Real-life success and complication rate of Esophyx TIF procedure.

There are only a handful of members on this board who have had the TIF.  I had mine in August of '11.

You say you have been "endoscopically diagnosed" with GERD -- do you mean that erosions and/or redness was observed?  The only way to definitively diagnose GERD is with pH studies and manometry...although manometry is often inconclusive.  Sometimes reflux can be observed during a barium study, although there is usually no way to tell the difference between normal and abnormal reflux.  You should have the full complement of tests, and therefore have more confidence in what you're dealing with, before you consider surgery.

You don't share details about your symptoms, and this has everything to do with your surgical choice.  If you have typical GERD symptoms (i.e. heartburn, erosions), and are not overweight, have no other esophageal pathologies, and don't have a hiatal hernia beyond 2.5cm, then you are probably a good candidate for the TIF.

I'm not sure where you found a 65% success rate for the TIF.  "Success rates" are slippery percentages, but 80-85% is probably closer to a more accurate number.  The problem with TIF procedures (or even lap fundos, for that matter) is that very few are pre-qualified, either by procedure, or initial recommendations.  What I mean by this is that it's possible to have a clinical success by the test numbers, but a patient is still suffering with symptoms.

Pre-TIF, my DeMeester score was about 22, with exposure ranges between 6-8%.  Post-TIF, my DeMeester is about 4, with exposures 2.4% to 2.9%.  Well within what is considered the "normal" reflux range.  This sounds like a success, but, in fact, it is not.  That's because my symptoms are atypical airway/respiratory, which means reflux is getting into my throat and lungs.

Compounding this is the fact that I am intolerant of PPIs...simply cannot take them because of massive, debilitating headaches.  Also have significant heart palpitations while on them.

I met with a surgeon who evaluated me for the Nissen, but he said that, realistically, an exposure rate of 2% is about the limit of a wrap.  So, in my case, it would not be worth the risks.  I'm left with managing my symptoms as best as I can, with diet, sleeping on an incline, and Gaviscon.  Like many others here, I am miserable, especially since I know that there is no hope for resolution of my symptoms, or gaining my life back.

The TIF is reversible, and the surgeon said if he were to do a wrap on me, he would take the TIF apart.  He didn't seem overly concerned about this.

The TIF is a much more durable procedure than the Nissen, but it is also not quite as effective.  Also, the manufacturer of the EsophyX device clearly states that the TIF is a "bridge" procedure between PPIs and the Nissen.  Meaning, again, that it is not quite as effective, and that expectations for long-term resolution of symptoms need to be evaluated.

Before you make any decisions, you need to take some time and carefully evaluate your symptoms, and consider what your expectations are.  If it means seeing another doctor, then so be it.  I've been to eight since 2008.  Also, I would take a good hard look at the gastric infections you are experiencing.  It's possible that these are exacerbating your symptoms, and if you cleaned your gut of infections, it could resolve your symptoms to a more comfortable level without surgery or heavy dependence upon PPIs.

Best of luck!

-Bruce

Hi Lucas --

The TIF uses 16 very strong polypropylene H-fasteners, similar to what you see holding clothing tags in stores. Impervious to stomach acid, etc. There are four concentric rows of four fasteners, each row rotated slightly, a few millimeters apart. The limitation is how efficiently the EsophyX device can rotate when the fasteners are stapled, and it's not a perfect 360-degree wrap, like a Nissen. However, the way the fundus is tightly secured against the LES, allows for post-surgical attachments that enhance the strength of the fasteners, making for a really robust fundoplication. This assumes that there is good thickness to the esophagus, which is usually the case.

Contrast that with the Nissen. The fundus is lifted higher with the Nissen, requiring separation first from tissues like the spleen, etc. The only thing holding the Nissen in place are four, very strong sutures cinching the fundus around the esophagus, and perhaps one or two minor sutures (or a longer loop from one of the four main sutures) through the esophageal wall. There is a significant weight of the GI tract being supported by all this, requiring a long, gentle recovery time, and lifestyle changes if heavy lifting is involved. One of the advantages of the laparascopic procedure is that an oversized hiatus can be repaired, but this only prevents the surgical site from sliding upwards, not in supporting the effects of gravity.

There may be some natural attachment that goes on over time with the Nissen (or Toupet), to be sure, but not to the degree that occurs with the TIF. The fastening is different: TIF goes through the tissues, essentially folding and stapling them together, while the Nissen wraps the fundus against the esophagus from exterior sutures, pinning the wrap in place. (If you make a circle with your finger and thumb, imagine that this is the fundus. The sutures only go through the tips of your fingers.) Plus, less weight is being supported by the TIF than the Nissen, and other tissues are still in place to help with any additional load.

On the other side of the coin, the TIF surgical site is perhaps half the size of the Nissen, and not as well-equipped to prevent reflux. Hence, the Nissen outperforms the TIF slightly. There is peristaltic benefit from both procedures, but since more fundus is involved with the Nissen, it grips the lower esophagus better.

Hope this helps.

-Bruce

Hi joe --

Sorry to hear of your difficulties. I can certainly empathize!

Stem cell research into something that might become an accepted procedure, unfortunately, is so far in the future that it should not be part of your hopes. I'm not trying to be a kill-joy, just trying to frame what we have to deal with into the present.

The only way bile reflux can be diagnosed is with the impedence pH test. This test is becoming more and more difficult to find, unless you live near a large city or medical center. Is this the 24-hour test you had done? The other pH test, the Bravo, does not detect bile.

My last pH study in January measured 54 episodes during the 24 hours.

Apparently most doctors don't put much weight into DeMeester scores -- what they focus on is the % value under a pH of 4. "Normal" range is anywhere from 0 to 5%. You can find this on your test results, which you should have a copy. A correctly-done Nissen should get you at approximately 2%.

I hope you won't be discouraged by what I'm going to say. If you can tolerate PPIs, this at least gives you a safety net. If, on the other hand, you are like me, then you are going to have to manage this as best as you can. I can't really comment without knowing your % score, but it sounds like it's unlikely a redo would be of any benefit to you.

Some LPR patients, despite their insistence to the contrary, aren't actually getting either a measurable or significant amount of reflux into their airway/throat. What instead is happening is an allergic or reactive pathology that triggers nerves and muscles to sympathetically react as if they are being burned, simply by their proximity to the esophagus. Once an inflammation begins, it continues to feed itself, so to speak, as a result of the irritation. To test if this was the case with me, I was prescribed a very low dose of Nortriptyline to see if a desentizing of the nerves would decrease symptoms. I made it two doses, but I'm so sensitive to meds, that the dizziness and impairment forced me to stop. I can taste and feel the acid in my mouth in the morning, anyway, so I know that I'm not in this category.

The worst of my present symptoms are neck pains and headaches (directly attributed to stronger reflux episodes), dysphagia/borderline globus, weak vocal cords, and faux asthma.

One thing you should consider being tested for is eosinophilic esophagitis. I have a moderate form of this (which may be partly behind my symptoms, and is a reaction to the reflux and not a food allergy), and take a twice-weekly dose of a corticosteroid inhaler, that I swallow. EoE is found through biopsies, of which there should be an upper, mid, and lower taken during an endoscopy. EoE symptoms can mimic reflux.

I try to limit my exposure as best as I can. I don't really have that many trigger foods, and eat a bland diet anyway. I don't eat out, where I would be subjected to a lot of fried foods. (I'm vegetarian, btw.) I sleep on an incline, either in a recliner, or with a foam wedge in bed. The incline should be at least 10" or so. Don't use pillows, as this will cause a poor sleep posture that will actually make the reflux worse. The wedge should start from your hips/lower back, and depending upon how tall you are, you may need to build the top up with folded blankets or towels to support your pillow. I wouldn't go the route of lifting your bed frame, as it would be difficult to raise it that much, and perhaps be dangerous for pets. Plus, you'd end up sliding off the bottom.

Gaviscon is an OTC antacid, with a unique foaming property. It comes in two forms, liquid and tablet. I have tried both, and found that the tablets foam better, and coat all the way down when I swallow. I chew two before bed. The benefit probably only lasts 2-3 hours, at best, but it's one more tool to limit your exposure.

Finally, I don't eat or drink within 10 hours of bed. I know this sounds radical, and goes against conventional wisdom. But even water, in an empty stomach, will still reflux into the throat, carrying with it acid. If I chew the Gaviscon tablets on an empty stomach, there will be little or no stomach contents to dilute the antacid, and it will work more efficiently and for a longer period of time.

I'm sorry I can't give you more to go on. Unfortunately, if your Nissen is intact and functioning, and you are still experiencing atypical symptoms, any competent GI or surgeon will tell you that PPIs are your only recourse. The other pharmaceutical treatment I suggested is experimental, at this stage.

Hope something here is helpful.

-Bruce

Yes, I agree, this is a depressing disease. I only came back to this forum a couple days ago when I saw this thread. I found that I can't visit here like I did -- doing so forces me to focus on what's happening to me, and I get overwhelmed by seeing everyone else who's suffering too. I'm having an extremely difficult time emotionally right now, as I can't imagine having to live the rest of my life like this.

In your case, if you're actually having bile reflux, PPIs won't help. IMO, I think you should have your GI focus on testing your gall bladder. You shouldn't be having a large volume of bile into your stomach.

I eat a large enough meal to hold me through the afternoon and evening without getting too hungry.

-Bruce

If you look at the studies I have posted on this board previously, you will see that PH monitoring for GERD/LPR is highly controversial. There is no baseline on which to measure the PH scores, and many healthy adults with no reflux have worse scores than people with massive GERD/LPR. I am not a doctor or a researcher, but these PH studies look like "sleep studies" to me: time consuming and expensive procedures that make doctors wealthy, but do little for the patient.

Maybe more research is needed ...

I think LPR is an immunological and mechanical problem: in my case, my immune system simply doesn't function properly. It is in overdrive 24-7, due to environmental allergies, and a host of other factors. An extreme immune response creates inflammation and swelling, and this inflammation can interfere with the mechanical processes our body depends on. Example: swelling in the maxillary sinus tissue causes blockage, and this leads to other systemic problems.

Other mechanical problems are hiatal hernia: that will certainly cause issues with acid and bile coming up into the esophagus. This has very little to do with PH levels or acid amount: it is a digestive abnormality that might require surgery to fix.

Now the surgeries scare me: not being able to burp or vomit just sounds really bad, and I can see that leading to all kinds of other health issues. It could even be fatal if you are accidentally poisoned. Surgery would be absolutely the last resort for me. My friend had a fundo from one of the best surgeons in the midwest and could only drink protein shakes for 10 months afterwards. He was in constant pain--no thanks.

Tandem,how long ago did you have the tif done.

hi everyone. my demeester was post op..like .8 or 1. the thing is they waited too long and so much of my throat tissue was already burned. if my throat was pink and not cobblestoned id be in great shape. but in order for the throat to heal one must arrest all the reflux. i dont know what to do this pain is bad. if i didnt have the pain i honestly would be doing well.

Towers equals were. Sorry, typing from my phone.