S1116 Transoral Incisionless Fundoplication Is a Safe and Effective Therapeutic Option for Refractory GERD: A 3-Year Retrospective Experience at a Quaternary Center

Introduction: Refractory GERD is seen in up to 40% of patients who experience persistent symptoms despite optimal therapy with acid-suppressing agents, including proton pump inhibitors (PPI) and H2 blockers (H2B). Such individuals may be candidates for invasive interventions. Transoral incisionless fundoplication (TIF) is a minimally invasive intervention, which can be performed alone or in conjunction with laparoscopic hiatal hernia repair (HHR). Our study aimed to evaluate the technical and clinical success of TIF performed at a quaternary center in the management of refractory GERD. Methods: This is an IRB approved retrospective chart review of patients who underwent TIF alone or TIF with HHR (TIF+HHR) for refractory GERD from 2018 to 2021. Technical success was defined as completed procedures without major complications. Clinical success was measured by reduction in PPI and/or H2B use as well as symptom resolution quantified by the GERD HQRL Questionnaire. Results: A total of 58 patients with a mean age of 55.7 years were included of whom 62.7% were female. 19.0% underwent TIF only, while 81.0% underwent TIF+HHR. Hill grade I, II, III, and IV was respectively present in 9.3%, 32.6%, 44.2%, and 9.3% of patients with a mean hiatal hernia length of 2.36 cm. The technical success rate was 98.3% - there was only one patient in whom the procedure could not be completed as the TIF device was not able to be inserted even after esophageal dilation. At 12 months, 85.7% of patients reported reduction in PPI use of whom 76.2% stopped completely and 9.6% reduced dosing by ≥ 50%. Similar results were seen in those with H2B use with 85.7% of patients stopping completely. Preop mean HQRL score was 29.59 which decreased significantly to 6.56 and 3.27 at 6 and 12 months, respectively. At 12 months, 81.8% reported satisfaction with their condition, whereas 9.1% were neutral and 9.1% were dissatisfied. Complications occurred in 4 patients, including self-resolving oozing and superficial mucosal tears not requiring intervention. Conclusion: Our study confirms that TIF is a viable treatment option in the management of refractory GERD. Similar to prior studies, we experienced high technical success rates with no major complications as well as clinical success with a majority of patients being able to reduce or stop PPI and/or H2B completely. In those who were unable to be titrated off acid suppression, postop evaluation suggested alternative diagnoses such as esophageal hypersensitivity or functional dyspepsia.