Transoral Incisionless Fundoplication (TIF) is a minimally invasive procedure that involves the reconstruction of the GEV without laparoscopic incisions [8]. It utilizes the EsophyX ® device which is inserted through the oral cavity and advanced into the stomach where it lengthens, strengthens, and tightens the lower esophageal sphincter (LES) by creating a 3 cm, 270-degree esophagogastric fundoplication [7,8]. The device places 20+ SerosaFuse fasteners at four different positions around the wrap to stabilize it, thus restoring the integrity of the GEV and subsequently correcting the underlying cause of GERD [1,8]. The TIF procedure is revolutionary, with an operation time of one-hour maximum and an approximate success rate of 98% [9]. In a study consisting of 257 patients, 51 underwent the TIF procedure. 50 out of 51 patients reported complete symptomatic relief, indicating efficacy [9].

There are criteria that must be met before being considered for the TIF procedure. Refractory GERD, the presence of a hiatal hernia on EGD, and Barrett's esophagus are features that make patients a good candidate for this procedure [10]. Some contraindications include a BMI over 35 kg/m2, age over 70 years old, a hiatal hernia that’s more than 3cm, irreducible hernias, and severe medical comorbidities such as heart or lung disease [10]. These may decrease the efficacy of the procedure or affect the patient’s ability to tolerate it. Our patient had the classical symptoms of GERD that were refractory to the maximum dosage of PPI; there was no hiatal hernia on preoperative EGD and the patient did not have any severe health comorbidities, thus making him a good candidate.

There is a paucity of research comparing Nissen Fundoplication and TIF. A network meta-analysis compared the efficacy of TIF, NF, and PPI therapy. They found that although there was more sphincter enhancement in NF, there was an increased quality of life in persons who underwent TIF [11]. NF includes a tight fundoplication to rebuild the GEV, however, TIF creates a longer valve that is not twisted or torqued allowing food to pass easily [12]. The gastric blood vessels and vagus nerve branches are in close proximity to the fundus and distal esophagus; when damaged during circumferential wrapping, dysphagia and gastroparesis may arise which presents as bloating, belching, and upper abdominal discomfort [13].  In TIF, the GEJ is only partially tightened, thus decreasing the rate of these complications, and allowing patients to resume their daily activities quickly [12]. TIF is also an incisionless procedure, so it eliminates the risk of skin infections, scarring, and pain associated with laparoscopic surgery [7].

Studies have shown that 90% of patients who undergo TIF have improved symptomatic control of refractory GERD in comparison to standard methods of management [9]. In a study, 94% of patients reported symptomatic resolution that led to the complete cessation of PPI use [9]. Furthermore, TIF is a durable solution for GERD with studies showing that the procedure maintains its efficacy for up to ten years [14]. Patients would not require multiple surgeries or future treatments which are cost-effective. Some notable side effects of TIF include mild throat, chest, or shoulder pain which resolves within a couple of weeks [11]. Studies show that the risk of serious complications such as mucosal tears and bleeding is approximately 3% to 10% [15].

The TIF diet is followed for several weeks after the surgery. It allows the stomach and esophagus to settle into their new shape and heal, preventing complications [11]. The diet consists of liquids for one-week, soft foods for two weeks, and solid foods after the third week [15]. Spicy or fried foods and caffeine should be avoided for several months to prevent gastroesophageal irritation [15].

In this case, our patient who had been suffering from refractory GERD benefitted immensely from the TIF procedure with a report of complete symptom resolution. Due to its minimally invasive nature, the patient experienced less pain and discomfort with no postoperative complications. This advanced fundoplication procedure should be highly considered in the treatment of moderate to severe refractory GERD. Decreased recovery times, instant symptomatic relief and reduced risk of side effects are some of TIF's notable benefits, which make it superior to Nissen Fundoplication regarding a patient’s quality of life.