Systematic Review and Network Meta-Analysis: Comparative Effectiveness of Transoral Incisionless Fundoplication(TIF)vs Laparascopic Nissen Fundoplication(Nissen)vs PPIs for the Treatment of Gastroesophageal Reflux Disease

Abstract

Introduction: TIF has recently emerged as an effective therapy for GERD, however it is not recommended as first line therapy. Gold standard treatment for GERD is either long term PPIs or Nissen. While both TIF & Nissen have been compared with either PPIs or sham, head to head comparison of TIF vs NISSEN has not. We performed a systematic review and network meta-analysis of randomized controlled trials(RCTs) to assess the efficacy of TIF vs NISSEN for the treatment of GERD. Methods: Cochrane Central Register of Controlled Trials & MEDLINE from inception to May 1, 2016. Data were extracted independently by two authors. Methodological quality was assessed using the Cochrane risk of bias tool. A network meta-analysis was performed using the Bayesian methods under random-effects multiple treatment comparisons. Results were summarized as odds ratio along with credibility intervals. The ranking probability was assessed by surface under the cumulative ranking curve(SUCRA). To assess the impact of follow up time a meta-regression was performed on the Health Related Quality of Life(HRQOL). The Maude database was also reviewed for adverse events. Results: Overall 7 studies were included: 2 RCTs (n=173)TIF vs sham, 2 RCTs(n=120)TIF to PPIs, and 3 RCTs(n=835)Nissen vs PPI(Figure 1 summarizes these comparison). SUCRA ranking indicated TIF had the highest probability of symptomatic remission followed by Nissen, sham, then PPIs(0.96, 0.66, 0.35 and 0.042, respectively). Persistent esophagitis was highest in sham followed by TIF, Nissen, then PPIs(0.74, 0.69, 0.38 and 0.19). Nissen had the highest probability of achieving improved % time pH < 4 followed by PPIs, TIF, then sham(0.99, 0.64, 0.32, and 0.05), as well as increase in LES pressure followed by TIF then PPI(0.78, 0.72 and 0.01) Figure 2. Meta-regression showed a significant association between follow-up time and HRQOL for NISSEN but not TIF indicating follow up time was a significant confounder. Maude database revealed 54 adverse events with at least 28 hospitalizations and 14 esophageal perforations.Figure 1Figure 2Conclusion: Nissen has a higher ability to improve physiological parameters associated with GERD including improving LES pressure and % time pH < 4. PPIs were superior to all for reducing esophagitis. Although TIF appeared superior for achieving symptomatic remission this is likely related to shorter follow up time compared to Nissen and PPIs.