Tailored Fundoplication for GERD With Impedance Planimetry (EndoFLIP™)

Introduction: Impedance planimetry with the endoluminal functional lumen imaging probe (FLIP) has been used to measure the gastroesophageal junction (GEJ) tightness, the distensibility index (DI), during anti-reflux surgery. We describe our institutional experience of a tailored fundoplication algorithm utilizing FLIP to select whether patients should have Laparoscopic Nissen Fundoplication (LNF) or Toupet Fundoplication (LTF) for treatment of gastroesophageal reflux disease (GERD). Methods and procedures: A prospectively maintained quality database was queried. Patients who underwent laparoscopic fundoplication for GERD from 2008 to June 2021 were analyzed. Multiple patient factors and intraoperative FLIP measurements were used to guide decision making from 2017 to 2021. Outcomes included quality of life surveys, Reflux Symptom Index, Gastroesophageal Reflux Disease-Health Related Quality of Life (GERDHRQL), and Dysphagia score. Results: A total of 357 patients were reviewed, 2008-December 2016 (N = 248, 81% LNF) and January 2017 to June 2021 (N = 109, 32% LNF). In the FLIP group, LNF patients had a larger DI compared to LTF patients, 6.5 ± 2.4 mm2/mmHg at hernia reduction ( P < .01). Upon 2-year follow-up, FLIP patients reported lower gas-bloat scores, 0.9 ± 1.1 versus 1.8 ± 1.4 in non-FLIP patients ( P < .01). Patients with normal esophageal motility in the FLIP group had less gas-bloat syndrome than the non-FLIP group (0.9 ± 1.1 vs 1.9 ± 1.4, P < .01). Conclusions: Incorporating FLIP into a tailored fundoplication algorithm led to less gas bloat. Careful selection of which patients can tolerate a Nissen fundoplication may optimize outcomes. Continued exploration with intraoperative impedance planimetry can impact the postoperative quality of life after anti-reflux surgery.