The transoral incisionless fundoplication is a minimally invasive treatment for gastroesophageal reflux disease (GERD) that is performed in the outpatient setting. The TIF procedure is performed from inside the patient’s stomach without incisions. This procedure delivers patient outcomes similar to those provided by conventional ARS procedures, but is less invasive, has fewer adverse effects, and does not limit future treatment options. Following the principles of ARS, the TIF procedure repairs the anti-reflux barrier by reducing a hiatal hernia (≤ 2 cm), and creating a valve 2 to 4 cm in length and greater than 270 degree circumferential wrap, thus restoring the dynamics of the angle of His.
A Less Invasive Approach to Fundoplication
Fundoplication procedures have been used to effectively treat patients with GERD for over 50 years. The TIF procedure differs from a traditional fundoplication procedure because it is performed through the mouth rather than through laparoscopy or open abdominal incisions.
During a TIF procedure, the patient is placed under general anesthesia so that the EsophyX device, used with a flexible endoscope, can be gently introduced into the stomach under constant visualization. The endoscope and the device are retroflexed and a helical retractor is engaged into the tissue slightly distal to the Z line. The fundus of the stomach is folded up and around the distal esophagus utilizing the tissue mold and chassis of the device. After locking all the tissue manipulating elements, an integrated suction apparatus is activated to gently grasp the distal esophagus and position it in the abdominal cavity distal to the diaphragm. H-shaped SerosaFuse fasteners, made of polypropylene with strength equivalent to 3-0 sutures, are then delivered through apposed layers of esophageal and fundus tissue to anchor the repair. This process is repeated to create a full thickness, partial circumference, gastroesophageal fundoplication. Approximately 20 fasteners are implanted during the procedure to create the fusion of the esophageal and fundus tissues and form the valve.
Evolution of the TIF Procedure
The TIF procedure that is currently performed in the United States is the result of several iterations of development. The original variation of the procedure performed early in U.S. experience, and predominantly in Europe was known as endoluminal fundoplication (ELF). This first generation procedure was developed to assess the feasibility of the approach and was designed–first and foremost–to demonstrate safety and efficacy. At the time, investigators were concerned with placing fasteners through the distal esophagus and elected instead to create gastro‐gastric plications distal to the gastroesophageal junction. After experience was gained with the first generation procedure and devices, subsequent iterations of the technique were pursued to more closely replicate the principles and outcomes of traditional surgical procedures.