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Bell et al. Mini-invasive Surg 2022;6:43 https://dx.doi.org/10.20517/2574-1225.2022.30 Page 3 of 5

Paradoxically questions about efficacy and durability, along with a somewhat cumbersome early device
iteration, resulted in limited use of transoral incisionless fundoplication (TIF) to surgeons with expertise,
specialization, and research goals.

It seems absurd in retrospect that surgical research on the reflux barrier focused on the intrinsic lower
esophageal sphincter (whose native function cannot be restored surgically without artifice and which can be
manipulated to some extent physiologically), and gauged the success of hiatal hernia repair by whether or
not the hernia recurring. It was left to gastroenterologists including Peter Kahrilas, John Pandolfino, Daniel
Sifrim and Ravi Mittal to clearly demonstrate that hiatal hernia destroyed the role of the diaphragmatic
crura as a major component of reflux barrier, though this was the portion of the reflux barrier surgeons
could much more naturally correct [8-11] .

Providentially the physiologic role of the diaphragmatic crural sphincter was elucidated when research into
failure of the LINX and EsophyX procedures demonstrated that surgical repair of even a minimal hernia
increased the success rate of both procedures dramatically. For TIF, the landscape changed dramatically.
During the intervening time, a new iteration of the device (EsophyX Z) had increased usability and
performance. In the U.S., at least gastroenterologists began collaborating with surgeons in the operating
room, the surgeon performing a laparoscopic hiatal hernia repair and the gastroenterologist the TIF
[12]
procedure . Recognizing that the results of this combined procedure (abbreviated C-TIF) are pending, and
the natural question of why perform a TIF instead of a partial fundoplication, the procedure has ushered in
a new, deep form of collaboration between gastroenterologists and surgeons. Technology once again
authoring collaboration exemplifying the goals of the Foregut Societies.

Peroral endoscopic myotomy (POEM) is a foregut intervention that demonstrates the blurring of surgical
and GI boundaries. Both surgeons and interventional GIs are performing the procedure in the U.S. and
elsewhere, and turf wars regarding which specialty should be performing the procedure have been limited to
provincial disputes. Societies including the AFS and the European Foregut Society (EFS) promote a
commitment to expertise rather than background, and it is again technology that leads to coalescence of the
two specialties. In the U.S., the Fellowship Council, which accredits non-board post-graduate training
programs, has not only approved a surgical foregut fellowship, it has committed to developing a GI foregut
fellowship, both of which would incorporate the diagnostic and interventional aspects of foregut disease.

Diagnostic tools including manometry, ambulatory reflux testing, and novel technologies furthering
Barrett’s diagnosis and therapy have found a place in both the foregut surgeon’s and foregut GI’s
armamentarium. Wide Area Transepithelial Sampling (WATS), Tissue Cypher’s biomarker assay to help
predict disease progression in Barrett’s, Confocal Laser Endoscopy (CLE), RF ablation with Halo, various
Argon Plasma Coagulation, and Cryotherapy are some such technologies that the foregut specialists
recognize as advances in patient care.

Surgical robotics has gained a solid foothold in foregut disease, especially in mediastinal dissection,
providing a stable visual field and instrument articulation. Preliminary studies indicate improved patient
outcomes with this approach to paraesophageal hernia repair . The future of robotics in foregut will be in
[13]
endoluminal procedures; currently, stable visual fields are fleeting and articulation is almost non-existent.
NOTES (Natural Orifice Transluminal Endoscopic Surgery), introduced prematurely a few decades ago, will
become possible with endoscopic robotics. When an endoluminal device uses a knife to cut through the
intestine, operate external to the organ, and close the enterotomy, no longer will it be possible to distinguish
the interventional gastroenterologist from the surgeon. Such technology will require specific training and