461. BARRETT'S ESOPHAGUS POST-ABLATION TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) WITH OR WITHOUT HIATAL HERNIA REPAIR (CTIF):A PROSPECTIVE FEASIBILITY TRIAL
Authors: Canto Marcia Irene , Parker Brett , Brewer-Gutierrez Olaya , Dunbar Kerry , Rubenstein Joel , Shaheen Nicholas , Ngamrhuengphong Saowanee 
Published: September 2024

Abstract
Transoral incisionless fundoplication without (TIF) or with concomitant hiatal hernia repair(cTIF) are treatment options for GERD. Lifelong PPI therapy is recommended for BE patients, even after endoscopic eradication therapy (EET), but concern for adverse effects of chronic PPI use has increased. Full barrier surgical therapy (Nissen fundoplication, magnetic sphincter augmentation) is a highly effective treatment for GERD but is associated with dysphagia and gas-bloat. We hypothesized that TIF/cTIF may be reasonable alternatives. AIM: We studied the safety and efficacy of TIF/cTIF in post-EET BE patients with refractory GERD symptoms or esophagitis despite PPI, and those averse to chronic PPI. METHODS: We prospectively enrolled BE patients with BMI &lt;35 after successful EET (EMR, RFA, cryoablation) who underwent TIF (HH &lt; 2cm, Hill grade ≤2) from Nov 2017-2020 or cTIF (HH ≥2cm, Hill grade ≥3) from Nov 2020-2022. Preoperative evaluation included baseline standardized GERD questionnaires, EGD, and selective pH testing and manometry. The primary outcome was GERD/LPRD symptom control. Secondary outcomes were presence of esophagitis, PPI use, patient satisfaction (rated as satisfied/neutral/dissatisfied), average duration of symptom control off PPI, failure rate, BE recurrence, and adverse events. RESULTS: To date, 30 patients have had TIF or cTIF (Table 1) after EET for LGD/HGD/ImCA (n=19) or no dysplasia + family history of BE/ECA, n=11). Median follow-up to date is 3 years (IQR 2-4, range 0.5-6). 22/30(76%) were asymptomatic on once/twice daily PPI at baseline but PPI averse. All TIFs/cTIFs were completed without serious adverse events. At 6 months post TIF/cTIF, GERD/LPRD symptom control was 86% (GERD-HRQL score) and 93% (Reflux Symptom Index score) (Fig 1B), esophagitis was absent in all patients, PPI discontinued or reduced to occasional use in 83% (Fig 1B), and acid exposure time was normal in 74%. At last follow-up, GERD and LPRD symptoms remained controlled in 93% and 96%, respectively, esophagitis absent in 95%, PPI discontinued or reduced in 71% (Fig 1D). Overall, the mean duration off PPI from TIF/cTIF was 30.4 months (range 4.4-72.5). Patient satisfaction improved from 43% at baseline, to 69% at 6 months, to 79% at last follow-up (Fig 1C). TIF/cTIF failure (defined as resumption of daily/twice daily PPI, symptom recurrence, and/or abnormal AET) was 9(32%), greater in TIF (50%) than cTIF (8%) (p=0.039). Median recurrent hiatal hernia length was 1(IQR 0-1.5). Nondysplastic BE recurrence noted in 1 patient treated with APC and TIF (3.3%). Dysphagia (10%) and gas bloat (7%) improved from baseline (37% and 20%, respectively). CONCLUSION: Transoral partial fundoplication is a safe and effective alternative to chronic PPI or full barrier surgical therapy in BE patients after EET. Surgical hiatal hernia repair (cTIF) provides added durability.