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Background <p>Achalasia is a debilitating esophageal motility disorder characterized by absent peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Myotomy procedures—primarily peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM)—aim to reduce LES pressure and alleviate dysphagia. The functional lumen imaging probe (FLIP) measures real-time changes in esophagogastric junction (EGJ) compliance and distensibility during myotomy. We conducted a systematic review and meta-analysis of peer-reviewed literature on the use of preprocedural and intraprocedural FLIP in guiding myotomy adequacy and their impact on clinical outcomes.</p> Methods <p>We conducted a systematic review and meta-analysis adhering to PRISMA and Cochrane guidelines. Literature searches (PubMed, Scopus, Cochrane CENTRAL, Web of Science, Google Scholar) were performed through December 2023. We included studies (<i>N</i> = 21) assessing FLIP use in achalasia patients undergoing POEM or LHM. Primary outcomes included FLIP measures (distensibility index [DI], cross-sectional area [CSA], diameter [Dmin]) and clinical outcomes (Eckardt score improvement, reflux esophagitis).</p> Results <p>A total of 1455 patients were analyzed (mean age 52.3&#xa0;years; 52.8% male). Both POEM and LHM led to significant increases in DI, CSA, and Dmin at 40&#xa0;mL FLIP distension (mean differences of 4.69, 100.35, and 4.90, respectively; <i>p</i> &lt; 0.001). Eckardt scores significantly decreased after myotomy (MD = −&#xa0;5.40; 95% CI −&#xa0;5.91 to −&#xa0;4.88), with POEM yielding a larger reduction than LHM (<i>p</i> = 0.03). Reflux esophagitis occurred in 28% of patients overall—31% following POEM versus 11% following LHM. Intraoperative FLIP was associated with lower esophagitis rates compared to preoperative FLIP use (26% vs. 46%, <i>p</i> &lt; 0.05).</p> Conclusions <p>FLIP-guided myotomy improves objective EGJ distensibility metrics and aligns with enhanced symptom relief in achalasia. POEM offers greater Eckardt score reductions but carries a higher risk of reflux esophagitis than LHM. Future prospective studies should standardize FLIP protocols, define optimal DI cutoffs, and assess long-term outcomes to further refine achalasia management.</p>

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FLIP use in achalasia: comparing POEM and Heller myotomy outcomes: a systematic review and meta-analysis

  • 期刊论文

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  • 发表日期：

    2025年5月21日

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  • Mohammad Alabbas,
  • Hamza Khoudari,
  • Gaurav Ghosh,
  • Omar T. Sims,
  • David Wan

摘要

Background

Achalasia is a debilitating esophageal motility disorder characterized by absent peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Myotomy procedures—primarily peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM)—aim to reduce LES pressure and alleviate dysphagia. The functional lumen imaging probe (FLIP) measures real-time changes in esophagogastric junction (EGJ) compliance and distensibility during myotomy. We conducted a systematic review and meta-analysis of peer-reviewed literature on the use of preprocedural and intraprocedural FLIP in guiding myotomy adequacy and their impact on clinical outcomes.

Methods

We conducted a systematic review and meta-analysis adhering to PRISMA and Cochrane guidelines. Literature searches (PubMed, Scopus, Cochrane CENTRAL, Web of Science, Google Scholar) were performed through December 2023. We included studies (N = 21) assessing FLIP use in achalasia patients undergoing POEM or LHM. Primary outcomes included FLIP measures (distensibility index [DI], cross-sectional area [CSA], diameter [Dmin]) and clinical outcomes (Eckardt score improvement, reflux esophagitis).

Results

A total of 1455 patients were analyzed (mean age 52.3 years; 52.8% male). Both POEM and LHM led to significant increases in DI, CSA, and Dmin at 40 mL FLIP distension (mean differences of 4.69, 100.35, and 4.90, respectively; p < 0.001). Eckardt scores significantly decreased after myotomy (MD = − 5.40; 95% CI − 5.91 to − 4.88), with POEM yielding a larger reduction than LHM (p = 0.03). Reflux esophagitis occurred in 28% of patients overall—31% following POEM versus 11% following LHM. Intraoperative FLIP was associated with lower esophagitis rates compared to preoperative FLIP use (26% vs. 46%, p < 0.05).

Conclusions

FLIP-guided myotomy improves objective EGJ distensibility metrics and aligns with enhanced symptom relief in achalasia. POEM offers greater Eckardt score reductions but carries a higher risk of reflux esophagitis than LHM. Future prospective studies should standardize FLIP protocols, define optimal DI cutoffs, and assess long-term outcomes to further refine achalasia management.