A single-center real-world experience of transoral incisionless fundoplication: Learning curve, proficiency and outcomes

Background: Transoral incisionless fundoplication (TIF) is an effective treatment for gastroesophageal reflux disease.As a technically demanding endoscopic procedure, TIF has a measurable learning curve that may influence procedural performance and outcomes.This study evaluates the learning curve associated with TIF and its impact on clinical outcomes.Methods: This is a retrospective study of patients who underwent TIF procedures at a tertiary center from January 2018 to December 2021.Proficiency was defined as reliably achieving a procedure length 45 minutes.Patient symptoms and procedure-related adverse events occurring up to two months were collected.Results: A total of 68 patients underwent 77 consecutive TIF procedures (67.6% female), with procedural proficiency achieved after 12 cases.After adjustment for body mass index, American Society of Anesthesiologists class, and Hill grade, Hill grade and procedure duration were not associated with the number of fasteners used (P = 0.475 and P = 0.091, respectively).Mean fastener use increased significantly over time, from 18.3 3.8 in the first tertile to 28.0 4.8 in the final tertile (Holm-adjusted P < 0.001).Immediate abdominal pain was reported by 28% of patients and was associated with increased fastener use (odds ratio 1.13 per fastener; 95% confidence interval 1.02-1.24).Among 29 patients with follow-up endoscopy, 62.1% had an intact wrap, with no association between fastener number and wrap integrity (P = 0.534).Conclusion: TIF has a defined learning curve, with proficiency achieved after 12 procedures.Operator experience influenced technical execution without compromising wrap integrity, supporting the safe adoption of TIF in experienced centers.