867 Efficacy and Safety of Transoral Incisionless Fundoplication (TIF) in Refractory Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Refractory gastroesophageal reflux disease (GERD) is common and can affect up to 40% of patients who are on proton pump inhibitor therapy. Surgical fundoplication (Nissen fundoplication) has proven to be an effective treatment option for these patients but it remains an invasive procedure in this era of minimally invasive surgery. Several endoluminal approaches to GERD management have been developed as a potential bridge between medical management and surgical fundoplication. Transoral incisionless fundoplication (TIF) is a novel endoscopic technique which has shown some promise in early studies; however, its safety profile and efficacy remain uncertain. We aimed to assess the efficacy and safety of TIF in refractory GERD through a systematic review and meta-analysis. METHODS: We performed a thorough literature search using PubMed, EMBASE, Cochrane library, Medline, Google Scholar and Science citation index between January 2010 to January 2018. Search terms included MeSH and non-MeSH terms relating to gastroesophageal reflux disease, refractory gastroesophageal reflux disease, endoscopic techniques in gastroesophageal reflux disease and transoral incisionless fundoplication. Additional case-reports, case series, and abstracts were retrieved by searching from references of relevant studies. Primary outcomes measured were cumulative technical success rate and adverse events. Secondary outcomes measured were the improvement in Gastroesophageal Reflux Symptom Score (GERSS), DeMeester score and Reflux symptom index (RSI). RESULTS: Based on our search criteria, 41 studies were identified and 6 were excluded after careful review. 35 studies which included 1586 patients (49.4% males) were analyzed. The overall technical success rate of TIF was 98.4% (95% confidence interval [CI] 96 to 99, P < 0.001) and had an adverse event rate of 3.2% (95% CI 1 to 4, P < 0.001). Post TIF, there was a significant improvement in GERSS score (mean difference 17.29, 95% CI 17.26 to 18.28, P < 0.001), RSI (mean difference 14.37, 95% CI 13.39 to 15.19, P < 0.001) and DeMeester score (mean difference 9.78, 95 % CI 8.12 to 11.89, P < 0.001). CONCLUSION: TIF is a technically feasible and effective endoscopic therapeutic option for refractory GERD with good clinical responses. However, more controlled trials are required in future to compare the efficacy and safety between TIF and Nissen fundoplication.