Liam from Houston sent us this question: “I was diagnosed with Both eosinophilic esophagitis (biopsies) and GERD (lax LES). Motility test showed motility as fine.
EOE is being treated with steroids and might switch to a biologic. Count is now down to zero.
Question is should I go for Nissen Fundoplication, which might reduce motility given my EOE, or go with the endoscopic procedure (TIF) which has a lesser risk of motility issues but less long-term data on effectiveness? Thank you”.
The gold standard treatment for acid reflux disease is a properly performed Nissen fundoplication. At Houston Heartburn and Reflux Center we don’t consider TIF a reliable treatment option for GERD. TIF success rate and durability are low. TIF or transoral incisionless fundoplication is not even a fundoplication. “Bunching up” a bit of stomach tissue around the lower esophageal sphincter is not a fundoplication by any stretch of the imagination. Furthermore, TIF does not address the complex pathophysiology of GERD. Hence, very few patients benefit from a TIF procedure.
A properly performed floppy and short Nissen fundoplication along a hiatal hernia repair is associated with a very low dysphagia rate. Indeed, dysphagia or difficulty swallowing is expected to improve after a properly performed Nissen fundoplication. For chronic acid reflux damages esophageal motility. Stopping acid reflux ameliorates esophageal contractions and swallowing. By the same token, a poorly performed Nissen fundoplication may damage esophageal motility leading to worsening dysphagia.
Acid reflux may cause or worsen eosinophilic esophagitis by increasing inflammation in esophageal lining. For GERD increases permeability of esophageal mucosa. Food allergens can easily penetrate esophagus wall and illicit an allergic reaction. Conversely, eosinophilic esophagitis weakens the anti-reflux barrier leading to development or worsening of GERD. Chronic inflammation reduces lower esophageal sphincter pressure favoring reflux. Furthermore, it weakens esophageal motility allowing refluxed acid to linger longer within the esophagus.
Eosinophilic esophagitis may occur by itself independent of any measurable acid reflux. However, in cases of concomitant acid reflux and eosinophilic esophagitis, stopping acid reflux is crucial to reduce inflammation and control symptoms. The most effective solution to control acid reflux reliably and safely, in the setting of eosinophilic esophagitis, is a properly performed Nissen fundoplication.