Is transoral incisionless fundoplication (TIF) an answer to post-peroral endoscopic myotomy gastroesophageal reflux? A multicenter retrospective study

Abstract

Background: The use of peroral endoscopic myotomy (POEM) for achalasia has a high incidence of post-procedural gastroesophageal reflux (GER). Transoral incisionless fundoplication (TIF) may be an ideal endoscopic treatment. We report our experience with the use of post-POEM TIF. Methods: In this multicenter retrospective study, post-POEM patients with GER who underwent TIF were included. The study end points were: (i) technical success; (ii) safety; (iii) effectiveness (changes in symptoms, scores, proton pump inhibitor [PPI] use, pH studies). Results: 12 patients underwent TIF after POEM, nine of whom had daily symptoms, with 91.7% requiring twice daily (BID) PPIs. Technical success was achieved in all patients. Two adverse events occurred. There were significant decreases in the percentage of patients on BID PPIs (P = 0.03), frequency of daily symptoms (P = 0.03), Reflux Severity Index questionnaire, and GERD Health-related Quality of Life scores (P = 0.03 and P = 0.003; n = 6). pH studies performed in seven of the patients showed a significant reduction in the mean DeMeester score (P = 0.05) and mean percentage acid exposure time (P = 0.04). Conclusion: Our experience suggests that TIF may be effective and safe in treating GER after POEM. Larger prospective trials are needed.

Is peroral endoscopic myotomy the new gold standard for achalasia therapy?

“…In a small multicenter study of TIF in 12 patients with GERD after POEM, a low proportion of patients responded with healing of esophagitis, normalized pH studies, or PPI discontinuation. 77 POEM + FUNDOPLICATION (POEM + F, POEF) P OEF UTILIZES THE submucosal tunnel to safely access the peritoneal cavity and create an anterior fundoplication similar to a Dor. Inoue et al, 78 the inventor of this ingenious technique, reported initially 100% technical success and intact fundoplication at 2 months in 95% of patients, but pH study data and long-term durability were lacking.…”

“…Even as a separate‐session procedure, however, TIF has shown rather underwhelming preliminary results. In a small multicenter study of TIF in 12 patients with GERD after POEM, a low proportion of patients responded with healing of esophagitis, normalized pH studies, or PPI discontinuation 77 …”

Management of GERD After Myotomy for Achalasia

“…All procedures were technically successful and a statistically significant improvement in the frequency of symptoms, twice-daily PPI requirement, symptom scores and improvement in Demeester score on objective pH testing was reported. 52 Most recently, a pilot study by Benias et al showed that same procedure POEM-TIF was technically feasible and showed an objective reduction in post-myotomy GERD with 80% of patients (4/5) having pH testing that was negative for pathologic reflux. 53 As further studies define the predictive risk of GERD after myotomy, it is likely that POEM-TIF will meaningfully improve outcomes in the subset of patients deemed to be at highest risk.…”

Post‐per‐oral endoscopic myotomy heartburn: It’s not always reflux: Expert review

“…Earlier methods of endoloop and clip application for endoscopic fundoplication have now evolved to endoscopic suturing. 44,[46][47][48] NOVEL TECHNIQUES OF PREDICTING POST-POEM REFLUX F EMALE SEX, THE presence of a hiatus hernia, body mass index >35 kg/m 2 , low integrated relaxation pressure, and full thickness myotomy are the predictors of post-POEM GERD in various studies. 4,[14][15][16][17] Importantly, the intraprocedure EndoFLIP measurement showing a higher distensibility index (≥2.7) and higher crosssectional area (≥83) are more likely to develop in post-POEM reflux esophagitis.…”