Transoral Incisionless Fundoplication in Post-POEM GERD

EGD (esophagogastroduodenoscopy) is a safe procedure used extensively to evaluate the esophagus, stomach and small intestine. With the assistance of the anesthesiology team, we will put you to sleep partially to minimize discomfort during the insertion of the endoscopy. This is normally how this procedure is performed and deemed very safe. Potential complications include breathing problems, holes in the intestine, and bleeding. These occur very infrequently. In our study, EGD will be used at three checkpoints (all of which are part of standard of care):

1. at the time of POEM to rule out other unusual structural abnormalities
2. at 3 months during measurement of acid exposure in the esophagus via Bravo pH
3. 3 months after TIF placement (6 months after enrollment and POEM) to document resolution in acid reflux.

Esophageal manometry is a non-endoscopic procedure that involves using a safe numbing cream to allow passage of the manometry catheter from the nose down to the end of the esophagus. Different measurements are taken from the catheter and the catheter is then removed. This is a standard of care procedure in the evaluation of patients with esophageal motility/swallowing disorders. It will be used in the following settings and all are part of standard of care:

1. 3 months after POEM as part of standard of care to assess improvement in the swallowing
2. 3 months after TIF (6 months post POEM) only if swallowing issues reappear.

Bravo pH study is used to assess abnormal acid reflux and is considered gold standard in identifying the degree of acid reflux. It is standard of care for this procedure to be performed in patients with suspected acid reflux and post-POEM to assess need for long term acid suppression. It involves performing an endoscopy first, followed by deployment and implantation of the Bravo pH capsule into the end of the esophagus. Risks include bleeding, injury to the esophagus or dislodgment of the capsule. However, these are rare instances.

POEM Those enrolled into the study will undergo a diagnostic endoscopy at the same allotted time as the POEM. It will be explained to you in detail but involves endoscopically cutting the muscle at the end of the esophagus, called a myotomy. It is less invasive than its surgical equivalent Heller's myotomy, but equally effective. Two endoscopist (one with extensive experience in POEM and the other with formal training in POEM) will be performing the actual POEM procedures.

TIF The TIF procedure is performed using the FDA approved EsophyX-Z device (EndoGastricSolutions, Redmond, Wash, USA). It has been shown to be effective in the management of acid reflux in patients who fail acid suppression therapy or in patients who would like to avoid long term acid suppression with acid suppression therapy due to the potential side effects. It involves the use of a flexible suturing apparatus that fits over the endoscope and is used to create an artificial wrap around the end of the esophagus, thereby mimicking the effects of the typical surgical wrap. In the right setting it is as effective as its surgical counterpart but less invasive. Due to the incisionless approach, patients undergoing TIF experience less discomfort and faster recovery than those undergoing traditional anti-reflux surgery.