Role of Functional Luminal Imaging Probe (FLIP) in the Management of post Myotomy Clinical Failure

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Gastrointestinal endoscopy


INTRODUCTION: Small percentage of patients with esophageal dysmotility disorders (EDD) fail to improve or relapse following management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying the patients who might benefit from LES-directed re-treatment.

METHODS: This was a retrospective study at 6 tertiary care centers (4 USA, 1 Europe, 1 Asia) between 01/2015 and 04/2021 involving patients with prior failed myotomy. The primary outcome was the impact of FLIP utilization on the management of patients with prior failed myotomy.

RESULTS: A total of 123 patients [F 62 (50%), mean age 53±21.1 years] who underwent LHM (n=53, 43%) or POEM (n=70, 57%) for the management of achalasia, (n=98) or other EDD (n=25) had clinical failure at a median time of 10.8 (IQR: 0.8-17.3) months post-procedure. A total of 29 patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) > 15mmHg on HRM and distensibility index (DI) < 2.8 mm(2)/mmHg on FLIP, with ultimate change in management noted in 15 patients (10 directed towards conservative management, 5 directed towards LES directed re-treatment). The impact of FLIP on both the diagnosis and management was noted in 15/29 (52%) patients. In the subgroup analysis of patients who underwent LES-directed re-treatment (n=44), clinical success was highest among patients with both abnormal IRP and DI, 21/25 (84%) vs. patients with only abnormal IRP, 8/14 (57%), or only abnormal DI, 3/5 (60%), (p=0.04), with DI at 40 ml distension volume on FLIP identified as an independent predictor of clinical success, (OR 1.51; 95% CI 1.02-2.1, p=0.03).

CONCLUSION: The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure post myotomy.

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ePub ahead of print