In the following webinar, broken down into short segments below, followed by the webinar in its entirety, Dr. Michael Murray looks the impact of GERD on patients and society, outlines his experience treating the disease, and provides practical tips relating to TIF and a hiatal hernia repair, as well as expected failure rates and options for a redo, if needed. Dr. Murray is a general surgeon based at the Northern Nevada Medical Center in Reno, Nevada. Dr. Murray is a fellow of the American College of Surgeons and faculty at the University of Nevada, Reno Medical School. Dr. Murray was trained to perform the TIF procedure in May of 2010 and has completed over 250 TIF procedures. He was one of the early trail blazers by performing laparoscopic hiatal hernia repair concomitant to a TIF procedure.
Webinar Series: GERD is a complex and progressive disease. Michael Murray, MD Northern Nevada Medical Center, Reno, NV
Dr. Murray puts the problem of GERD into perspective highlighting how the disease is generally thought to affect about 20 percent of the population, resulting in significant drug costs and lost productivity. He demonstrates how this is a surgically underserved community with an incredible 35 percent of GERD patients dissatisfied with their PPI therapy, and many could benefit from a surgical approach. With the introduction of PPIs, surgeons have been relegated to the late stages of reflux, which is a progressive disease. Dr. Murray presents a late-stage case with every component of the reflux barrier deteriorated and a massive hiatal hernia as an example of why he started doing TIF: to effectively treat the disease at a far earlier stage.
Webinar Series: Issues Surrounding Traditional Surgical Approaches
After a poll in the audience, in which there were many general surgeons, it was revealed that 70 percent had Nissen fundoplication as a surgical option to address reflux, which Dr. Murray concedes has been the gold standard evolving to a full 360-degree wrap, full fundus mobilization, 2.5 to 3 cm in length. The problem, he points out, is that it is technically challenging. There is a fine balance between too tight of a wrap resulting in dysphagia and too loose resulting in recurrence of reflux. The procedure also entails a lot of dissection. In the long-term, 47 percent of Nissen fundoplications will deteriorate, requiring reoperations which can be very challenging, and many patients experience dysphagia, flatulence and an inability to belch or vomit post-Nissen.
Dr. Murray then provides a brief comparison of Nissen fundoplication with TIF. Using the EsophyX® device, the gastroesophageal junction is reconfigured through a series of plications using the stomach that’s closest to the esophagus, as opposed to the Nissen where the tissue is taken furthest away and wrapped around the esophagus. The end-result with a TIF is a 2-3cm, 270-degree valve, similar like a Nissen, which is an effective reflux barrier.
Webinar Series: Why the TIF procedure makes sense. Michael Murray, MD Northern Nevada Medical Center, Reno, NV
Building on the previous section in the webinar, Dr. Murray displays the latest version of the EsophyX® Z+ Device, which has evolved with an emphasis on making fastener deployment consistently easy to do. Dr. Murray notes that patients with a great response to their PPI, don’t typically seek additional treatment options. However, those suffering atypical symptoms such as regurgitation and LPR, are better treated with a mechanical block. TIF is a good operation for this block, demonstrated by patient satisfaction levels with up to 4-years of follow-up.
Webinar Series: How to approach concomitant procedures. Michael Murray, MD Northern Nevada Medical Center, Reno, NV
Dr. Murray summarizes his approach to repairing a hiatal hernia concomitantly with a transoral incisionless fundoplication (TIF). While doing the hernia repair, he emphasizes paying close attention to the lines of tension and what might pull on the TIF. Using little dissection, he creates a nice window behind the esophagus, like doing a Nissen; however, in this case he leaves most of the left side of stomach alone so that if he ever must come back and operate on this patient again, the left side has not been traumatized by surgery. He also leaves the blood supply to the fundus completely alone. He notes that the hernia always looks a bit larger than when viewed through an endoscope.
Regarding the TIF, Dr. Murray asserts that insufflation is an important part of this. Surgeons don’t like to see everything go away, but in this operation, when doing the wrap de-sufflation will occur and visualization will be temporarily lost. He cautions against a tendency to panic at this point and to simply let the stomach insufflate again before firing the fasteners, as it is important so see that there is good coaptation of the tissue mold before firing.
Webinar Series: Setting expectations for GERD patient’s journey over time. Michael Murray, MD Northern Nevada Medical Center, Reno, NV
Dr. Murray looks at the efficacy of TIF over time, with the caveat that follow-up data for TIF is currently limited to 4 years. He states the data for Nissen fundoplications shows that 47 percent will break down within a 12-year period and there’s no reason to think the TIF won’t have a similar failure rate, which currently fails about 20 percent of the time fairly early, with a lower, but steady failure rate over time. Dr. Murray asserts that people who overeat and gain weight, following an anti-reflux procedure tend to suffer recurrent reflux. He claims that one of the significant advantages of TIF, over a Nissen, is that it’s a lot easier to redo a TIF as the greater curvature hasn’t been taken down or wrapped completely around the esophagus, leaving a plane to access, which can be converted to a Nissen, if need be. If an anterior corner comes off, it can be repaired endoscopically, with most patients doing fine afterwards.
Shaping the Future of GERD Management: Full Webinar
View the full webinar below, to see each of the highlighted segments above, in their full context, from Dr. Michael Murray, a general surgeon based at the Northern Nevada Medical Center in Reno, Nevada, who has completed over 250 TIF procedures and who helped pioneer the idea of concomitantly repairing a hiatal hernia laparoscopically, followed by a TIF. In this webinar, Dr. Murray demonstrates the scope of how widespread and damaging GERD can be. He draws upon his vast experience with these operations to provide practical tips on how to best carry them out, demonstrating the advantages of TIF over Nissen and expected failure rates. At the end of the webinar, Dr. Murray fields questions from a well-informed audience in which there are many general surgeons present.