Sept. 23, 2025
Gastroenterologists and gastrointestinal (GI) surgeons know that choosing the right procedure to treat gastroesophageal reflux disease (GERD) is challenging.
While the goal is to repair the underlying anatomical issue and improve quality of life, it's not simply a question of whether a particular operation or endoscopic procedure will fix the issue. If the solution does not meet that patient's expectations, preferences and willingness to make lifestyle changes, quality of life may change but not improve.
"It's a balancing act," says Steven Bowers, M.D., an advanced GI and bariatric surgeon at Mayo Clinic in Jacksonville, Florida. "We are always striving to find that balance, and that includes tapping into our resources and expertise to offer patients the full spectrum of antireflux therapies."
Offering a range of treatment options is part of the clinical team's commitment to optimal outcomes. "Our approach allows people to think about what's best for them without predetermining the treatment," says Dr. Bowers.
Comprehensive GERD treatment
When more-conservative methods of treating GERD are unsuccessful or not appropriate, surgical and endoscopic treatment options can be effective. However, these procedures can vary in their ability to control reflux. They also differ in the lifestyle changes required to minimize postoperative side effects.
The range of antireflux procedures performed at Mayo Clinic includes:
- Laparoscopic Nissen fundoplication. This antireflux surgery is the most effective treatment for controlling reflux. It involves wrapping the top portion of the stomach, known as the fundus, fully around the lower esophageal sphincter to tighten it. This procedure can eliminate reflux in even the most severe cases, but not every patient is a candidate for it. Because of a decreased ability to belch, patients must commit to changing their dietary behavior to avoid increased gas and bloating, which can lead to severe discomfort and flatulence. Dietary changes are vital to improving a person's quality of life after this procedure.
- Laparoscopic Toupet fundoplication. This partial fundoplication procedure creates a 270-degree wrap around the lower esophagus, differing from the 360-degree wrap achieved with the Nissen fundoplication. This partial solution is not as effective as a full fundoplication for long-term reflux control in severe cases, but it creates fewer gas-related side effects. It also offers a better resolution for trouble swallowing.
- Transoral incisionless fundoplication (TIF). During this endoscopic procedure, a valve made of stomach tissue is created at the base of the esophagus. This approach allows perfect placement of the valve and a minimized side effect profile, but it may not control reflux as effectively as a full fundoplication. The procedure can be combined with hiatal hernia repair (concomitant TIF or cTIF).
- Reflux management system. A small, flexible magnetic band is fitted around the gastroesophageal junction to control reflux. While it doesn't offer a high level of control for GERD, patients may have a better quality of life because they can belch and don't have to make many changes to their dietary habits.
"Alternatives to Nissen fundoplication may not be quite as effective in the long term, possibly lasting only 15 to 20 years, but there can be fewer gas and bloating issues," says Dr. Bowers.
Determining appropriate antireflux treatment
When a center offers many reflux therapy options, the preoperative process is especially important.
"We want to understand patients' esophageal physiology in as much detail as possible — how much reflux they have, the shape of their gastroesophageal junctions, how the esophagus functions when stressed," says Dr. Bowers. "All that information is important when putting together a treatment plan."
Not all patients require a full physiology workup, especially if they've had prior evaluations. If a full workup is needed, they may meet with a gastroenterologist for an endoscopy or visit the motility lab for diagnostic testing to measure pH and esophageal motility.
Once the team gathers diagnostic data, Dr. Bowers says the next step is a discussion with the patient. "Most people have a preconceived notion of what they want," he says. "We try to make sure that what they want is appropriate for them as a medical treatment and a lifestyle choice."
The most effective plan for some individuals involves preoperative weight loss guided by bariatric specialists. "There are many patients who have a lot of upper abdominal visceral fat, and we want to make their recovery easier," explains Dr. Bowers. "But to do that, we need to make the operation easier. Getting support and guidance from the Bariatric Center in Florida can help patients optimize their bodies prior to the operation."
Leaders in revisional operations for reflux and hiatal hernia
A significant part of Mayo Clinic's practice includes revisional operations in people who had their first surgeries at another center. The surgical team also often does revisions on recurring hiatal hernias, which are hard to prevent in such a dynamic space.
"We are on the cutting edge in terms of our medical knowledge and ability to perform primary repairs and revisional operations," says Dr. Bowers. Revisional operations are more technically demanding and require surgeons to cut through scar tissue surrounding very fragile organs. "Our center has some of the largest published reports of outcomes in revisional-type operations — revisions for fundoplication failure, revisional bariatrics, and revisions for achalasia or swallowing disorders."
Dr. Bowers says widespread expertise allows them to think outside the box for revisional surgery. "There is considerable overlap in the revisional space between antireflux procedures and bariatric surgery," he says. "Sometimes a bariatric operation is the best solution for someone who does not have success with fundoplication." At the same time, there are people who develop reflux following bariatric surgery and then need foregut surgery to fix the issue.
Dr. Bowers explains, "We try to offer everything that is in the mainstream because meeting patient expectations is really the most important measure of success in foregut surgery."
For more information
Bariatric Center in Florida. Mayo Clinic.
Refer a patient to Mayo Clinic.