasia and GERD symptoms as those outside this range.


The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study, we performed intraoperative FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relationship between EGJ distensibility and postoperative symptoms.

Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured with FLIP at two time points during LHM and POEM: (1) at baseline after induction of anesthesia, and (2) after operation completion.

Measurements were performed in 20 patients undergoing LHM and 36 undergoing POEM. Both operations resulted in an increase in DI, although this increase was larger with POEM (7 ± 3.1 vs. 5.1 ± 3.4 mm2/mmHg, p < .05). The two patients (both LHM) with the smallest increases in DI (1 and 1.6 mm2/mmHg) both had persistent symptoms postoperatively and, overall, LHM patients with larger increases in DI had lower postoperative Eckardt scores. In the POEM group, there was no correlation between change in DI and symptoms; however, all POEM patients experienced an increase in DI of >3 mm2/mmHg. When all patients were divided into thirds based on final DI, none in the lowest DI group (<6 mm2/mmHg) had symptoms suggestive of reflux (i.e., GerdQ score >7), as compared with 20 % in the middle third (6-9 mm2/mmHg) and 36 % in the highest third (>9 mm2/mmHg). Patients within an "ideal" final DI range (4.5-8.5 mm2/mmHg) had optimal symptomatic outcomes (i.e., Eckardt ≤ 1 and GerdQ ≤ 7) in 88 % of cases, compared with 47 % in those with a final DI above or below that range (p < .05).

Intraoperative EGJ distensibility measurements with FLIP were predictive of postoperative symptomatic outcomes. These results provide initial evidence that FLIP has the potential to act as a useful calibration tool during operations for achalasia.


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