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Digestive Disease Interventions
DOI: 10.1055/s-0044-1788888
Review Article

EndoFLIP Use in De Novo and Revisional Foregut Surgery

Jennifer S. Colvin 
1   Department of Surgery, University of Cincinnati, Cincinnati, Ohio
,
Joseph Imbus
1   Department of Surgery, University of Cincinnati, Cincinnati, Ohio
,
Neha Wadhwa
2   Department of Gastroenterology, University of Cincinnati, Cincinnati, Ohio
› Author Affiliations Funding None.
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Abstract

EndoFLIP technology, utilizing impedance planimetry, has revolutionized the assessment of gastrointestinal sphincters by providing real-time measurements of cross-sectional area and pressure to calculate distensibility. This review explores its application in de novo and revisional foregut surgeries. Preoperatively, EndoFLIP has demonstrated efficacy in evaluating gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders, including achalasia, by distinguishing motility patterns and identifying sphincter incompetence. In gastroparesis, EndoFLIP's measurement of pyloric distensibility correlates with gastric emptying and symptom severity, guiding therapeutic decisions for pyloric interventions. Intraoperatively, EndoFLIP optimizes surgical outcomes in antireflux procedures, such as fundoplication and hiatal hernia repairs, by balancing effective reflux control with minimizing postoperative complications like dysphagia and gas bloat. For esophageal myotomy, including Heller myotomy and per oral endoscopic myotomy, EndoFLIP ensures adequate sphincter relaxation, reducing reflux risks. Additionally, during endoscopic pyloromyotomy for gastroparesis, EndoFLIP predicts clinical success by assessing postprocedural distensibility. While promising, further research is essential to establish standardized intraoperative protocols and ideal measurement targets, enhancing the reproducibility and accuracy of EndoFLIP applications. Overall, EndoFLIP offers a significant advancement in foregut surgery, improving diagnostic precision and therapeutic outcomes.

Keywords

endoFLIP - esophagus - gastroparesis - achalasia - gastroesophageal reflux disease

Authors' Contribution

All the authors meet the criteria for authorship as defined by ICMJE.


J.S.C.: manuscript writing, literature review, editing.


J.I.: literature review, manuscript editing.


N.W.: manuscript writing, editing.




Publication History

Received: 26 June 2024

Accepted: 15 July 2024

Article published online:
23 August 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Desprez C, Roman S, Leroi AM, Gourcerol G. The use of impedance planimetry (Endoscopic Functional Lumen Imaging Probe, EndoFLIP® ) in the gastrointestinal tract: a systematic review. Neurogastroenterol Motil 2020; 32 (09) e13980
    CrossrefPubMedSearch in Google Scholar
  • 2 McMahon BP, Frøkjaer JB, Drewes AM, Gregersen H. A new measurement of oesophago-gastric junction competence. Neurogastroenterol Motil 2004; 16 (05) 543-546
    CrossrefPubMedSearch in Google Scholar
  • 3 McMahon BP, Frøkjaer JB, Liao D, Kunwald P, Drewes AM, Gregersen H. A new technique for evaluating sphincter function in visceral organs: application of the functional lumen imaging probe (FLIP) for the evaluation of the oesophago-gastric junction. Physiol Meas 2005; 26 (05) 823-836
    CrossrefPubMedSearch in Google Scholar
  • 4 Carlson DA, Kahrilas PJ, Lin Z. et al. Evaluation of esophageal motility utilizing the functional lumen imaging probe (FLIP). Am J Gastroenterol 2016; 111 (12) 1726-1735
    CrossrefPubMedSearch in Google Scholar
  • 5 Donnan EN, Pandolfino JE. EndoFLIP in the esophagus: assessing sphincter function, wall stiffness, and motility to guide treatment. Gastroenterol Clin North Am 2020; 49 (03) 427-435
    CrossrefPubMedSearch in Google Scholar
  • 6 Ghosh SK, Kahrilas PJ, Brasseur JG. Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study. Am J Physiol Gastrointest Liver Physiol 2008; 295 (05) G920-G933
    CrossrefPubMedSearch in Google Scholar
  • 7 Kwiatek MA, Pandolfino JE, Hirano I, Kahrilas PJ. Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc 2010; 72 (02) 272-278
    CrossrefPubMedSearch in Google Scholar
  • 8 Lottrup C, McMahon BP, Ejstrud P, Ostapiuk MA, Funch-Jensen P, Drewes AM. Esophagogastric junction distensibility in hiatus hernia. Dis Esophagus 2016; 29 (05) 463-471
    CrossrefPubMedSearch in Google Scholar
  • 9 Tucker E, Sweis R, Anggiansah A. et al. Measurement of esophago-gastric junction cross-sectional area and distensibility by an endoluminal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease. Neurogastroenterol Motil 2013; 25 (11) 904-910
    CrossrefPubMedSearch in Google Scholar
  • 10 Carlson DA, Kathpalia P, Craft J. et al. The relationship between esophageal acid exposure and the esophageal response to volumetric distention. Neurogastroenterol Motil 2018; 30 (03)
    CrossrefPubMedSearch in Google Scholar
  • 11 Carlson DA, Gyawali CP, Kahrilas PJ. et al. Esophageal motility classification can be established at the time of endoscopy: a study evaluating real-time functional luminal imaging probe panometry. Gastrointest Endosc 2019; 90 (06) 915-923.e1
    CrossrefPubMedSearch in Google Scholar
  • 12 Carlson DA, Kou W, Rooney KP. et al. Achalasia subtypes can be identified with functional luminal imaging probe (FLIP) panometry using a supervised machine learning process. Neurogastroenterol Motil 2021; 33 (03) e13932
    CrossrefPubMedSearch in Google Scholar
  • 13 Ponds FA, Bredenoord AJ, Kessing BF, Smout AJPM. Esophagogastric junction distensibility identifies achalasia subgroup with manometrically normal esophagogastric junction relaxation. Neurogastroenterol Motil 2017; 29 (01)
    CrossrefPubMedSearch in Google Scholar
  • 14 Triggs JR, Carlson DA, Beveridge C. et al. Upright integrated relaxation pressure facilitates characterization of esophagogastric junction outflow obstruction. Clin Gastroenterol Hepatol 2019; 17 (11) 2218-2226.e2
    CrossrefPubMedSearch in Google Scholar
  • 15 Yadlapati R, Kahrilas PJ, Fox MR. et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0© . Neurogastroenterol Motil 2021; 33 (01) e14058
    CrossrefPubMedSearch in Google Scholar
  • 16 Carlson DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. FLIP Panometry helps identify clinically relevant esophagogastric junction outflow obstruction per Chicago Classification v4.0. Am J Gastroenterol 2023; 118 (01) 77-86
    CrossrefPubMedSearch in Google Scholar
  • 17 Camilleri M, Sanders KM. Gastroparesis. Gastroenterology 2022; 162 (01) 68-87.e1
    CrossrefPubMedSearch in Google Scholar
  • 18 Ye Y, Jiang B, Manne S. et al. Epidemiology and outcomes of gastroparesis, as documented in general practice records, in the United Kingdom. Gut 2021; 70 (04) 644-653
    CrossrefPubMedSearch in Google Scholar
  • 19 Talley NJ, Locke III GR, Lahr BD. et al. Functional dyspepsia, delayed gastric emptying, and impaired quality of life. Gut 2006; 55 (07) 933-939
    CrossrefPubMedSearch in Google Scholar
  • 20 Parkman HP, Yates K, Hasler WL. et al; National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium. Clinical features of idiopathic gastroparesis vary with sex, body mass, symptom onset, delay in gastric emptying, and gastroparesis severity. Gastroenterology 2011; 140 (01) 101-115
    CrossrefPubMedSearch in Google Scholar
  • 21 Parkman HP, Wilson LA, Hasler WL. et al. Abdominal pain in patients with gastroparesis: associations with gastroparesis symptoms, etiology of gastroparesis, gastric emptying, somatization, and quality of life. Dig Dis Sci 2019; 64 (08) 2242-2255
    CrossrefPubMedSearch in Google Scholar
  • 22 Borges CMR, Secaf M, Troncon Lde A. Clinical features and severity of gastric emptying delay in Brazilian patients with gastroparesis. Arq Gastroenterol 2013; 50 (04) 270-276
    CrossrefPubMedSearch in Google Scholar
  • 23 Malik Z, Sankineni A, Parkman HP. Assessing pyloric sphincter pathophysiology using EndoFLIP in patients with gastroparesis. Neurogastroenterol Motil 2015; 27 (04) 524-531
    CrossrefPubMedSearch in Google Scholar
  • 24 Saadi M, Yu D, Malik Z, Parkman HP, Schey R. Pyloric sphincter characteristics using EndoFLIP® in gastroparesis. Rev Gastroenterol Mex (Engl Ed) 2018; 83 (04) 375-384
    PubMedSearch in Google Scholar
  • 25 Gourcerol G, Tissier F, Melchior C. et al. Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther 2015; 41 (04) 360-367
    CrossrefPubMedSearch in Google Scholar
  • 26 Jacques J, Pagnon L, Hure F. et al. Peroral endoscopic pyloromyotomy is efficacious and safe for refractory gastroparesis: prospective trial with assessment of pyloric function. Endoscopy 2019; 51 (01) 40-49
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Snape WJ, Lin MS, Agarwal N, Shaw RE. Evaluation of the pylorus with concurrent intraluminal pressure and EndoFLIP in patients with nausea and vomiting. Neurogastroenterol Motil 2016; 28 (05) 758-764
    CrossrefPubMedSearch in Google Scholar
  • 28 Jehangir A, Malik Z, Petrov RV, Parkman HP. EndoFLIP and pyloric dilation for gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty. Dig Dis Sci 2021; 66 (08) 2682-2690
    CrossrefPubMedSearch in Google Scholar
  • 29 Vosoughi K, Ichkhanian Y, Jacques J. et al. Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video). Gastrointest Endosc 2020; 91 (06) 1289-1299
    CrossrefPubMedSearch in Google Scholar
  • 30 Hofstetter WL, Peters JH, DeMeester TR. et al. Long-term outcome of antireflux surgery in patients with Barrett's esophagus. Ann Surg 2001; 234 (04) 532-538 , discussion 538–539
    CrossrefPubMedSearch in Google Scholar
  • 31 Oelschlager BK, Quiroga E, Parra JD, Cahill M, Polissar N, Pellegrini CA. Long-term outcomes after laparoscopic antireflux surgery. Am J Gastroenterol 2008; 103 (02) 280-287 , quiz 288
    CrossrefPubMedSearch in Google Scholar
  • 32 Frazzoni M, Piccoli M, Conigliaro R, Frazzoni L, Melotti G. Laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 2014; 20 (39) 14272-14279
    CrossrefPubMedSearch in Google Scholar
  • 33 Dallemagne B, Weerts J, Markiewicz S. et al. Clinical results of laparoscopic fundoplication at ten years after surgery. Surg Endosc 2006; 20 (01) 159-165
    CrossrefPubMedSearch in Google Scholar
  • 34 Walle KV, Funk LM, Xu Y. et al. Persistent dysphagia rate after antireflux surgery is similar for Nissen fundoplication and partial fundoplication. J Surg Res 2019; 235: 52-57
    CrossrefPubMedSearch in Google Scholar
  • 35 Salvador R, Vittori A, Capovilla G. et al. Antireflux surgery's lifespan: 20 years after laparoscopic fundoplication. J Gastrointest Surg 2023; 27 (11) 2325-2335
    CrossrefPubMedSearch in Google Scholar
  • 36 Li G, Jiang N, Chendaer N, Hao Y, Zhang W, Peng C. Laparoscopic Nissen versus Toupet fundoplication for short- and long-term treatment of gastroesophageal reflux disease: a meta-analysis and systematic review. Surg Innov 2023; 30 (06) 745-757
    CrossrefPubMedSearch in Google Scholar
  • 37 Omura N, Yano F, Tsuboi K. et al. Surgical results of laparoscopic Toupet fundoplication for gastroesophageal reflux disease with special reference to recurrence. Esophagus 2018; 15 (04) 217-223
    CrossrefPubMedSearch in Google Scholar
  • 38 Papasavas PK, Keenan RJ, Yeaney WW, Caushaj PF, Gagné DJ, Landreneau RJ. Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy. Surg Endosc 2003; 17 (08) 1200-1205
    CrossrefPubMedSearch in Google Scholar
  • 39 Turner B, Helm M, Hetzel E, Gould JC. Is that ‘floppy’ fundoplication tight enough?. Surg Endosc 2020; 34 (04) 1823-1828
    CrossrefPubMedSearch in Google Scholar
  • 40 Su B, Callahan ZM, Kuchta K. et al. Use of impedance planimetry (EndoFLIP) in foregut surgery practice: experience of more than 400 cases. J Am Coll Surg 2020; 231 (01) 160-171
    CrossrefPubMedSearch in Google Scholar
  • 41 Su B, Novak S, Callahan ZM, Kuchta K, Carbray J, Ujiki MB. Using impedance planimetry (EndoFLIP™) in the operating room to assess gastroesophageal junction distensibility and predict patient outcomes following fundoplication. Surg Endosc 2020; 34 (04) 1761-1768
    CrossrefPubMedSearch in Google Scholar
  • 42 Wu H, Attaar M, Wong HJ. et al. Impedance planimetry (EndoFLIP™) reveals changes in gastroesophageal junction compliance during fundoplication. Surg Endosc 2022; 36 (09) 6801-6808
    CrossrefPubMedSearch in Google Scholar
  • 43 Shah A, Nguyen DT, Meisenbach LM. et al. A novel EndoFLIP marker during hiatal hernia repair is associated with short-term postoperative dysphagia. Surg Endosc 2022; 36 (07) 4764-4770
    CrossrefPubMedSearch in Google Scholar
  • 44 Nwokedi U, Nguyen DT, Meisenbach LM. et al. Short-term outcome of routine use of EndoFLIP during hiatal hernia repair. Surg Endosc 2021; 35 (07) 3840-3849
    CrossrefPubMedSearch in Google Scholar
  • 45 Wu H, Attaar M, Wong HJ. et al. Impedance planimetry (EndoFLIP™) after magnetic sphincter augmentation (LINX®) compared to fundoplication. Surg Endosc 2022; 36 (10) 7709-7716
    CrossrefPubMedSearch in Google Scholar
  • 46 Perretta S, Dallemagne B, McMahon B, D'Agostino J, Marescaux J. Video. Improving functional esophageal surgery with a “smart” bougie: EndoFLIP. Surg Endosc 2011; 25 (09) 3109
    CrossrefPubMedSearch in Google Scholar
  • 47 Alkhatib H, Haas AJ, Kara AM. et al. Tailoring the wrap: intraoperative functional lumen imaging probe (FLIP) during hiatal hernia repair. Surg Endosc 2024; 38 (06) 3425-3432
    CrossrefPubMedSearch in Google Scholar
  • 48 Su B, Dunst C, Gould J. et al. Experience-based expert consensus on the intra-operative usage of the EndoFLIP impedance planimetry system. Surg Endosc 2021; 35 (06) 2731-2742
    CrossrefPubMedSearch in Google Scholar
  • 49 Carlson DA, Kahrilas PJ, Ritter K, Lin Z, Pandolfino JE. Mechanisms of repetitive retrograde contractions in response to sustained esophageal distension: a study evaluating patients with postfundoplication dysphagia. Am J Physiol Gastrointest Liver Physiol 2018; 314 (03) G334-G340
    CrossrefPubMedSearch in Google Scholar
  • 50 Samo S, Mulki R, Godiers ML. et al. Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia. Surg Endosc 2021; 35 (08) 4418-4426
    CrossrefPubMedSearch in Google Scholar
  • 51 Su B, Callahan ZM, Novak S, Kuchta K, Ujiki MB. Using impedance planimetry (EndoFLIP) to evaluate myotomy and predict outcomes after surgery for achalasia. J Gastrointest Surg 2020; 24 (04) 964-971
    CrossrefPubMedSearch in Google Scholar
  • 52 DeHaan RK, Frelich MJ, Gould JC. Intraoperative assessment of esophagogastric junction distensibility during laparoscopic Heller myotomy. Surg Laparosc Endosc Percutan Tech 2016; 26 (02) 137-140
    CrossrefPubMedSearch in Google Scholar
  • 53 Ilczyszyn A, Hamaoui K, Cartwright J, Botha A. Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome. Dis Esophagus 2016; 29 (05) 455-462
    CrossrefPubMedSearch in Google Scholar
  • 54 Jain AS, Carlson DA, Triggs J. et al. Esophagogastric junction distensibility on functional lumen imaging probe topography predicts treatment response in achalasia-anatomy matters!. Am J Gastroenterol 2019; 114 (09) 1455-1463
    CrossrefPubMedSearch in Google Scholar
  • 55 Knight W, Kandiah K, Vrakopoulou Z. et al. Early outcomes following EndoFLIP-tailored peroral endoscopic myotomy (POEM): the establishment of POEM services in two UK centers. Dis Esophagus 2023; 36 (08) doac110
    CrossrefPubMedSearch in Google Scholar
  • 56 Familiari P, Gigante G, Marchese M. et al. EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy. United European Gastroenterol J 2014; 2 (02) 77-83
    CrossrefPubMedSearch in Google Scholar
  • 57 Amundson JR, Wu H, VanDruff V. et al. Esophagogastric junction compliance on impedance planimetry (EndoFLIP™) following peroral endoscopic myotomy (POEM) predicts improvement in postoperative Eckardt score. Surg Endosc 2023; 37 (02) 1493-1500
    CrossrefPubMedSearch in Google Scholar
  • 58 Attaar M, Wong HJ, Wu H. et al. Changes in impedance planimetry (EndoFLIP) measurements at follow-up after peroral endoscopic myotomy (POEM). Surg Endosc 2022; 36 (12) 9410-9415
    CrossrefPubMedSearch in Google Scholar
  • 59 Attaar M, Su B, Wong HJ. et al. Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM). Surg Endosc 2021; 35 (08) 4555-4562
    CrossrefPubMedSearch in Google Scholar
  • 60 Law YY, Nguyen DT, Meisenbach LM. et al. Intraoperative diagnosis and treatment of achalasia using EndoFLIP during Heller myotomy and Dor fundoplication. Surg Endosc 2022; 36 (04) 2365-2372
    CrossrefPubMedSearch in Google Scholar
  • 61 Teitelbaum EN, Soper NJ, Pandolfino JE. et al. Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes. Surg Endosc 2015; 29 (03) 522-528
    CrossrefPubMedSearch in Google Scholar
  • 62 Ngamruengphong S, von Rahden BHA, Filser J. et al. Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study. Surg Endosc 2016; 30 (07) 2886-2894
    CrossrefPubMedSearch in Google Scholar
  • 63 Holmstrom AL, Campagna RJ, Carlson DA. et al. Comparison of preoperative, intraoperative, and follow-up functional luminal imaging probe measurements in patients undergoing myotomy for achalasia. Gastrointest Endosc 2021; 94 (03) 509-514
    CrossrefPubMedSearch in Google Scholar
  • 64 Verga MC, Mazza S, Azzolini F. et al. Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach. World J Gastrointest Surg 2022; 14 (01) 12-23
    CrossrefPubMedSearch in Google Scholar
  • 65 Khashab MA, Stein E, Clarke JO. et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc 2013; 78 (05) 764-768
    CrossrefPubMedSearch in Google Scholar
  • 66 Kahaleh M, Gonzalez JM, Xu MM. et al. Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a multicenter international experience. Endoscopy 2018; 50 (11) 1053-1058
    Thieme ConnectPubMedSearch in Google Scholar
  • 67 Mekaroonkamol P, Shah R, Cai Q. Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide. World J Gastroenterol 2019; 25 (08) 909-922
    CrossrefPubMedSearch in Google Scholar
  • 68 Podboy A, Hwang JH, Nguyen LA. et al. Gastric per-oral endoscopic myotomy: current status and future directions. World J Gastroenterol 2019; 25 (21) 2581-2590
    CrossrefPubMedSearch in Google Scholar
  • 69 Xu J, Chen T, Elkholy S. et al. Gastric peroral endoscopic myotomy (G-POEM) as a treatment for refractory gastroparesis: long-term outcomes. Can J Gastroenterol Hepatol 2018; 2018: 6409698
    PubMedSearch in Google Scholar
  • 70 Malik Z, Kataria R, Modayil R. et al. Gastric per oral endoscopic myotomy (G-POEM) for the treatment of refractory gastroparesis: early experience. Dig Dis Sci 2018; 63 (09) 2405-2412
    CrossrefPubMedSearch in Google Scholar
  • 71 Strong AT, Landreneau JP, Cline M. et al. Per-oral pyloromyotomy (POP) for medically refractory post-surgical gastroparesis. J Gastrointest Surg 2019; 23 (06) 1095-1103
    CrossrefPubMedSearch in Google Scholar
  • 72 Spadaccini M, Maselli R, Chandrasekar VT. et al. Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis. Gastrointest Endosc 2020; 91 (04) 746-752.e5
    CrossrefPubMedSearch in Google Scholar
  • 73 Fathalizadeh A, Klingler M, Landreneau J. et al. Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop). Surg Endosc 2022; 36 (01) 745-752
    CrossrefPubMedSearch in Google Scholar
  • 74 Hedberg HM, Carbray J, Ujiki MB. Initial experience with endoscopic pyloromyotomy, with description and video of technique. J Gastrointest Surg 2019; 23 (08) 1706-1710
    CrossrefPubMedSearch in Google Scholar