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Incisionless Procedure Offers Less Invasive Treatment for Reflux

by Susan Kreimer •

Unlike the Nissen procedure, in which 5 to 10 percent of patients develop abdominal side effects, the TIF procedure does not seem to be associated with these drawbacks more than 1 percent of the time, said Reginald C.W. Bell, MD, a gastrointestinal surgeon in private practice in Englewood, Colo., who sees two to four LPR patients referred by otolaryngologists per week. “This is very important for patients with LPR, who often don’t have typical reflux symptoms and for whom the thought of developing GI side effects from a procedure (such as a Nissen) is not very appealing,” said Dr. Bell, who has performed more than 170 TIF procedures since 2009. “These patients with LPR have very good results from the TIF procedure. Symptomatic improvement is almost the same as with the Nissen when it comes to symptoms such as cough, throat clearing and hoarseness.”

Researchers involved in a recent Boston University School of Medicine study of 46 patients described TIF as “a promising approach for gastroesophageal reflux disease (GERD) that may decrease morbidity compared with conventional anti-reflux procedures” (J Thorac Cardiovasc Surg. 2012;143:228-234). They also concluded that TIF is effective at short-term follow-up and safe for patients with GERD, while cautioning that “long-term follow-up and randomized trials are required to assess the efficacy and durability of this approach compared with conventional surgical repair.”

Who Is a Candidate for TIF?

Patients with troublesome symptoms that are not too severe or life-threatening, and those with a hiatal hernia smaller than 2 centimeters, are appropriate candidates for the TIF procedure. “Someone who is bothered by hoarseness or throat clearing but is not a performer who depends on voice for their livelihood, I would consider a good patient for the EsophyX TIF,” Dr. Bell said.

However, for someone with life-threatening complications from reflux—for example, aspiration pneumonias or difficulty breathing—he generally recommends the traditional Nissen procedure.—SK

For about 80 percent of patients undergoing TIF, the positive results mean they can forgo daily acid blockers, which may interfere with the absorption of calcium, amino acids and magnesium, potentially leading to osteoporosis and hypothyroidism after multiple years of use, said Erik Wilson, MD, FACS, division chief of elective general surgery and vice chair for clinical affairs at the University of Texas Medical School at Houston.

“We’re doing more of these procedures than the standard laparoscopic approach more recently,” Dr. Wilson said. Patients typically also follow up with their otolaryngologist for management. “Over time, their voice can slowly improve because there’s less reflux irritating their vocal cords,” he explained, adding that “it’s not an overnight phenomenon.”

A Promising Option

Traditionally, surgery has often been perceived as a last resort for patients with GERD. Physicians commonly viewed this condition as more of a lifestyle issue than a life-threatening illness. “There’s been a reluctance on the part of the ENTs and other health care providers to take the chance of sending someone for surgery,” said Kevin Gillian, MD, of the Virginia Hernia Institute in Lorton, Va., and director of the heartburn treatment center at Virginia Hospital Center in Arlington.