Virginia Mason Medical Center Seattle, WA, United States
Shivanand Bomman, MD, Adil Ghafoor, MD, Sofya Malashanka, MD, Richard Kozarek, MD, Shayan Irani, MD, Andrew Ross, MD, Michal Hubka, MD, Rajesh Krishnamoorthi, MD Virginia Mason Medical Center, Seattle, WA
Introduction: Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder in the United States. Transoral Incisionless Fundoplication (TIF) has evolved as an accepted alternative to surgery for anatomic treatment of GERD. While introducing a new technique, there are challenges to maintaining patient safety and training personnel. In this report, we analyze our institution’s programmatic allocation of resources over time during TIF implementation experience.
Methods: We performed a retrospective analysis of all the patients who underwent TIF since introduction in January 2020 until February 2021. We describe a process of initial allocation of operating room (OR), surgical instruments and staff for added safety with planned overnight admission and routine post-operative esophagram (EG). After safe initial experience, staff were trained to perform TIF in the endoscopy suite (ES) in an outpatient setting in the ES with defined discharge criteria. Rescue inpatient admission with EG was performed only if clinically indicated. Patient safety and outcomes were evaluated during this transition.
Results: Over the study period, 30 patients underwent TIF. The mean age was 51.1±16.01 years and 60% (18) female. Initial 9 (30%) patients underwent the procedure in an OR with planned admission and subsequent 21 (70%) patients as outpatient in the ES. All patients were on acid suppressive therapy (AST) prior to the procedure. The mean DeMeester score was 57.1±46.4. TIF procedure was technically successful in 29/30 (96.6%) patients. OR patients had a median length of stay (LOS) of 1 day, whereas 4 (19%) from the ES group required clinically indicated admission. All the OR group patients had routine EG, while only 3 (14.2%) in the ES group required EG. There were no esophageal leaks or perforations, however, three (10%) patients had post-operative minor adverse events. The mean duration of procedure was significantly lower in the ES group [65.7 minutes vs 84 minutes, p value = 0.02] (Figure 1). Among the successful TIF patients who had 3 month follow up (24/29) 70.9% patients had stopped or reduced AST.
Discussion: We describe a successful stepwise process of planned decrease in hospital resource allocation over time for the safe introduction of TIF. This process allowed us to effectively initiate a new technique without any major complications while successfully transitioning to a fully outpatient procedure in majority of patients.
Figure: Figure 1. Implementation and transition of Transoral Incisionless Fundoplication (TIF) procedure from Operating Room (OR) to ES (Endoscopy Suite).
Shivanand Bomman indicated no relevant financial relationships.
Adil Ghafoor indicated no relevant financial relationships.
Sofya Malashanka indicated no relevant financial relationships.
Richard Kozarek: .
Shayan Irani: Boston Scientific – Consultant. Gore – Consultant.
Andrew Ross indicated no relevant financial relationships.
Michal Hubka indicated no relevant financial relationships.
Rajesh Krishnamoorthi indicated no relevant financial relationships.
Shivanand Bomman, MD, Adil Ghafoor, MD, Sofya Malashanka, MD, Richard Kozarek, MD, Shayan Irani, MD, Andrew Ross, MD, Michal Hubka, MD, Rajesh Krishnamoorthi, MD. P1715 - Safe Implementation of Transoral Incisionless Fundoplication as a New Technique in a Tertiary Care Center, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.