Concomitant Tif With Hiatal Hernia Repair: An Interdisciplinary Approach To Gerd

Transoral incisionless fundoplication (TIF) is an alternative treatment for gastroesophageal reflux disease (GERD). Ideal candidates are limited to patients with hiatal hernia (HH) and diaphragmatic hiatus £ 2cm and Hill Grade (HG) I or II. A novel approach of TIF immediately preceded by HH repair, coined concomitant TIF (cTIF), has emerged as a possible solution to address these limitations. To assess the efficacy, safety and feasibility of cTIF using a multidisciplinary approach between Interventional Gastroenterology and Foregut Surgery. Subjects with a HH or diaphragmatic hiatus too large to undergo TIF alone were selected for cTIF. During the same procedure, subjects underwent HH repair by a foregut surgeon followed by TIF by an interventional gastroenterologist. Variables studied included age, BMI, esophagitis, HH size, HG, Proton Pump Inhibitor (PPI) or H2 blocker (H2B) use pre and post procedure, and symptom relief based on the Reflux Disease Questionnaire (RSD) and GERD Health Related Quality of Life (HRQL) Index. Paired samples t-test was used for statistical analysis. 25 patients underwent cTIF with follow up of 2 weeks-6 months. At the time of cTIF, the mean age of subjects was 58 years, 52% were male and mean BMI was 26.4. Pre-cTIF, 60% of subjects had esophagitis. HH measurements: unmeasured paraesophageal hernia (1), 1cm (7), 2cm (8), 3cm (7), 4cm (2). 4 subjects had HG I, 9 HG II, 8 HG III, 4 HG IV. Pre-cTIF, 24 (96%) subjects were on anti-secretory agents of either PPIs or H2Bs. Early follow-up results show: Post cTIF, 19 subjects (76%) were off all anti-secretory agents, 3 subjects (12%) decreased the dose, 1 subject (4%) switched from PPI to H2B. 13 (52%) reported 100% symptom relief, 11 (44%) reported partial symptom relief, 1 (4%) reported no symptom relief. RDQ for symptom frequency was 14.6 pre-cTIF and 5 post-cTIF (p<0.01). RDQ for symptom severity was 12.1 pre-cTIF and 5.71 post-cTIF (p<0.06) (Figure 1). GERD-HRQL for heartburn severity was 15.7 pre-cTIF and 2.86 post-cTIF (p<0.01). GERD-HRQL for regurgitation severity was 9.86 pre-cTIF and 1.86 post-cTIF (p=0.05) (Figure 2). Regarding adverse events, 1 patient (4%) had an upper gastrointestinal bleed one day after cTIF. 2 patients (8%) reported gas bloat symptoms. These early results suggest that concomitant HH repair and TIF appear to be safe and effective in patients with HH or diaphragmatic hiatus too large to undergo TIF alone. The rate of gas bloat appears to be low with this novel method. Many of these patients would not have met traditional criteria for complete or even partial fundoplication and so these patients may be receiving surgical therapy earlier in the disease spectrum. Prospective randomized studies comparing cTIF to HH repair with traditional laparoscopic Nissen Fundoplication are warranted.