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Intraoperative diagnosis and treatment of Achalasia using EndoFLIP during Heller Myotomy and Dor fundoplication

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Abstract

Background

Manometry is the gold standard diagnostic test for achalasia. However, there are incidences where manometry cannot be obtained preoperatively, or the results of manometry is inconsistent with the patient's symptomatology. We aim to determine if intraoperative use of EndoFLIP can provide a diagnosis of achalasia and provide objective information during Heller myotomy and Dor fundoplication.

Methods

To determine the intraoperative diagnostic EndoFLIP values for patients with achalasia, we determined the optimal cut-off points of the distensibility index (DI) between patients with a diagnosis of achalasia and patients with a diagnosis of hiatal hernia. To evaluate the usefulness of EndoFLIP values during Heller myotomy and Dor fundoplication, we obtained a cohort of patients with EndoFLIP values obtained after Heller myotomy and after Dor fundoplication as well as Eckardt score before and after surgery.

Results

Our analysis of 169 patients (133 hiatal hernia and 36 achalasia) showed that patients with DI < 0.8 have a >99% probability of having achalasia, while DI > 2.3 have a >99% probability of having hiatal hernia. Patients with a DI 0.8–1.3 have a 95% probability of having achalasia, and patients with a DI of 1.4–2.2 have a 94% probability of having a hiatal hernia. There were 40 patients in the cohort to determine objective data during Heller myotomy and Dor fundoplication. The DI increased from a median of 0.7 to 3.2 after myotomy and decreased to 2.2 after Dor fundoplication (p < 0.001). The median Eckardt score went down from a median of 4.5 to 0 (p < 0.001).

Conclusions

Our study shows that intraoperative use of EndoFLIP can facilitate the diagnosis of achalasia and is used as an adjunct to diagnose achalasia when symptoms are inconsistent. The routine use of EndoFLIP during Heller myotomy and Dor fundoplication provides objective data during the operation in a group of patients with excellent short-term outcomes.

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Authors and Affiliations

  1. Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA

    Yi Ying Law, Leonora M. Meisenbach, Ray K. Chihara, Edward Y. Chan & Min P. Kim

  2. Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA

    Ray K. Chihara, Edward Y. Chan & Min P. Kim

  3. Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA

    Duc T. Nguyen & Edward A. Graviss

  4. Department of Surgery, Houston Methodist Hospital, Houston, TX, USA

    Edward A. Graviss

Authors
  1. Yi Ying Law
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  2. Duc T. Nguyen
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  3. Leonora M. Meisenbach
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  4. Ray K. Chihara
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  5. Edward Y. Chan
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  6. Edward A. Graviss
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  7. Min P. Kim
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Correspondence to Min P. Kim.

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Disclosure

Min P Kim is a consultant for Veran, Intuitive Surgical, and Medtronic. Edward Chan is a consultant for Veran. Yi Ying Law, Duc T. Nguyen, Leonora M. Meisenbach, Ray Chihara, and Edward A. Graviss do not have any conflicts of interest.

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Law, Y.Y., Nguyen, D.T., Meisenbach, L.M. et al. Intraoperative diagnosis and treatment of Achalasia using EndoFLIP during Heller Myotomy and Dor fundoplication. Surg Endosc 36, 2365–2372 (2022). https://doi.org/10.1007/s00464-021-08517-8

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  • DOI: https://doi.org/10.1007/s00464-021-08517-8

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