Transoral Incisionless Fundoplication

About This Procedure

Transoral Incisionless Fundoplication (TIF) is a minimally invasive procedure used by surgeons in the Division of Gastrointestinal & Oncologic Surgery at Massachusetts General Hospital to treat gastroesophageal reflux disease (GERD).

GERD is a digestive disorder caused when gastric acid from your stomach flows back up into your food pipe or esophagus. Heartburn is the most common symptom of GERD.

Our surgeons in the Gastroesophageal Surgery Program work closely with the Swallowing and Heartburn Center at the Mass General Digestive Healthcare Center, as well as patients and referring physicians, to determine the treatment plan that is best for each patient.

What Is TIF?

Transoral Incisionless Fundoplication is a surgical procedure performed under general anesthesia that reconstructs the valve at the top of the stomach to prevent acid reflux. The instruments that are used to perform the procedure are introduced through the mouth so there are no skin or muscle incisions.

TIF uses a device guided with an upper gastrointestinal (GI) endoscope to create a valve at the top of the stomach that prevents abnormal acid reflux. The valve is similar to that created by laparoscopic partial fundoplication. The valve is created by folding the tissue and securing the valve with tissue fasteners through the endoscopic device.

Fundoplication is a medical term used described folding of the stomach around the esophagus to construct a valve at the junction of the stomach and esophagus. The purpose of this valve is almost always to prevent acid reflux. Fundoplications that are 360° completely encircle the esophagus, and are often referred to as Nissen fundoplications. When the stomach is folded 240° or less around the esophagus it is described as a partial fundoplication. Before the introduction of the TIF procedure, all fundoplications were constructed either with open surgery or laparoscopic (keyhole) surgery.

Patient Evaluation

Before considering a TIF procedure, patients must undergo a careful evaluation that includes:

• Barium swallow, an X-ray test where the patient drinks a liquid containing barium solution that is easily visualized during an X-ray. This allows the radiologist to determine if a hiatal hernia is present, assess the degree of the reflux and get a sense of how effectively the esophagus is functioning
• Esophageal motility testing and PH probe studies involve placing a catheter through the mouth or nose into the esophagus and recording the pressure generated inside the esophagus during swallowing. This can be an important piece of information in determining whether the esophagus is strong enough to propel food through a newly constructed valve at the gastroesophageal junction (fundoplication)
• GI endoscopy

Recovery Time

The TIF procedure is performed under general anesthesia. Patients need to be on a liquid diet for a week after surgery and a soft diet for an additional several weeks.

Strenuous activity may be limited during this time. Most patients have a follow up appointment with their surgeon two weeks after surgery to monitor recovery progress.

Eligible Candidates

Not all patients are candidates for this procedure. A full evaluation is needed to determine if a patient is eligible.

Candidates most suited for this procedure include patients who:

• Have GERD documented by the evaluation described above
• Ideally do not have hiatal hernias, but may be considered if a hiatal hernia is 2 cm or less
• Body Mass Index (BMI) < 35
• Have not had prior gastric surgery

The Mass General Difference

Mass General is consistently recognized among the best hospitals in the country by U.S. News and World Report. Our surgeons, among the most experienced nationally and internationally, are leaders in the treatment of gastric and esophageal diseases. This program is multidisciplinary and offers coordination between various departments. Our surgeons are accustomed to seeing patients with multiple medical conditions and offer treatments customized for each patient.

TIF is a safe and well-tolerated procedure; however, all surgical procedures have risks and it is important to speak with your surgeon to identify your risk factors. Since not all patients are good candidates for TIF, a suitable alternative is usually available. Surgical outcomes have been widely published and our outcomes for treatment of GERD are excellent.

Fundoplications can cause temporary difficulty in swallowing solid foods. Sometimes they can lead to trapping of gas in the stomach with distention or bloating. These side effects tend to be temporary and resolve once swelling from surgical procedures has resolved. It is possible to burp/belch after nearly all types of fundoplications. However, it is difficult, if not impossible, to vomit with an intact 360° fundoplication. It is, however, possible to vomit with a partial fundoplication.

Clinical Studies

Mass General has been involved in various studies analyzing outcomes after surgery.

A Quality of Life (QOL) survey was sent to all patients who underwent laparoscopic fundoplications. This survey was used to evaluate long-term results and quality of life.

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Another QOL survey was developed to analyze the severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication.

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