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FLIP useful in achalasia, EoE; more research needed in GERD
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An AGA clinical practice update on the functional lumen imaging probe advised that the technology appears useful in the evaluation of achalasia and in severity assessment and treatment monitoring in eosinophilic esophagitis.
Conversely, the document indicates that current evidence is insufficient to support the role of the functional lumen imaging probe (FLIP; Crospon) in the routine management of GERD, although it “may be a useful tool to aid antireflux procedures,” such as fundoplication.
The FLIP is cleared by the FDA for clinical use with the EndoFLIP system to measure pressure and dimensions in the esophagus, pylorus and anal sphincters, as an adjunct to other diagnostics for GI motility disorders. It can also be used to guide bariatric and esophageal procedures.
John E. Pandolfino
“Although it has been commercially available since 2009 [FLIP] has had limited penetrance into clinical settings outside of specialized centers ... primarily because of a paucity of data supporting its utility in general practice and a lack of standardized protocols and data analysis methodology,” John E. Pandolfino, MD, of the department of medicine, division of gastroenterology and hepatology at Northwestern University Feinberg School of Medicine in Chicago, and colleagues wrote. “However, data are accumulating that are providing guidance regarding emerging applications in the evaluation and management of foregut disorders.”
In their expert review, Pandolfino and colleagues offered five best practice statements regarding the use of FLIP:
- Diagnosis or treatment decisions should not be based on FLIP assessment alone;
- FLIP should be used as an adjunct for evaluating the dynamics of the esophagogastric junction (EGJ) opening and the stiffness of the esophageal wall;
- Specific protocols and analysis paradigms should be followed for FLIP use based on the given disease state;
- FLIP should not be used for routine diagnostic assessment in GERD; and
- FLIP should not be used to diagnose EoE but may have a role in evaluating disease severity and treatment outcomes.
Pandolfino and colleagues noted that the strongest evidence for FLIP is focused on the management of achalasia, and concluded the device seems well suited for evaluation of these patients.
“A hallmark of achalasia is lower esophageal sphincter (LES) dysfunction and achalasia treatments target the resultant EGJ outflow obstruction,” they wrote, and therefore recommended FLIP “should be used to provide additive information beyond manometry in the management of achalasia.”
Further, while FLIP appears “uniquely suited” for evaluating the esophageal wall’s mechanical properties in EoE, available evidence and analysis paradigms are limited. “Thus, one could consider performing FLIP in routine clinical management of EoE if the analysis expertise is available,” they wrote.
Finally, they recommended that more outcomes data are needed to confirm the utility of FLIP in GERD management, but noted that it may be a useful aid in antireflux procedures, as “patients with fundoplication seem to have reduced EGJ distensibility compared with control subjects,” and several studies have demonstrated its feasibility in this setting.
Further research is needed “on optimizing data analysis, standardizing protocols, and defining outcome metrics before the widespread adoption into general clinical practice,” they concluded.
“Developments on further analysis and reporting modules are in progress,” John O’Dea, CEO and founder of Crospon, said in a press release. “The introduction of real-time FLIP topography and analytics of maximal esophageal diameter in future software updates along with additions to our EndoFLIP product line later this year will address a number of these issues.” – by Adam Leitenberger
Disclosures: Pandolfino reports ties to Medtronic and Sandhill Scientific. O’Dea is employed by Crospon.
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