Transoral fundoplication for gastroesophageal reflux disease

Transoral incisionless fundoplication (TIF) has recently been proved to be an effective therapeutic option as an alternative to medical and surgical therapy. TIF reconfigures the tissue to obtain a full-thickness gastro-esophageal valve from inside the stomach, through serosa-to-serosa plications including the muscle layers. Current issues about TIF refer to: (I) the capability of the procedure to effectively control gastroesophageal reflux disease (GERD)-related esophageal (heartburn and regurgitation) and extra-esophageal symptoms, heal esophagitis and reduce hiatal hernia; (II) the capability to control gastro-esophageal reflux, as measured by 24-h pH-impedance recording; (III) the long-term efficacy of the procedure, compared with surgery; (IV) the cost-effectiveness of the procedure, compared with surgery. Two recent meta-analyses showed that TIF performed either by EsophyX or MUSE is effective as surgery in controlling GERD symptoms, extra-esophageal symptoms, and gastro-esophageal reflux in the short-/ medium-term period. Long-term results are still few; the 7 prospective observational studies reporting 3 to 6 years results showed that efficacy of TIF persists up to 6 years. The long-term post-TIF results are similar to those with surgical fundoplication, without any of the surgery-related persistent side effects such as dysphagia and gas bloat. TIF appears to be cost-effective compared to laparoscopic Nissen fundoplication. To date available findings confirm that TIF can offer an effective and safe therapeutic option for carefully selected symptomatic GERD patients, with Hill grade of the valve I and II or hiatal hernia not longer than 2 cm, who refuse life-long medical therapy or surgery, are intolerant to proton pump inhibitor (PPI), or have some risk of persistent post-surgical side effects.