Development of expert consensus protocols for diagnostic and procedural use of the EndoFLIP system

The EndoFLIP system is currently the only available impedance planimetry system, providing real-time, detailed information on the diameter, luminal area, distensibility, and compliance of the esophagogastric junction (EGJ), along with its 2D representation. EndoFLIP can support diagnosis and provide physiological feedback to potentially guide interventions for structural and functional gastroesophageal disorders. However, the lack of standardized usage protocols complicates the interpretation and comparability of results. This paper aims to establish a consensus on protocols to standardize the use of the EndoFLIP system in both diagnostic and intraoperative settings, so as to ensure consistent application across varied clinical and scientific settings.

A multidisciplinary European Advisory Board (AB) comprising eight gastroenterologists and surgeons with extensive experience in EndoFLIP use undertook a structured international expert consensus process. Following a systematic literature review and a face-to-face expert meeting, candidate statements were developed and independently rated using an electronic survey. Consensus was predefined as ≥ 75% agreement ('agree' or 'strongly agree'), whereas statements requiring neutral responses to achieve this threshold were classified as weak consensus. A final expert meeting was convened to review the results and ratify the recommendations.

Standardized protocols for obtaining EndoFLIP measurements in preoperative/diagnostic and intraoperative settings were developed. The statements forming the protocols (25 related to diagnostic use and 20 to intraoperative measurements) were voted on by the AB panel, with consensus reached for all statements.

EndoFLIP has demonstrated great potential in complementing endoscopy for diagnosing achalasia and providing intraoperative guidance for treating achalasia and gastroesophageal reflux disease. The implementation of the developed standardized protocols in real-world settings is essential to validate them, as it will enable the collection of consistent data on the pre- and intraoperative use of EndoFLIP, facilitate its routine use, and better define patient pathways.