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

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.

© 2025. The Author(s).