When medication isn’t enough to manage symptoms of gastroesophageal reflux disease, Johns Hopkins surgeons have a range of minimally invasive options to help.

“Some of them are classic techniques that we’ve modernized and are now performing via minimal access surgery, whether that includes a robot or just laparoscopic surgery,” says gastrointestinal and foregut surgeon Brett Parker. “Some techniques are extremely new, and we are seeing amazing results.”

Most often, patients with refractory symptoms of the condition — commonly known as acid reflux — have a hiatal hernia (the stomach protrudes into the chest). “The first step of any anti-reflux surgery,” Parker says, “is to repair the hiatal hernia,” either laparoscopically or robotically.

After that, there are several options to re-create the anti-reflux barrier, he says. Most require an overnight hospital stay.

• Fundoplication: During this procedure, surgeons wrap the stomach around the bottom of the esophagus to reinforce the esophagus and create a high-pressure zone to stop acid reflux. The wrap is tailored to the patient’s condition — it is either a complete 360 degree or a partial 270 degree wrap.
• Magnetic sphincter augmentation: Surgeons implant a flexible ring of small magnets around the bottom of the esophagus to reinforce the lower esophageal sphincter.
• Combined transoral incisionless fundoplication: For patients with a hiatal hernia and acid reflux, surgeons first fix the hiatal hernia either laparoscopically or robotically. Then they use an endoscope to insert a device through the mouth to wrap the stomach partially around the esophagus from the inside, to create an anti-reflux flap valve. Patients who don’t have a hiatal hernia can receive only transoral incisionless fundoplication using the endoscope. A small number of institutions across the U.S. offer this option — Johns Hopkins has a collaborative research center through which surgeons and gastroenterologists work together to determine who would most benefit from this technique.

Additionally, surgeons offer minimally invasive Roux-en-Y gastric bypass to patients who are obese or for whom other surgical treatments for acid reflux have failed, says Gina Adrales, director of the Division of Minimally Invasive Surgery. The procedure involves creating a small pouch from the stomach and connecting it to the small intestine, bypassing the acid-producing portion of the stomach. It also eliminates bile reflux. Some patients who are obese who receive testing are found to have reflux-related damage to the esophagus even without symptoms.

“Obesity increases the risk for acid reflux,” Adrales says. “It’s a concern because there’s a rising rate of adenocarcinoma of the esophagus, which we think is directly related to acid reflux.”

Most patients receive a complete foregut work-up to determine the most appropriate procedure, Parker says. This includes an upper endoscopy with biopsies, esophageal pH testing, manometry to assess swallowing function, and imaging. Recommendations are made based on patients’ symptoms, motility and disease severity, including any signs of erosive disease or precancerous changes known as Barrett’s esophagus.