When psychiatrist Gerald Maguire was in medical school decades ago, he began to experience “a horrible discomfort” in his chest. He first thought it was the result of long nights studying and working, and a poor diet. Over-the-counter antacids didn’t help.
A few years later when he was a resident, Maguire was diagnosed with gastroesophageal reflux disease (GERD), a condition that affects millions of Americans. It occurs when stomach acid flows back into the esophagus — the tube connecting the mouth and stomach — and irritates the esophageal lining.
Antacids and proton pump inhibitors such as omeprazole gave him some relief but he still had to prop himself with pillows to sleep. He also avoided anything spicy or too acidic. Over time, those measures became less effective. Finally, a doctor treating Maguire’s father for a hiatal hernia suggested Maguire get checked to see if he had one, too.
Sure enough, a diagnostic endoscopy in February 2022 revealed a sliding hiatal hernia that allowed the top of his stomach to push through a 4- to 5-centimeter opening in his diaphragm, the thin muscle that separates the chest and abdomen. This was the cause of Maguire’s GERD.
While hiatal hernias are sometimes left untreated, Maguire didn’t want to face several more decades of pain and the risk of developing esophageal cancer from GERD like his late father.
The cTIF alternative
He turned to Dr. Kenneth Chang, executive director of the UCI Health Digestive Health Institute, who had developed a state-of-the-art surgical procedure called concomitant transoral incisionless fundoplication (cTIF) to repair hiatal hernias.
For patients who don’t get adequate acid reflux relief from medication and behavior modification — weight loss, exercise and diet — cTIF surgery to reconstruct and strengthen the esophageal valve is a good option.
Until now, the most common current surgical procedure for hiatal herna repair has been laparoscopic Nissen fundoplication (LNF). It entails wrapping the top of the stomach around the esophagus. While it is quite effective, there are potential downsides because it tightens the esophageal opening to the stomach more than is normal, Chang says.
A healthy esophageal sphincter prevents excess acid from refluxing into the esophagus, yet allows gas to vent from the stomach and intestine. It also allows people to regurgitate when necessary. This tightened valve is why some LNF patients have good acid reflux control but they are unable to burp to relieve gas or to vomit.
A partial wrap
The cTIF procedure, which combines laparoscopic hiatal hernia repair with endoscopic transoral incisionless fundoplication (TIF), only partially wraps the esophagus.
There’s less risk of a too-tight fit causing unwanted side effects because cTIF “restores the valve as close to its natural functioning as possible,” Chang says.
Another advantage is that cTIF allows easier access to strengthen the esophageal valve a decade or two later if it loosens. Redoing an LNF requires taking apart the old fix and rewrapping the stomach around the esophagus.
With cTIF, if the hernia hasn’t recurred, the valve can be tightened endoscopically, which is easier and less invasive, Chang says. “We don’t have to take everything down in order to tighten it.”
A team approach
Chang worked with UCI Health gastrointestinal surgeon Dr. Ninh T. Nguyen to pioneer cTIF. Over the last few years, they have performed about 300 of these procedures.
Maguire underwent cTIF in September 2022. He was sent home the next day after a confirmatory upper GI X-ray. He followed a careful diet for six weeks, starting with liquids then gradually transitioning to soft and solid food.
He now enjoys dishes that were strictly off-limits, such as “spicy pasta sauces, garlic and even coffee,” he says. “I used to get some reflux, but now I can enjoy a cup of coffee in the morning!”
Maguire is delighted that he no longer needs medication to control his reflux. “My quality of life is so much better. I’m able to enjoy a nice meal and a glass of wine with my wife and daughter.”