SAGES-EAES clinical practice guidelines for the use of FLIP/impedance planimetry in the surgical work-up and management of GERD, achalasia, and gastroparesis.

BACKGROUND

The Functional Lumen Imaging Probe (FLIP) measures luminal geometry and distensibility to assess esophagogastric function during endoscopy and foregut surgery. It is increasingly used in gastroesophageal reflux disease, achalasia, and gastroparesis for diagnostic and intraoperative guidance. However, the lack of standardized protocols limits consistent clinical use, prompting the need for evidence-based recommendations.

METHODOLOGY: A systematic review conducted from January 1, 2005, to June 24, 2025, addressed four key questions regarding FLIP use in adult and pediatric surgical patients. Findings were presented to an international, multidisciplinary panel of surgeons and gastroenterologists, including those from both the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association of Endoscopic Surgeons (EAES). GRADE methodology was used to develop evidence-based recommendations.

RESULTS

All recommendations were based on very low certainty of evidence. A conditional recommendation suggests FLIP may be used as a triage tool to rule out achalasia prior to anti-reflux surgery, with high-resolution manometry being performed if FLIP is positive. The panel suggests that anti-reflux surgery in adult patients may be performed with or without FLIP. Conditional recommendations suggest intraoperative FLIP during peroral endoscopic myotomy in adults and during esophagomyotomy in pediatric patients. No evidence-based recommendation could be made regarding preoperative FLIP prior to pylorus-directed therapy for gastroparesis.

CONCLUSIONS

Current evidence evaluating FLIP in surgical practice is limited and, largely, of very low certainty, but FLIP shows potential as a complementary diagnostic and intraoperative tool in foregut disorders. These recommendations provide an initial framework for the responsible, evidence-informed use of this technology in clinical practice. Further prospective studies are essential to establish standardized protocols, define clinically meaningful thresholds, and strengthen future guideline updates in adult and pediatric populations.