Raman Muthusamy, MD, MAS
Professor of Medicine
Medical Director of Endoscopy
UCLA Health


Physician’s Weekly spoke with Raman Muthusamy, MD, MAS, professor of medicine and medical director of endoscopy at UCLA Health, about the basics of transoral incisionless fundoplication (TIF).

Physician’s Weekly: How common is gastroesophageal reflux disease (GERD)?

Dr. Muthusamy: GERD is quite prevalent. In fact, it is estimated that roughly 40% of U.S. adults (80 million people) experience GERD symptoms. The first approach to managing it is typically lifestyle changes in terms of diet, exercise, timing of meals, and losing weight.

For patients who are still symptomatic, they are progressed to medications including antacids for mild reflux, H2 blockers, and proton pump inhibitors (PPIs). However, many patients and physicians are concerned about the long-term use of these, particularly PPIs, because they have been associated with kidney disease, fractures, vitamin deficiencies, and infections. Additionally, PPIs only reduce the concentration of acid (the burning sensation) and do not address the actual act of regurgitation.

What role does the anatomy play in GERD?

The two most important anatomic factors in the pathogenesis of GERD are:

  1. Lower esophageal sphincter (LES) which we consider to be the “inside valve” is a circular muscle that dynamically closes to prevent acid from coming up.
  2. Diaphragmatic crura (the “outside valve”) which wraps around the esophagus + stomach junction (GEJ), creating a pinching / angulation to also decrease acid reflux.

These two valves make up the natural anti-reflux barrier and work together in a coordinated fashion to prevent acid reflux. When one or both valves become too loose, the balance is thrown off and may require anatomic alterations.

What treatments options are available to GERD sufferers?

Outside of lifestyle changes, behavioral modifications and medications, there are anti-reflux procedures and surgeries. The most common surgical option is the Nissen fundoplication. Traditionally performed laparoscopically, in a Nissen procedure, the surgeon takes the fundus and essentially wraps it around the lower esophageal sphincter to correct the valve(s). While effective, there is a lot of variability in surgical technique which contributes to side-effects such as dysphagia (trouble swallowing) and gas bloat in as many as 25-50% of patients who undergo the surgery.

A less-invasive option is the endoscopic TIF® (transoral incisionless fundoplication) procedure, which helps to lengthen, strengthen, and tighten the LES without the need for surgery. In patients requiring a repair of the diaphragmatic crura/external valve (a hiatal hernia greater than 2cm), TIF can be performed concomitantly with a hiatal hernia repair (HHR). The procedure is roughly 45 minutes and addresses anatomic defects without the side effects of traditional anti-reflux surgery (eg, Nissen).

How does TIF bridge this treatment gap?

GERD is a spectrum disease that requires an individualized treatment plan. The combination of medications that do not address anatomical deficiencies and the long-term side effects associated with traditional anti-reflux surgeries (eg, Nissen) have created a significant treatment gap and left GERD sufferers without many options.

TIF offers both, patients and providers, an alternative, less invasive and durable treatment option which yields reproducible outcomes without the long-term side effects.

Is TIF a new procedure?

No, in fact, the original procedure received FDA clearance in 2007. Since then, there have been procedural technique improvements, as well as modifications to the EsophyX device, through which the TIF procedure is performed.

What should be discussed with patients?

It’s important to find out their goals and have an honest discussion about the pros and cons of each treatment option before the patient decides how to proceed. Right now, many patients are opting to try TIF because the data shows it can help alleviate symptoms, eliminating the need for medications, and avoiding the side effects of traditional fundoplication.