S0358 Role of Endoscopic Functional Luminal Imaging Probe (EndoFLIP) for the Management of Post Myotomy Clinical Failure

Abstract

INTRODUCTION: Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller myotomy (LHM) have evolved as effective management tools in relieving lower esophageal sphincter (LES) pressure in patients with esophageal motility disorders. However, a small percentage of patients fail to improve or relapse after time. The challenge remains in identifying the patients who might benefit from repeat myotomy as opposed to conservative managements. In the following study, we describe the role of endolumenal functional lumen imaging probe (EndoFLIP), in addition to high-resolution manometry (HRM), for managing such patients. METHODS: This was a multicenter, international retrospective study conducted between January 2015 and October 2019. Patients with a diagnosis of achalasia, esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), or jackhammer esophagus (JE) who underwent a prior failed myotomy were included. Clinical success of post repeat myotomy in the form of POEM was considered the primary outcome. RESULTS: A total of 72 patients [Female = 28 (39%), mean age 55 ± 17.3] with clinical failure and Eckardt score (ES) > 3 who underwent post LHM (33) or POEM (39) were included. On HRM evaluation, 27 were deemed candidates for repeat myotomy based on abnormal integrated relaxation pressure (IRP) measurements >15mmHg. On EndoFLIP evaluation,13/27 had an abnormal distensibility index (DI) < 2.8 mm2/mmHg at 40 ml balloon volume distension (Figure 1). A total of 30 patients underwent conservative management - pneumatic balloon dilation (n = 9) and repeat myotomy (n = 33) (Table 1). Post repeat myotomy mean ES improved from 5.8 ± 2.7 to 1.1 ± 1.4, (P < 0.001), and median DS improved from 2 (IQR: 1-3) to 1 (0-2), (P = 0.03), at a median follow-up time of 2 (IQR: 0-4.5) months post-procedure. Clinical success was achieved in 23/33 (70%) of the patients (Table 2). DI at 40 m balloon distension volume (P = 0.01; odds ratio, 1.51; 95% confidence interval, 1.02-2.1) was identified to be the best independent predictors of clinical success post repeat myotomy, with DI < 3.3 mm2/mmHg having sensitivity and specificity of 64% and 80%, respectively, for predicting clinical success. Therefore, the theoretical impact of EndoFLIP utilization for the management and diagnosis was in 16/72 (22%). CONCLUSION: The findings of this study demonstrate the important role of using EndoFLIP, in addition to HRM, in evaluating patients with clinical failure post myotomy.Figure 1Table 1Table 2