Endoscopic Anti-Reflux Procedures – The TIF®️ Procedure
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Endoscopic Anti Reflux Procedures The Tif Procedure
Technology drives progress in healthcare. Over the last twenty years or so, we’ve moved from the era of open to minimally invasive “keyhole” surgery. Operations, which for decades required large incisions and left big scars, are now routinely performed using tiny cuts.
Whereas patients routinely experienced significant post-operative pain and stayed in hospital for many days, following laparoscopic surgery they now return home on the same day as their surgery. Recovery is usually rapid and after a LINX®️ operation, for example, most people will have resumed normal activities and be back to work within a fortnight.
Of course, the technology to perform endoscopic examinations of the gastro-intestinal tract such as during a gastroscopy or colonoscopy using high-definition cameras mounted on the end of flexible “scopes” has been widely used for decades. Over time examination has been combined with treatments and interventions, such as excisions of early tumours, stenting of blockages or removal of polyps, becoming routine. But we’re now moving towards the next step in minimally invasive intervention.
“Per-oral” techniques were introduced twenty years ago, in which complex procedures can be performed on the upper gastro-intestinal tract from within, without incisions in the abdomen. The technique of “POEM” used to treat patients with a relatively rare condition called achalasia (difficulty or inability to swallow) has become widely available in the UK.
So why not use the same approach to offer a non-surgical alternative to treat GORD which is so much more common? Several techniques have been introduced over the last 20 years. Some have fallen by the wayside, while others have fulfilled their early promise. The TIF®️ procedure, or Transoral Incisionless Fundoplication, was introduced in 2005 and has become the most commonly performed; by 2023 nearly 30,000 people had undergone treatment around the world. The technique has evolved and refined, so while there were some early problems these have been resolved; the technique is now offered as a routine procedure in many countries. Published studies suggest that, in the right patients, TIF®️ procedures can safely achieve excellent and durable relief of reflux symptoms and that the side effects that can follow fundoplication seem to be much less of a problem. And, of course, people recover rapidly, most getting back to normal within a week or so and without scars.
For patients whose medication (such as PPIs) doesn’t work sufficiently well, who can’t or don’t want to take these drugs and who would prefer to avoid surgery, the TIF®️ procedure has become an evidence-based treatment alternative. It’s not for everyone; when a hiatus hernia is present it should be avoided as it is less likely to work. So it sits as another “arrow in the quiver” of the specialist reflux service enabling us to tailor treatment to each individual patient’s condition and choice. The standard approach taken by surgeons, that fundoplication is for everyone, is just not right in our view, and patients deserve the right to be offered and choose what’s best for them from all the possible treatment options. This is why RefluxUK now offers the TIF®️ procedure as well as LINX®️, RefluxStop™ and all the variants of fundoplication. As further new technologies are developed, we’re committed to evaluate and introduce these when appropriate.
But the big question is “why is it taking so long for all of these new anti-reflux techniques and technologies to be widely adopted and offered to patients?”. It’s not the case in the US, for instance, where patients themselves drive change. In some respects, it’s baffling; the potential advantages to patients, the healthcare system in terms of reduced hospital bed requirement and to society at large are self-evident. But 15 years after it was introduced and despite the enormous weight of evidence demonstrating its safety and efficacy LINX®️ is still not widely available in the UK. We remember that when laparoscopic surgery itself was introduced many surgeons were resistant to move away from open operations quickly despite the obvious benefits. We believe that many clinicians, wrongly, think PPIs are almost always the answer to GORD, or that any anti-reflux intervention is unwarranted and excessive; there’s an “institutional bias” against anti-reflux surgery generally in our view. And there’s the cost; payers, including the NHS as well as private medial insurers, resist the introduction of technologies they fear will meet unmet demand.
Ultimately, the RefluxUK view is that patients are their own best advocates and will vote with their feet. We see our job is to offer all new technologies which work, provide as much information about the available choices that we can and to make sure they are applied optimally.
Endoscopic techniques can offer enormous promise and we’re delighted to offer the TIF®️ procedure to our patients.