Using impedance planimetry (EndoFLIP™) in the operating room to assess gastroesophageal junction distensibility and predict patient outcomes following fundoplication

Introduction The purpose of this study is to evaluate the utility of using a functional lumen imaging probe (EndoFLIP™) intra-operatively during hiatal hernia repair and fundoplication. Additionally, we hypothesize that these measurements correlate with long-term outcomes. Methods A prospectively maintained quality database was queried. Between 2013 and 2018, 175 patients underwent laparoscopic fundoplication, the majority of which also had a hiatal hernia repair. The EndoFLIP™ was used to measure minimum diameter ( D min ), balloon pressure, and distensibility index (DI) at different timepoints throughout the operation. Clinical outcomes were measured up to 2 years after treatment. Results Crural closure and fundoplication resulted in a significant increase in balloon pressure and decrease in DI when compared to initial measurements as well as measurements taken after hernia reduction. After 1 year, patients with a final DI < 2.0 mm 2 /mmHg reported significantly more gas bloat and dysphagia than those with a final DI ≥ 2.0 mm 2 /mmHg ( p = 0.040 and p = 0.025, respectively). This disparity became even more dramatic at 2 years ( p = 0.006 and p = 0.004, respectively), with a final DI < 2.0 mm 2 /mmHg being significantly associated with higher prevalence of daily gas bloat (43.8% vs. 12.0%; p = 0.03). Additionally, patients with a final DI between 2.0 and 3.5 mm 2 /mmHg reported significantly lower Reflux Symptom Index scores at one year compared to those with a final DI < 2.0 or > 3.5 mm 2 /mmHg ( p = 0.042). Conclusion EndoFLIP™ measurements correlate well with patient outcomes, with a final DI between 2 and 3.5 mm 2 /mmHg potentially being ideal. The EndoFLIP™ can be a useful adjunct in the operating room by providing objective measurements of esophageal distensibility after crural closure and fundoplication.