TIF Procedure (Transoral Incisionless Fundoplication)

What is a TIF procedure?

A TIF procedure is an endoscopic operation to treat chronic acid reflux (GERD) and hiatal hernia. “Endoscopic” means that it’s done with the aid of an endoscope, a long tube with a camera that goes through your mouth into your esophagus. This is less invasive than surgery because there’s no cutting.

“TIF” stands for transoral incisionless fundoplication. “Transoral“ means through the mouth, and “incisionless“ means there are no surgical incisions. “Fundoplication“ is the operation itself. It means folding (plicating) the top part of your stomach (the fundus). The procedure folds your fundus around your esophagus.

How does the TIF procedure treat GERD?

Fundoplication reinforces your gastroesophageal junction (GEJ), the junction where the end of your esophagus meets the top of your stomach. If you have chronic acid reflux (GERD), it’s because this junction has become too relaxed, allowing stomach acid to flow backward into your esophagus.

Often, a hiatal hernia is also involved in GERD. This means that the top of your stomach (fundus) is emerging through the esophageal hiatus. That's the opening in your diaphragm that your esophagus passes through to meet your stomach below it. A TIF procedure can also correct a hiatal hernia.

Who is the TIF procedure for?

The TIF procedure is an option for people with mild to moderate GERD and/or hiatal hernias who want a lasting solution, but don’t want or can’t have surgery. It offers a third choice between surgery and lifelong medication with proton pump inhibitors (PPIs), which is the usual treatment for GERD.

Some people with GERD find that PPIs become less effective in managing their symptoms over time. This may be because their GEJ continues to weaken. Others have concerns about taking PPIs long-term for various reasons. The TIF procedure allows them to safely reduce or stop taking these medications.

What happens before you have a TIF procedure?

If you’re interested in the TIF procedure, discuss it with a healthcare provider. A gastroenterologist or general surgeon can perform it. They’ll assess you first, to make sure you’re a good candidate for the procedure. They might look at your esophagus and/or hernia or assess how much acid reflux you have.

You might need a few tests, including:

• Esophagram. An esophagram takes video X-rays (fluoroscopy) of your esophagus swallowing.
• Upper endoscopy. This exam involves looking inside your esophagus with an endoscope.
• Esophageal pH test. This test measures the acid content inside your esophagus through a small wireless receiver. Your provider places the receiver in your esophagus during an endoscopy.
• Esophageal manometry. This test measures muscle activity in your esophagus, using pressure sensors embedded in a nasogastric tube. It can confirm if your muscles aren’t working right.

The TIF procedure might not be the right treatment for you if you have:

• A large hiatal hernia.
• A swallowing disorder.
• Severe erosive esophagitis.
• Permanent tissue changes, like Barrett’s esophagus or esophageal stricture.

How will I be prepared for the TIF procedure?

Your provider will review your current medications and make adjustments if necessary. They’ll also ask you to avoid food and drink for 12 hours before your appointment. After you arrive, they’ll give you medication through an IV before, during and after the procedure to ensure your safety and comfort.

Common medications include:

• Anesthesia. Most people have the procedure under general anesthesia, which means you’ll be asleep and won’t feel anything.
• Analgesics. You’ll also have separate pain medications through your IV to keep you comfortable when you wake up.
• Muscle relaxers. These help to keep your esophageal muscles relaxed and pliable while they operate.
• Antibiotics. Prophylactic antibiotics help to prevent infections resulting from the procedure.
• Antiemetics. These medications prevent nausea and vomiting during and after the procedure.

What happens during the TIF procedure?

During a TIF procedure, your provider will operate on your gastroesophageal junction through your mouth, using an endoscope and a special fundoplication device. They’ll use the device to wrap the top of your stomach (fundus) securely around your lower esophagus, creating a tighter valve between them.

There are several different TIF devices your provider might use. Each operates a little differently. Your provider will use the device to grasp and mold your tissues and secure them with fasteners, surgical staples or stitches. The endoscope will project images to a screen that they’ll watch while they operate.

How long does the TIF procedure last?

It takes about 45 to 60 minutes to perform the TIF procedure. Your whole appointment will be longer than that, though. You’ll need time for the anesthesia to take effect and to wear off again. After it’s worn off, you may be able to go home or you may need to stay in the hospital overnight.

How painful is a TIF procedure?

You won’t feel anything during the procedure, while you’re under general anesthesia. Afterward, you’ll have pain relievers as needed. Most people only need moderate pain relief, and only for a day. If you seem to need more, your provider will check for possible complications, like bleeding or infection.

It’s normal to have some minor discomforts for a few days afterward, like a sore throat, chest pain or shoulder pain. Throat and chest irritation are side effects of the tubes and devices that were in your esophagus. Shoulder pain is a side effect of the gas they pump into your esophagus before operating.

What are the risks or possible complications from a TIF procedure?

Complications from the procedure are unlikely but possible. They include:

• Injury to your esophagus or fundus, causing bleeding, a tear or perforation.
• Infection, including chest infections like mediastinitis, which can lead to an abscess.
• Symptoms gradually return, requiring a new operation or treatment plan.

What is the success rate of the TIF procedure?

The TIF procedure is still new, so we don’t have a lot of research following long-term outcomes yet. But early results suggest an 80% success rate after five years. Success means people experience immediate and lasting relief from their symptoms and are able to reduce or discontinue using their medications.

What is the recovery time from a TIF procedure?

You’ll continue medications for a few days after the procedure, including antibiotics and pain relief as needed. You’ll start to feel better soon after, but it will take several weeks for your esophagus to heal completely. Your provider will instruct you on how to modify your diet while you’re recovering.

Typically, you’ll start on a clear liquid diet, then progress to full liquids, and then to a soft diet. This might last two to six weeks. You can return to most activities, including school and work, after a few days, but you should avoid vigorous physical activity for up to a month after the procedure.

How is the TIF procedure different from Nissen fundoplication?

Nissen fundoplication is the original surgical procedure to treat acid reflux and hiatal hernia. The main difference is that a surgeon accesses your gastroesophageal junction through an incision in your abdomen. Or it may be several small incisions, if you’re having minimally invasive laparoscopic surgery.

Another difference is that the Nissen technique traditionally makes a tighter fold around your esophagus than the TIF procedure. This strong reinforcement has made the procedure very effective in treating GERD and hiatal hernias, especially when they’re severe. But for some people, it’s too tight.

Reported complications after Nissen fundoplication include difficulties with swallowing, burping and vomiting. This happens when the fundoplication is too tight. The TIF procedure isn’t associated with these types of long-term side effects. You can still burp and swallow normally after the TIF procedure.

Overall, the TIF procedure offers a more moderate type of correction for a more moderate type of problem. If your hiatal hernia isn’t too big and your acid reflux isn’t too severe, you can benefit from the TIF procedure without risking overcorrecting. You can also avoid surgery and its longer recovery time.

Is the TIF procedure worth it?

For the right candidate, the TIF procedure is well worth considering. It offers long-lasting relief in return for a short operation and recovery. It’s especially worthwhile if your hernia or reflux causes problems that medications don’t fix. PPIs can ease your symptoms, but they can’t stop reflux from happening.