Novel Interdisciplinary Approach to GERD: Concomitant Laparoscopic Hiatal Hernia Repair with Transoral Incisionless Fundoplication

Abstract

BACKGROUND: Transoral incisionless fundoplication (TIF) is an endoscopic alternative for the treatment of GERD. However, TIF does not address the hiatal hernia (HH). We present a novel approach with a laparoscopic HH repair followed by same-session TIF, coined concomitant transoral incisionless fundoplication (cTIF). The aim of this study was to assess the efficacy, safety, and feasibility of cTIF in a collaborative approach between Gastroenterology and surgery. STUDY DESIGN: Patients with confirmed GERD and >2 cm HH who underwent cTIF between 2018 and 2020 were included. Symptoms were assessed using the Reflux Disease Questionnaire, GERD Health-Related Quality of Life Index, and the Reflux Symptom Index pre and post cTIF. One-way ANOVA and paired samples t-test were used for statistical analysis. RESULTS: Sixty patients underwent cTIF (53% were men, mean age was 59.3 years) with 100% technical success. Mean ± SD HH measurement on endoscopy was 2.9 ± 1.5 cm. Scores on Reflux Disease Questionnaire for symptom frequency and symptom severity improved significantly from before to 6 months after cTIF (17.4 to 4.72; p < 0.01 and 16.7 to 4.56; p < 0.05, respectively). According to the GERD Health-Related Quality of Life Index, significant decreases were seen post cTIF in heartburn (23.26 to 7.37; p < 0.01) and regurgitation (14.26 to 0; p = 0.05). Reflux Symptom Index similarly decreased after cTIF (17.7 to 8.1 post cTIF; p < 0.01). Mean DeMeester score decreased from 43.7 to 4.9 and acid exposure time decreased from 12.7% to 1.28% post cTIF (p = 0.06). CONCLUSIONS: We present a novel multidisciplinary approach to GERD using a combined endoscopic and surgical approach with close collaboration between Gastroenterology and surgery. Our results suggest that cTIF is safe and effective in reducing reflux symptoms in a large spectrum of GERD patients.

State of evidence and future perspectives in minimally invasive management of gastroesophageal reflux disease (GERD)

“…Patients who underwent obligatory dissection and hiatal repair, regardless of the presence of a hiatal hernia, fared better by multiple measures compared to patients without obvious hernia who had MSA placed using minimal dissection without cruroplasty [Table 1] [18,19] . These MSA studies and two small studies of transoral incisionless fundoplication (TIF) combined with a laparoscopic hiatal hernia repair [20,21] provide clinical confirmation that failure or inability to restore the crural sphincter may be an inherent limitation of endoscopic therapies, regardless of the presence or absence of a hiatal hernia.…”

Recent Advances in the Endoscopic Management of Gastro-esophageal Reflux Disorder: A Review of Literature

“…A mucosal tear occurred in one patient intraoperatively. On postoperative day 1, one patient suffered a non-life-threatening upper gastrointestinal hemorrhage and ileus, and another was readmitted for gas bloat and delayed stomach emptying [48]. At six months of follow-up, another retrospective review analysis revealed statistically significant improvements in GERD-HRQL and RSI scores in 29 patients and normalization of EAE after c-TIF in 21 out of 22 patients.…”

“…The c-TIF (also known as HH-TIF: combined laparoscopic hiatal hernia repair with TIF 2.0) is a new modified approach that combines laparoscopic hiatal hernia repair and TIF in the same session. Choi et al [48] enrolled 60 patients in their c-TIF trial, with an average age of 59.3 years and a BMI of 30.0 kg/m 2 . This study comprised people with BE, LA grade C/D esophagitis, a mean HH of 2.9 ± 1.5 cm, and HG I-IV.…”

Endoscopic Management of GERD

“…There continues to be an increased interest in performing TIF along with concomitant laparoscopic hiatal hernia repair (cTIF) [47]. For surgeons performing both LARS and TIF, the rationale for cTIF includes: (1) a trend away from Nissen Fundoplication due to higher incidence of postoperative gas/ bloat and dysphagia coupled with established data that TIF produces much less gas/bloat, dysphagia [2], and emerging data suggesting that cTIF also produces less gas/bloat than traditional LARS [34,35,48], (2) the non-standardization of the partial fundoplication (Dor or Toupet), and (3) the concern over potential effects of stronger MRI machines in the future on the magnetic sphincter augmentation device [49].…”