Real-time Intraoperative Utilization of Endoscopic FLIP for Tailored Laparoscopic Fundoplication: First Case Report from India

The Endoluminal Functional Lumen Imaging Probe (EndoFLIP) is an emerging diagnostic modality that measures esophageal luminal dimensions and pressure using impedance planimetry, offering quantitative insights into esophagogastric junction (EGJ) distensibility in real time intraoperatively when a surgical or endoscopic therapeutic procedure in on going. While predominantly utilized in the evaluation of achalasia and dysphagia, its intraoperative application in antireflux surgery remains underexplored, particularly in Indian context. It is being used for intraoperative tailoring of myotomy and fundoplication. We present the case of a 58-year-old woman with a history of Nissen fundoplication in 2021, who presented with retrosternal discomfort, postprandial regurgitation, and belching. Upper GI endoscopy revealed distal esophagitis (Los Angeles Grade II) and a lax lower esophageal sphincter, with wrap migration. CT imaging confirmed a herniated fundoplication wrap above the diaphragm. The patient underwent a redo laparoscopic fundoplication with intraoperative EndoFLIP guidance. Baseline EGJ distensibility index (DI) was 9.2 mm²/mmHg with a diameter of 19.1 mm. Following crural dissection and hernia reduction, DI increased to 9.9 mm²/mmHg, further it declined to 6.3 mm²/mmHg after crural closure, and finally to 3.2 mm²/mmHg post-completion of the 360-degree wrap, with concurrent increases in intraluminal pressure. This case illustrated the utility of EndoFLIP in real-time assessment and tailoring of surgical repair, potentially minimizing postoperative complications such as dysphagia. To our knowledge, this is the first reported case in India utilizing intraoperative EndoFLIP for laparoscopic fundoplication, that too in redo fundoplication case, highlighting its potential to enhance surgical precision and tailor the management of Gastroesophageal Reflux Diseases.