Nissen fundoplication surgery is the gold standard treatment for acid reflux disease or GERD. Dr. Nissen first introduced the procedure more than 50 years ago. He astutely observed that by wrapping the gastric fundus around the distal esophagus acid reflux resolved. Interestingly, the first case Dr. Nissen performed was following a distal esophagectomy. The wrap worked independent of the presence of a lower esophageal sphincter. Indeed, Nissen surgery offers a different level of acid reflux control independent of lower esophageal sphincter. The surgery has been extensively studied and perfected over time. A key component to the success of Nissen fundoplication is the adequate mobilization of the gastric fundus. The gastric fundus is a posterior structure that constitutes the upper part of the stomach. It is attached to blood vessels and adjacent structures. During surgery the gastric fundus is completely released and mobilized to serve as a floppy wrap around the esophagus. Failure to do so results in a poorly constructed fundoplication with several side effects like dysphagia and bloating as well as poor long-term acid reflux control. How does gastric fundus wrapping around the esophagus stop acid reflux is not fully understood. One thing for sure, mobilizing the gastric fundus and changing its position relative to the gastro-esophageal junction is key to anti-reflux surgery.
Bunching up some gastric tissue around the lower esophagus using an endoscope, also called TIF (Transoral Incisionless Fundoplication) is not a Nissen fundoplication by any stretch of the imagination. Yet, the procedure has been developed, labeled and advertised as a fundoplication for treatment of GERD.
A 42-year-old female patient presented to my office with longstanding history of GERD related symptoms including heartburn and food regurgitation. She underwent TIF procedure in 2012 with absolutely no symptom improvement. She therefore continued daily PPI therapy and bedtime Zantac. She reports multiple breakthrough symptoms like coughing, throat clearing, and heartburn. She suffers from weekly nocturnal symptoms preventing her from sleeping. She denies dysphagia but reports bloating. An upper endoscopy showed no hiatal hernia, and bunched up gastric tissue around the distal esophagus with some pledgets sticking out of the mucosa. Ambulatory pH testing showed evidence of severe acid reflux with elevated DeMeester score.
Decision was made to convert TIF to Nissen to cure GERD. Luckily, the patient had minimal intra-abdominal adhesions. She tolerated the procedure with no complications. Postoperatively, all GERD related symptoms resolved.
I don’t want to make a guideline from this single case. However, I have serious doubts about TIF as a reasonable solution for GERD. Does it work like a Nissen? Is it durable and reliable? The answer in my opinion is NO.