Dr. Kenneth Chang is a Gastroenterologist and the Chief of the GI Division and Executive Director of the Comprehensive Digestive Disease Center at UCI Medical Center in Irvine, California. Dr. Chang is a fellow of both the ACG and AFGE and a Professor of gastroenterology and hepatology at the UCI School of Medicine. In this webinar, Dr. Chang shares his experience with endoscopic treatment for GERD using transoral incisionless fundoplication, or TIF, focusing on when, why and how this procedure can be successfully accomplished. Highlights of the webinar are broken down into a few short segments below, followed by the webinar in its entirety.
GERD Surgical Candidacy Criteria
While looking at various patient profiles for GERD, Dr. Chang highlights how a great many patients can have a very normal looking anatomy, citing a recent study of 918 patients with a very abnormal DeMeester score and who clinically had GERD, about 40-45 percent had a normal looking anatomy, with a normal ileus, no hiatal hernia, and no open diaphragmatic hiatus. Dr. Chang delves into how determining the appropriate procedure for addressing GERD comes down to two main factors: 1) Baseline endoscopy, where the length of hernia is measured, as well as the Hill grade, or diaphragmatic hiatus and whether there’s the presence of esophagitis and the LA Class A, B, or C. 2) The ambulatory PH study, done through a trans-nasal catheter or, preferably, the wireless telemetry with the Bravo PH capsule to confirm the objective presence of GERD, and to further assist in selecting the appropriate procedure, regarding upright vs. supine reflux, with criteria as to when esophageal manometry can be avoided. Using 3D graphics and endoscopic footage, Dr. Chang walks through Hill grades 1-4, noting the distinctions and endoscopic vs. surgical treatments for each grade. Finally, Dr. Chang demonstrates how to classify patients on the spectrum of GERD and whether an endoscopic TIF would be appropriate, or if a surgical option is required.
Evolution of the TIF procedure
Dr. Chang reviews the current EsophyX® TIF procedure, explaining how the H-shaped fasteners fuse serosa to serosa, so that even if these fasteners come off, the serosal fusion maintains its long durability. Furthermore, the TIF procedure creates about a 270-degree-wrap, and has various similarities in mechanisms to the Nissen Fundoplication, which is a 360-degree-wrap.
Dr. Chang then walks through the evolution of TIF, starting with the ELF procedure, which was mostly done in Europe, and which avoided putting fasteners through the esophagus, but rather in the gastric cardia. Although ELF did produce a high-pressure zone, it was all in the stomach rather than the sweet spot it needs be in at the Ge-junction. He then describes the TIF 1 procedure, which included grabbing the esophagus, pulling it down, and then placing the fasteners through both the esophageal and gastric walls. TIF 1 got the high-pressure zone closer to the Ge-junction, but did not include a wrapping component. With the TIF 2, which is our current technique, it includes both lengthening and coupling the esophagus and the stomach, but also has a wrapping component to it, like the traditional gold standard: the Nissen Fundoplication.
Recurrent GERD Symptoms
Dr. Chang notes that a sizeable majority of patients have positive outcomes with a TIF, where they discontinue PPI therapy (90%), resolve typical symptoms (80%), experience normalized or improved GERD-HRQL and RSI scores (71%) and normalized PH (83%), all without the side effects commonly associated with a Nissen, such as dysphagia, bloating, or flatulence. However, if 2 or 3 years after a successful TIF a patient reports a return of reflux symptoms, Dr. Chang looks at options to reassess and replace some fasteners, which is straightforward. Patients typically have a good response to a redo with a TIF, as opposed to a Nissen redo, which Dr. Chang asserts is a significant advantage of the endoscopic treatment. If the patient didn’t respond to the first TIF, Dr. Chang will then escalate to surgery.
Dr Kenneth Chang Webinar on Treating GERD Symptoms with TIF Procedure
View the full webinar, with the above excerpts in context, as Dr. Chang provides a detailed overview of the TIF procedure with the EsophyX® device as a viable treatment option among a significant portion of GERD patients; yielding excellent results, both initially and in redo situations, without the side effects of Nissen Fundoplication. Dr. Chang denotes his criteria for endoscopic treatment options for patients with varying degrees of symptoms on the GERD spectrum. After his presentation, Dr. Chang fields questions from an audience of predominantly surgeons and gastroenterologists ranging in topics from addressing mild esophagitis, to manometry, to accurately measuring a hiatal hernia and ending with an interesting exchange with Dr. Glenn Ihde MD regarding using cricoid pressure to allow better distension of the Ge-junction for accurate Hill grade measurement.
Dr. Kenneth J. Chang MD, FACG, FASGE is an accomplished Gastroenterologist and the Executive Director of the H.H. Chao Comprehensive Digestive Disease Center as well as Chief and Professor, Division of Gastroenterology and Hepatology, Department of Medicine, UC Irvine School of Medicine, Irvine, California.