Invited Commentary on the American Foregut Society White Paper on Transoral Incisionless Fundoplication: Transoral Incisionless Fundoplication: Where Are We and Where Do We Go From Here?

Gastroesophageal reflux disease (GERD) affects a large segment of the population. Initial treatment includes lifestyle changes and medications such as proton pump inhibitors (PPIs). For a more definitive option or to avoid long-term medication use, there are various effective invasive interventions. Some reasons to avoid PPIs include the risk of side effects such as infections and osteoporosis, incomplete response, or patient preference to avoid lifelong use.1 Endoscopic and surgical treatments can be offered after an appropriate workup. Historically, the procedure of choice was antireflux surgery (ARS): a hiatal hernia repair if one was present combined with a fundoplication. These are now mostly done laparoscopically or robotically as minimally invasive techniques have become widespread. Options for fundoplication include 360° full, or Nissen, fundoplication and various partial fundoplications, such as 270°, or Toupet, fundoplication or 180° anterior fundoplication. Debate as to which fundoplication is best is ongoing; a recent multi-society consensus guideline reported that subjective and objective reflux control was better with full fundoplication, whereas hiatal hernia recurrence, dysphagia, and gas/bloat was better with partial fundoplication.1 In addition to surgery, there are now several endoscopic treatment options. These include radiofrequency energy, or Stretta, and Transoral incisionless fundoplication, or TIF. TIF was initially used starting in 2006 with the EsophyX® device and is now upgraded to a 2.0 option using the EsophyX® Z+ device that allows a greater wrap to 270° to 320°.2,3 Combining a surgical hiatal hernia repair with TIF is concomitant TIF or cTIF.2 Another hybrid option is a magnetic sphincter augmentation (MSA), or LINX®. Gutierrez et al2 as part of The American Foregut Society Clinical Practice Committee TIF Working Group present a comprehensive and well-written summary of TIF and cTIF.2 They delineate some of the differences between TIF and ARS, indications for TIF, recommended workup, and delve into the steps of both TIF and cTIF. They also discuss post-procedure care, complications, and outcomes, in addition to briefly touching on reimbursement. This paper is a useful review both for those previously unfamiliar with TIF and for those with prior knowledge. There are several highlights. The first is their explanation of the physiology of the antireflux mechanism, comparing TIF and fundoplication. The second is their clear description for patient selection and recommendations for preoperative workup. They note that endoscopic treatments such as TIF offer an option of intermediate invasiveness between medications and surgery. Patients with Hill Grade I and II are candidates for TIF whereas those with Hill Grade III and IV, hiatal hernias greater than 2 cm, or patients with LA grade C and D esophagitis should be offered cTIF or ARS. Those with dysmotility may be candidates. Another feature of this review is the technical description of TIF. The authors describe the initial esophagogastroduodenoscopy, possible dilation, and the 2 operators needed for device and endoscope management. The procedure itself is described in a “how to” fashion, including relevant details such as how to position the fasteners, insertion of the endoscope and device, the rotation of the device and starting fundoplication at the 11 o’clock position, “setting” the device, and onwards throughout the fundoplication. They point out tips, important steps, and pitfalls and detail the cTIF procedure and some of its advantages, as well. Their pictures are excellent and a very useful adjunct to the description. Their review of outcomes highlights the role of TIF in the treatment of GERD. One advantage is that TIF has 1170589 GUTXXX10.1177/26345161231170589ForegutNarula research-article2023