Transoral incisionless fundoplication (TIF)
The last 2 decades have seen the emergence of procedures claimed to be less invasive than laparoscopic anti-reflux surgery in the attempt to cure acid reflux. One of these procedures is TIF, transoral incisionless fundoplication. TIF is a procedure which uses a device which is applied along with the endoscope and passed through the mouth into the oesophagus. The device is preloaded with forceps and fasteners. The device has a wide diameter and frequently requires dilatation, which is a stretch of the oesophagus before it can be applied. The procedure starts by grabbing the lower end of the oesophageal lining down, and then wrapping part of the stomach, fundus, around it. The wrapped part is kept in place by plastic fasteners.
Analysis of the TIF procedure
– One of the main reasons for failure of TIF is that it does not include the most important step of repair of the muscles of the diaphragm.
– It is technically impossible to do a full wrap of the stomach around the oesophagus with TIF and this is another factor for its failure.
– It is claimed that TIF is less invasive than surgery, but this is not true. TIF causes more pain than surgery and this is caused by the insertion of a very bulky device through the throat and oesophagus. Also, the plastic fasteners used during TIF can cause a lot of pain in the upper abdomen for many days. These do not happen in the case of laparoscopic anti-reflux surgery. In a recent questionnaire, we asked patients who have had TIF and then came for laparoscopic fundoplication after failure of the TIF, about the level of pain after each procedure. All patients reported that pain after TIF was much worse than after laparoscopic anti-reflux surgery in the ratio of 10:2.
– Nearly all studies looking at the effectiveness of TIF are only measuring the reduction of use of acid suppressants and not the rate of the cure of reflux or comparing it with the gold standard anti-reflux surgery.
– TIF is sometimes marketed as a procedure which avoids difficulty in swallowing after laparoscopic anti-reflux surgery. This is not accurate, as laparoscopic anti-reflux surgery, if performed properly, would rarely cause difficulty in swallowing (less than 1%). And even if this happens, it can be easily corrected. On the other hand, TIF patients can have difficulty in swallowing for many weeks after the procedure and many patients feel a knot inside their abdomen.
I have experience of more than 120 TIF procedures, including performance of the procedure, reviewing and operating on patients who had TIF previously and failure to control the reflux.
I find TIF not effective at all in curing reflux, and I have not seen a single patient yet who had effective control over reflux 2 years after the TIF.
