EndoFLIP Correlates with Postoperative Dysphagia and Reflux after Fundoplication

Yalini Vigneswaran, MD1, Matthew Gitelis2, Lava Patel, MD2, Brittany Lapin, MPH2, Joann Carbray2, Michael B Ujiki, MD2. 1University of Chicago, 2NorthShore University HealthSystem

Introduction:  FLIP is being more commonly used intraoperatively to adequately evaluate the GEJ as a smart bougie. However it is unclear how these measurements correlate with postoperative function, symptoms and patient related outcomes.

 Methods:  After 2011 a prospective cohort study of patients presenting to a single surgeon for surgical treatment of gastroesophageal junction pathology were evaluated intraoperatively with the FLIP device.  These patients included achalasia, GERD and paraesophageal hernias. Beginning in 2011 diameter was measured pre and postoperatively and in 2014 distensibility was also recorded.  All patients were evaluated pre and postoperatively with health related outcome scores. Based on postoperative 3 week health reported outcomes patients were designated as clinical success or clinical faliures. Clinical success was classified as Eckardt equal to zero, RSI ≤15, Dysphagia Score ≤2 or GERD ≤10. Differences were analyzed using paired t-test, Mann-Whitney U test, and ANOVA.

Results:  Preoperative mean FLIP diameters were significantly different between pathologies (p<0.02): achalasia (6.18 mm+/- 1.73, n=30) and GERD/paraesophageal hernia (9.63+/-6.06,  n=36 ). Distensibility was also significantly different: achalasia (1.25mm2/mmHg +/- 1.0, n=20) and GERD/paraesophageal hernia (4.29 +/-8.29, n=31). Diameter and distensibility improved after treatment in all cohorts.

Postoperatively, GERD and paraesophageal hernia repairs that had significant dysphagia (Dysphagia score >2, n=12) were 3.0 times more likely to have an intraoperative pressure >30mmHg and always had a diameter <10mm (p<0.05). Distensibility measured after treatment did not seem to correlate to symptoms. One patient who required dilation postoperatively due to significant dysphagia had an intraoperative diameter 8.6mm and pressure 34 mmHg.  One third of patients that had significant reflux (RSI>15)  had a pressure <20mmHg as compared to 0% of patients who did not have significant symptoms. Significant dysphagia after myotomy for achalasia (n=8) did not seem to correlate with intraopertive measurements. However achalasia patients with significant GERD postoperatively were 5.7 times more likely to have diameter >10mm (p=0.02).  Other measurements did not appear to correlate with symptoms.

Conclusion:  The FLIP device may have a role in helping make intraoperative decisions to avoid poor health related outcomes postoperatively. Patients with significant postoperative symptoms of dysphagia or reflux were more likely to have specific geometery as  measured by FLIP at the time of the procedure. Larger population studies are necessary to clearly define the goal measurements required before leaving the operating room for good clinical outcomes in these patients.

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