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CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(11): E1785-E1791
DOI: 10.1055/a-1547-6599
Original article

The learning curve for transoral incisionless fundoplication

Mohamad Dbouk‡
1   Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
2   Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Olaya I. Brewer Gutierrez‡
1   Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Bijun Sai Kannadath
3   Department of Internal Medicine, University of Arizona – College of Medicine – Phoenix, Arizona, United States
,
Jose Valentin Camilion
4   Nova Southeastern College of Osteopathic Medicine, Davie, Florida, USA
,
Saowanee Ngamruengphong
1   Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Vivek Kumbhari
1   Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Mouen Khashab
1   Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Michael Murray
5   UNRMed-University of Nevada, Reno, Nevada, United States
,
Peter Janu
6   Fox Valley Surgical Associates, ThedaCare Regional Medical System, Appleton, Wisconsin, United States
,
Glenn Ihde
7   Matagorda Regional Medical Center, Bay City, Texas, United States
,
Kenneth Chang
8   H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine, California, United States
,
Nirav Thosani   **
9   Division of Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, Texas, United States
,
Marcia Irene Canto   **
1   Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Abstract

Background and study aims Transoral incisionless fundoplication (TIF) is a safe and effective minimally invasive endoscopic technique for treating gastroesophageal reflux disease (GERD). The learning curve for this technique has not been reported. We studied the learning curve for TIF when performed by a gastroenterologist by identifying the threshold number of procedures needed to achieve consistent technical success or proficiency (consistent creation of TIF valve ≥ 270 degrees in circumference, ≥ 2 cm long) and efficiency after didactic, hands-on and case observation experience.

Patients and methods We analyzed prospectively collected data from patients who had TIF performed by a single therapeutic endoscopist within 17 months after basic training. We determined thresholds for procedural learning using cumulative sum of means (CUSUM) analysis to detect changes in achievement rates over time. We used breakpoint analysis to calculate procedure metrics related to proficiency and efficiency.

Results A total of 69 patients had 72 TIFs. The most common indications were refractory GERD (44.7 %) and proton pump inhbitor intolerance (23.6 %). Proficiency was achieved at the 18th to 20th procedure. The maximum efficiency for performing a plication was achieved after the 26th procedure, when mean time per plication decreased to 2.7 from 5.1 minutes (P < 0.0001). TIF procedures time varied until the 44th procedure, after which it decreased significantly from 53.7 minutes to 39.4 minutes (P < 0.0001).

Conclusions TIF can be safely, successfully, and efficiently performed in the endoscopy suite by a therapeutic endoscopist. The TIF learning curve is steep but proficiency can be achieved after a basic training experience and 18 to 20 independently performed procedures.

** Drs. Thosani and Canto are co-senior authors.




Publication History

Received: 05 February 2021

Accepted: 22 June 2021

Article published online:
12 November 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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