Pearls from Grand Rounds: “Endoscopic Fundoplication for GERD: Where Do We Stand in 2026?”
Wasseem Skef, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth Houston
Gastroesophageal reflux disease (GERD) is a primarily anatomically driven condition. While proton pump inhibitors (PPIs) effectively suppress gastric acid, they do not repair a mechanically disrupted anti-reflux barrier (ARB). For patients experiencing incomplete symptom control, severe regurgitation, or medication intolerance, interventional management bridges the gap between chronic medical therapy and conventional surgery.
1. Defining “Actionable” GERD
- According to the updated Lyon Consensus 2.0, identifying optimal candidates for intervention requires clear objective evidence:
- Actionable GERD: Conclusive reflux pathology on endoscopy (e.g., severe erosive esophagitis, Barrett’s esophagus) and/or abnormal reflux monitoring with compatible, troublesome symptoms.
- Actionable Refractory GERD: Persistent pathologic acid exposure (AET > 4%) and >80 reflux episodes in 24 hours despite optimized, high-dose antisecretory regimens.
2. The Mechanics of Transoral Incisionless Fundoplication (TIF 2.0)
TIF 2.0 is an endoscopic, serosa-to-serosa plication that reconstructs a 2- to 4-cm, 270° to 300° valve to restore gastroesophageal flap valve dynamics and tighten gastric sling fibers. By allowing gas to escape normally, TIF significantly reduces the troublesome side effects commonly associated with traditional 360° surgical wraps, such as gas bloat, flatulence, and dysphagia.
3. Patient Selection & Efficacy
- Anatomical Boundaries: Standard TIF 2.0 alone is strongly recommended for patients with an intact or minimally disrupted crural diaphragm (Hill Grade I or II; select Hill Grade III with hiatal hernia ≤ 2 cm).
- The Hybrid Approach (cTIF): For patients with larger hernias (Hill Grade III >2 cm or Hill Grade IV), Concomitant Hiatal Hernia Repair with TIF (cTIF) combines laparoscopic crural repair with endoscopic fundoplication in a single session.
- Clinical Outcomes: Multicenter data and randomized controlled trials (such as the TEMPO and RESPECT trials) demonstrate that TIF eliminates troublesome regurgitation in up to 67% to 97% of partial responders, normalizes esophageal acid exposure, and allows roughly 90% of patients to completely discontinue PPI therapy.
4. Expanding Frontiers in 2026
Recent data highlight TIF’s versatility beyond primary GERD. It serves as an effective therapy for post-POEM (peroral endoscopic myotomy) reflux and recurrent symptoms after failed surgical wraps. Furthermore, because TIF preserves the gastric body, it can be safely performed during the same session as metabolic bariatric therapies, such as laparoscopic sleeve gastrectomy (LSG) or endoscopic sleeve gastroplasty (ESG), providing a crucial solution for patients navigating concurrent obesity and severe GERD.
Additional Reading & References
1. Gyawali CP, Yadlapati R, Fass R, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2023.
2. Gao Y, Jaber F, Masood M, et al. Efficacy of Second-generation transoral incisionless fundoplication (TIF 2.0) for treatment of gastroesophageal reflux disease (GERD) in hill grade (HG) III gastroesophageal junction (GEJ): A systematic review and pooled analysis. Innovative Surgical Trends. 2026;2(1):2.
3. Brewer Gutierrez OI, Choi D, et al. American Foregut Society White Paper on Transoral Incisionless Fundoplication. Foregut. 2023;3(3):242-254.