Endoflip for Heartburn Treatment: Tailoring the Fundoplication
Proper acid reflux testing is a crucial element of any successful heartburn and GERD management program. Endoflip, functional luminal imaging probe, is a relatively new testing modality that is finding its way into clinical practice. Endoflip uses an inflated balloon that is positioned within the esophageal lumen during upper endoscopy. Balloon is then inflated mimicking a food bolus. Intraluminal pressure and the corresponding cross-sectional area are then calculated to generate a compliance index. Traditional tests like high resolution esophageal manometry and barium contrast swallow do not assess esophageal wall compliance. Manometry measures esophageal peristalsis, contractile and lower esophagus sphincter pressure using a thin pressure catheter. UGI contrast study can detect esophageal strictures and diverticula as well as bolus clearance. Wall compliance, however, requires concomitant pressure and radius measurement to generate a compliance index.
A compliance index measurement is particularly useful in dysphagia patients with normal contrast study and esophageal manometry. Achalasia patients with recurrent dysphagia after Heller myotomy or acid reflux patients with persistent dysphagia after loose and floppy Nissen fundoplication are best evaluated with Endoflip. LINX patients suffer from high rates of post-operative dysphagia and may benefit from intra-operative Endoflip measurement to determine magnet ring size. I don’t see a role for intra-operative Endoflip to size hiatal hernia repair and Nissen fundoplication at Houston Heartburn and Reflux Center for a number of reasons. First, our post-operative dysphagia rate is very low. Second, we perform a loose, and floppy Nissen fundoplication. Third, we avoid overtightening the hiatal opening to avoid esophageal angulation and narrowing. I also avoid closing the anterior aspect of the hiatus unless the gap is quite large. Consequently, Endoflip is not likely to improve intra-operative technique or anti-reflux surgery outcome at Houston Heartburn and Reflux Center.