Transoral incisionless fundoplication is not associated with higher rates of post-surgical gastroparesis compared to anti-reflux surgery for GERD.

Transoral incisionless fundoplication (TIF) is a minimally invasive endoscopic procedure used for the management of gastroesophageal reflux disease (GERD) in patients with a hiatal hernia <>2 cm. Because TIF involves transmural fasteners placed across the gastroesophageal junction, there is a theoretical risk of vagal nerve injury leading to gastroparesis. Whether this risk differs from that seen with traditional anti-reflux surgery (ARS) remains unclear. Using the TriNetX multi-institutional database, we conducted a retrospective cohort study of adult patients with GERD who underwent either TIF or ARS. Patients with a prior history of gastroparesis or prior use of prokinetic agents were excluded. The primary outcome was the incidence of new-onset gastroparesis within 1 month to 1 year after the procedure; secondary outcome was the use of prokinetic agents. Propensity score matching was applied to balance baseline characteristics, including age, sex, race, BMI, diabetes, PPI, and opioid use. A total of 668 TIF and 53,996 ARS patients were identified. Before matching, gastroparesis incidence was similar between TIF (1.48%) and ARS (1.46%) (adjusted odds ratio [aOR] 1.01, 95% CI 0.54-1.9). After matching, the incidence remained comparable between TIF (0.7%) and ARS (1%) (aOR 1.0, 95% CI 0.22-2.26). The 1-year incidence of prokinetic agent use was lower in the TIF group (3.2%) than in the ARS group (6%) (aOR 0.51, 95% CI 0.3-0.9). In summary, post-surgical gastroparesis is rare after both TIF and ARS, with no significant difference between the two procedures. However, the need for prokinetic therapy was lower following TIF, suggesting a potentially lower burden of postoperative gastric motility symptoms. These findings may help guide counseling and individualized decision-making in GERD management.