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For Acid Reflux: An Innovative Alternative to Invasive Surgery

Acid Reflux

Johns Hopkins Heartburn Center is among few in the region to offer transoral incisionless fundoplication—a minimally invasive, endoscopic procedure offering faster recovery time and improved outcomes for certain patients.

The American Gastroenterological Association estimates that as many as one third of American adults experience acid reflux once a week. And ten percent live with heartburn every day.

“It’s so common that it’s hard to imagine a primary care physician who wouldn’t see a lot of heartburn patients,” says Mimi Canto, director of the new Johns Hopkins Heartburn Center. 

Canto says the center sees patients with refractory reflux, patients who no longer want to depend on proton-pump inhibitors, as well as patients with extra-esophageal symptoms like throat-fullness, hoarseness and a chronic cough. Finally, says Canto, there are patients who have simply tried everything.

“These are patients who have had surgery and their reflux symptoms have come back,” she says.

While Canto and her colleagues at the Johns Hopkins Heartburn Center offer numerous approaches to the condition, she and several other endoscopists are trained to perform the transoral incisionless fundoplication, or TIF, procedure. “It’s a great endoscopic alternative to Nissen surgery,” she says, referring to the invasive procedure that repairs the distal sphincter in the esophagus.

The lower esophageal sphincter normally serves as a one-way valve between the stomach and the esophagus, allowing food into the stomach while preventing reflux or regurgitation. Reasons for the valve’s failure range from obesity to hiatal hernia to pregnancy. 

In the TIF procedure, the endoscopist reconstructs the barrier without incisions on the chest wall or belly. With the patient under general anesthesia, the endoscopist uses a special device to create a new valve, fashioned from a small amount of stomach tissue near the end of the esophagus. Then, the endoscopist deploys tiny plastic fasteners to hold the new valve in place.

Canto says that studies show that patients with small hiatal hernias and a body mass index under 35 are the best candidates for TIF. And while TIF isn’t for every patient with reflux, patients who do fit the profile report a dramatic improvement in symptoms and quality of life. The majority are also able to stop their proton pump inhibitor medications. 

Canto says the TIF procedure involves creating a 270-degree new valve. 

“That way, we minimize some of the problems that come with 360-degree surgical fundoplication, such as gas bloat, trouble swallowing and the inability to belch or vomit,” she says. “This endoscopic valve is less restrictive, while still serving as the barrier for reflux.”

The TIF procedure has been shown to be more cost-effective than surgery and, perhaps best of all, Canto says, the recovery time from TIF is far shorter. Typically, patients spend a night in the hospital for observation, hydration and antibiotics. “We’re also sending more and more patients home the same day,” Canto says. “If they feel well enough, they can go home.”

While TIF patients should stick to a liquid diet for the first week and soft foods the second, Canto says patients can expect to return to work within a few days of the procedure and resume exercise and normal physical activity after three weeks.

Interested patients and referring physicians should email the Heartburn Center at


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