Amy L Holmstrom, MD, Ryan A Campagna, MD, Dustin A Carlson, MD, John E Pandolfino, MD, Ezra N Teitelbaum, MD, MEd, Eric S Hungness, MD. Northwestern Memorial Hospital
Background: Esophagogastric junction distensibility index (EGJ-DI), measured using the functional lumen imaging probe (FLIP), has been shown to be associated with symptomatic outcomes after interventions for achalasia. The objective of this study was to determine if the intra-operative use of FLIP was associated with improved outcomes following per oral esophageal myotomy (POEM) for achalasia.
Methods: A retrospective cohort study of patients undergoing POEM from 2012-2017 was performed using a prospectively maintained database. Use of intra-operative FLIP was based solely on catheter and technician availability, resulting in two natural patient cohorts. Patients otherwise underwent identical workup, procedural technique, and follow-up. Post-operative Eckardt symptom scores (ES) at 12 months and post-operative physiologic studies (timed barium esophagram [TBE], endoscopic evaluation for esophagitis based on LA classification, and manometric integrated relaxation pressure [IRP]) were compared between those with and without intra-operative FLIP. Operative video recordings were reviewed to determine when initial post-myotomy FLIP measurements led to the performance of additional myotomy. Associations were assessed using Mann-Whitney U and chi-square tests as appropriate.
Results: Overall, 178 patients were included in the analysis (81 with intra-operative FLIP and 97 without FLIP). Clinical outcomes at 12-months were available for 147 patients (83%; 61 FLIP, 86 no FLIP) and 137 patients (77%; 55 FLIP, 82 no FLIP) had at least one post-operative physiologic study. After POEM, the FLIP cohort had significantly fewer clinical failures (defined as ES>3) at 12 months post-operatively (6.6% vs. 19.8% without FLIP, p<0.05). There were no significant differences between the FLIP and no FLIP groups in post-operative TBE column height at 5 minutes (median 3.4cm, IQR 0-6cm vs. median 3.0cm, IQR 0-6.2cm, respectively; p=0.856), esophagitis on post-operative endoscopy (23.1% Grade B or higher vs. 29.4%, respectively; p=0.478), or manometric IRP (median 11mmHg, IQR 7-15mmHg vs. median 11mmHg, IQR 9-14, respectively; p=0.697). Video recordings were available for 78% of the FLIP cohort. Review of these operative recordings revealed that 65% of patients who underwent FLIP had additional myotomy performed following the initial post-myotomy FLIP measurement due to inadequate improvement in EGJ-DI.
Conclusions: This is the first study comparing outcomes of patients who did and did not undergo intra-operative FLIP during POEM. FLIP usage resulted in the surgeon performing additional myotomy in over half of cases and was associated with improved clinical outcomes. This study demonstrates the potential for a FLIP-tailored myotomy to improve outcomes in patients undergoing surgical myotomy for achalasia.
This abstract was accepted for Podium presentation at the 2020 SAGES Virtual Meeting in the Foregut topic. Its program number was: S098 and its Abstract ID was: 101341