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Reply to Chandnani et al.
We thank Dr. Chandnani and colleagues for their comments on the 1-year follow-up of patients with gastroesophageal reflux disease (GERD) who underwent transoral incisionless fundoplication (TIF) with the Medigus ultrasonic surgical endostapler (MUSE).
They focused on four issues, the first being that TIF is still considered a challenging therapy. A meta-analysis  has shown significant improvements in symptoms and reflux scores, a 91 % hiatal hernia reduction, and a discontinuation of proton pump inhibitor (PPI) therapy in 89 % of patients, so TIF is reliable.
The second was that there are no long-term studies comparing TIF with surgery. Eight studies on Esophyx and MUSE, reporting outcomes at 3, 4–6, and 10 years       , showed no differences between Esophyx and MUSE. Overall, two-thirds of patients were satisfied; one-third remained off PPI therapy and, in most of those who resumed PPIs, the doses were halved; four-fifths had significant improvements in heartburn, regurgitation, and GERD-HLQR scores. Overall, these long-term outcomes are similar to those of surgical fundoplication.
Thirdly, most patients who underwent TIF had Hill grade II of the gastroesophageal valve, and grade A or no esophagitis. TIF by MUSE is currently only considered for patients with proven GERD, PPI responsiveness, hiatal hernias that are < 2.5 cm and reducible, who are seeking an alternative to long-term medical or surgical treatment, rather than an alternative to surgery. Most of these patients, their number is steadily increasing, suffer from non-erosive reflux disease and are Hill grade II.
Fourthly, functional studies, performed in only 13 /20 patients, reported non-significant changes after TIF. Seven patients improved and refused to repeat functional investigations, which is not a selection bias but a consequence of a good outcome. Functional findings did not show significant changes, even if a longer lower esophageal sphincter high-pressure segment was found, probably because of the small numbers. However, most studies on TIF for GERD have reported discordance between the relief of symptoms and findings of pH-impedance recordings.
26 May 2021 (online)
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