The patient is a 69-year-old female with the past medical history of hypertension, hyperlipidemia, hypothyroidism, and with interstitial cystitis. A written informed consent for publication of this case has been obtained.
She reported GERD symptoms for the past 16 years. Her GERD symptoms included heartburn, oral acid taste, regurgitation and epigastric discomfort. Medical treatment using proton pump inhibitors (PPI) only provided partial relief of these symptoms. The patient became PPI dependent and was unwilling to stop PPI even for a wireless pH study. She also had undergone four esophagogastroduodenoscopies (EGDs) for diagnostic purposes only and was not offered any intervention apart from recommending a different PPI. She increased frequency of PPI use to twice daily.
The patient was referred for evaluation for transoral incisionless fundoplication (TIF). Her examination was remarkable for the scars from her previous surgeries (laparoscopic cholecystectomy and hysterectomy). Her body mass index was 33.9. She completed the GERD-related quality of life questionnaires. The score of the GERD health-related quality of life (GERD-HRQL) questionnaire was 20. Reflux symptoms index (RSI) questionnaire score was 11. GERD symptom score (GERSS) questionnaire score was 5.
Her preoperative evaluation consisted of barium esophagram which showed good esophageal motility and a small hiatal hernia. EGD showed 2 cm sliding hiatal hernia with Hill deformity of II. Patient had abnormal gastroesophageal junction with Los Angeles class A esophagitis. Patient declined to stop PPI for esophageal pH testing due to severe GERD symptoms. We performed 48 h wireless pH probe study yielding a DeMeester score of 1.7. Preoperative esophageal manometry showed normal peristalsis and normal lower esophageal sphincter pressure and relaxation.
We discussed the option of laparoscopic Nissen fundoplication; however, the patient was interested only in natural orifice anti-reflux procedures. She was found to be a good candidate for TIF. She was the second patient to undergo this procedure by a TIF certified experienced endoscopic surgeon. Informed consent was obtained after we discussed the nature of the procedure and the surgeon's experience. The patient clearly indicated that she did not want to receive blood or blood products regardless of medical consequences.
She underwent the standardized TIF procedure using EsophyX HD device (EndoGastric Solutions, Redmond, WA, United States). The endoscopic retroflexed views of the native gastroesophageal valve (GEV) and the reconstructed GEV after TIF are illustrated in Figure 1. We performed an approximately 270  fundoplication with a GEV length of 3 cm. Her postoperative course was unremarkable and she was discharged the following day. There were no complications, presentations to the emergency department, or return to the operating room.
The patient was successfully weaned off PPI within 2 weeks following TIF. She completed the same GERD-related questionnaires at 5 and 24 months following the TIF. The improvements are illustrated in Table 1.