Incisionless anti-reflux surgery: the future of preventing oesophageal cancer?

Gastroenterologist and interventional endoscopist Dr Rehan Haidry, University College Hospital London (UCLH) and the Cleveland Clinic, London, writes about how technology is used in a new procedure for oesophageal cancer.

The incidence of GERD is high in the general population, it is estimated to affect up to 20% of the population worldwide. Nowadays GERD is found to be the most common diagnosis made in a gastroenterology practice.

Gastroesophageal reflux disease (GERD) or chronic reflux can be severe – with a person experiencing symptoms as often as several times a week or even daily. Over time, GERD can damage the esophagus, or lead to pre-cancerous complications such as Barrett’s esophagus in up to 15% of patients. In Barrett’s oesophagus, repeated exposure to stomach acid causes changes to oesophageal cells. The longer a person has reflux, the higher the possibility of Barrett’s, which also increases the risk for oesophageal cancer — one of the fastest growing cancers in the Western world.

Those with chronic heartburn are typically prescribed daily drugs, such as proton pump inhibitors (PPIs), to keep their acid reflux under control and the NHS currently spends almost half a billion on these prescriptions. Unfortunately, research has shown that long term use of some heartburn medications has been linked to an increased risk of dementia, heart attack and kidney disease in some patients.

Preventative surgery is another option. During anti-reflux surgery (commonly performed on the NHS for patients with severe GERD and Barrett’s Oesophagus) incisions are made in the abdomen and the surgeon wraps the stomach around the lowest portion of the oesophagus. Anti-reflux surgery aims to control reflux symptoms and heal reflux induced oesophageal mucosal inflammation and thereby prevent progression of BE to adenocarcinoma. However, this surgery can cause side effects such as difficulty swallowing, bloating, and increased flatulence. The patient will also lose the ability to vomit, which some patients find distressing, and functions such as normal amounts of reflux/belching, can be limited.

An incisionless alternative to anti-reflux surgery: TIF

Transoral incisionless fundoplication (TIF) uses the ‘EsophyX’ device to reconstruct an ‘anti-reflux valve’ from the patient’s own gullet. By pushing the bottom of the gullet into the stomach and stitching it in place, this new valve prevents the highly acidic stomach contents from regurgitating and entering the oesophagus. The use of TIF to treat carefully selected patients with GERS is rising in the USA and Europe over the past five years. Studies have shown that for up to five years after the TIF procedure, GERD symptoms are significantly reduced and ~80% patients can stop taking daily heartburn drugs, such as PPIs. The procedure reduces the chronic acid reflux and thereby reduces the harm to the cells of the oesophagus (which may have turned cancerous over time if the chronic acid reflux had been left untreated). As important, it improves patient quality of life significantly.

22,000 TIF procedures have been carried out worldwide with minimal complications and a serious adverse event rate under 0.5%. TIF takes around 30 minutes and is performed in the endoscopy suite (making it lower risk for patients than surgery). It can help eliminate general GERD symptoms including upper abdominal pain, nausea/vomiting, stomach bleeding and swallowing disorders. It can also help with “atypical” symptoms of GERD from regurgitation (eg worsening asthma, hoarseness, cough, chest pain, aspiration, etc.) which medicines haven’t been very effective in treating.

TIF vs surgery

Tif

  • TIF mimics what surgeons do, but it’s completely incisionless and performed via endoscopy
  • TIF takes around 30 minutes and doesn’t require surgery
  • There is very little risk of swallowing problems (1%)
  • TIF patients maintain normal functions such as the ability to belch and vomit
  • TIF can only be done on patients with proven GERD and small hiatal hernias

surgery

  • Surgery involves multiple incisions
  • Surgery takes significantly longer
  • Surgery typically includes side effects such as difficulty swallowing (10-15%), bloating, and increased flatulence
  • The patient will also lose the ability to vomit, which some patients find distressing, and functions such as normal amounts of reflux/belching, can be limited.
  • Surgery is still needed for those with large hiatal hernias

The TIF procedure is currently available at the Cleveland Clinic Hospital in London and is covered by most private insurers.

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