Question of the Week: Can TIF procedure be done in cases of esophageal dysmotility due to scleroderma?

Scleroderma is a rare connective tissue disorder of unknown etiology. Scleroderma results in tightening of the skin due to increased synthesis of collagen. It can be localized or systemic. Systemic scleroderma affects internal organs like the esophagus. When the esophagus is affected by the disease, esophageal motility is lost resulting in dysphagia and GERD. GERD results from the inability of the esophagus to clear naturally occurring reflux. There is no cure for scleroderma and treatment is mainly focused on symptom relief.

Patients with early stage GERD, in the setting of scleroderma, may benefit from antacid medications like proton pump inhibitors. Prokinetic drugs have very limited effect on acid reflux symptom control. As scleroderma advances and esophageal dysmotility worsens, GERD symptoms like heartburn and food regurgitation become poorly controlled with proton pump inhibitors. For these advanced GERD stages, anti-reflux surgery is indicated. At Houston heartburn and reflux center we offer a partial posterior fundoplication also called Toupet fundoplication. The surgery is associated with excellent symptom control without worsening any pre-existing dysphagia. Toupet fundoplication like Nissen fundoplication prevents any backflow of gastric content into the esophagus. The exact mechanism of action of fundoplication is not well understood. It is likely that fundoplication reverses certain gastric motility patterns that are poorly understood resulting in reflux control.

TIF or transoral incisonless fundoplication is an endoscopic procedure presumably developed to reinforce the lower esophageal sphincter and mimic fundoplication surgery. The procedure has nothing to do with the gastric fundus itself and the nomenclature is misleading. Indeed, the gastric fundus is left untouched during TIF procedure. Rather, gastric cardia tissue is plicated around the distal esophagus hoping to restore the angle of His. Restoring the angle of His by itself is obviously not a fundoplication and consequently TIF is not a reliable GERD solution. At Houston Heartburn and reflux Center we offer reliable treatments for GERD. In my opinion, TIF is not one of them especially in the case of scleroderma and esophageal dysmotility.