Great River GERDs for new procedure

April 04--WEST BURLINGTON -- Those suffering gastroesophageal reflux disease now have another treatment option, though they may have to wait a year or so before getting the new procedure as insurance companies have been reluctant to approve it.

Transoral incisionless fundoplication (TIF) is an endoscopic procedure that reconstructs the gastroesophageal valve by pulling part of the esophagus into the stomach and fastening it there. As its name suggests, TIF does not require an incision.

Instead, the operating surgeon accesses the esophagus and stomach through the patient's mouth, Timothy Monson, a general surgeon at Great River Medical Center in West Burlington, explained.

After the patient has been anesthetized, a scope is used to make sure there is no food in the stomach or anything else that could get in the way of the procedure. Once it's determined to be clear, a dilator is used to open up the about 18 inches of esophagus, where it remains for about 10 minutes while a scope and the EsophyX Z, a one-time use device about the size of a 50-cent piece designed specifically for the TIF procedure, are prepared.

The adjustable device is inserted into the stomach through the esophagus along with a scope, which runs through the center of the EsophyX Z. The scope is positioned slightly below the device, allowing the surgeon to see where esophagus and stomach meet, as well as what the device being controlled by the surgeon is doing.

Once the device is positioned, the surgeon uses a corkscrew-like piece inside the device to grab esophageal tissue and pull it down into the stomach. That tissue is held in place by the device while about 20 fasteners are placed to create a 270-degree flapper valve that prevents things in the stomach from squirting back up into the esophagus.

"The theory behind it is that you create more length of esophagus inside the stomach, and that acts as a valve to prevent the acid from the stomach getting back up in the (esophagus). And that's the essential problem with acid reflux disease. The lower part of the esophagus is not functioning correctly," Monson said of the theory behind the procedure.

The procedure takes about 30 to 45 minutes, Monson said, though some surgeons can do it in 20.

Recovery time is significantly lower for TIF than for nissen fundoplication, the surgery used most often to treat GERD, and patients are able to go home the day of or the day after the surgery. Physical activity should be limited, but not as much as with nissen. There also are fewer complications, though TIF can result in minor transient bleeding at the corkscrew point, but that bleeding can be controlled.

"Interestingly, the major problem we've had -- and when I say we, it's physicians doing the procedure -- have had getting it going is insurance approval. It's a relatively new procedure that insurance companies have been relatively resistant to approve," Monson said.

The EsophyX Z is pricey, and the surgery was developed shy of 10 years ago. Monson said three-year data on patients who underwent the surgery show promising results and feels it won't be long before insurance is on board, especially because of increasing evidence of kidney damage and bone density issues.

"There's just literally thousands and thousands of patients out there who are on long-term antacid medications now that have been on it for years, and we're starting to see some significant side effects from that," Monson said. "I think (TIF's) going to be a better alternative to long-term medication use."

Physicians with Great River Surgeons see about 50 GERD cases each year. This year alone, they have seen about three patients whose conditions would have been ideal for the procedure.

"We haven't actually done any yet," Monson said.

He likely will perform the first TIF procedure later this year, when a patient with a moderate hiatal hernia who had a failed nissen will undergo a dual procedure involving laproscopic repair of the hernia immediately followed by the TIF. By doing it this way, insurance will cover the costs of the surgery, though the hospital likely will foot the bill for the device.

For more information about TIF, talk to a physician or call Great River Digestive Health at (319) 768-3125.

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