Approaches to anti-reflux surgery: Laparoscopic, robotic, and endoscopic

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal (GI) diseases in the United States (US) affecting approximately 40% of the entire population annually. GERD is a physiologic disorder of the lower esophageal sphincter (LES) which allows for the reflux of stomach acid into the esophagus. While initially a benign disease, GERD can present with a broad variety of both esophageal and extra-esophageal symptoms and can progress to precancerous and cancerous lesions. Currently, GERD is treated in a “step-up” approach, first with lifestyle modifications followed by medical therapy. While lifestyle changes and medical therapy can provide patients with symptomatic relief in 80% of cases, many patients will ultimately require alternative procedural intervention for complete symptom resolution. Laparoscopic antireflux surgery (LARS) and robotic assisted laparoscopic fundoplication (RALF) are the two most commonly performed procedures for GERD at present. Both are associated with excellent short-term morbidity and have been demonstrated to be effective alternatives to medical therapy. However, new endoscopic techniques are now competing for traction in the academic GERD community. These new endoscopic procedures were designed to address both the short and long-term side effects of traditional reflux surgery, bloating and dysphagia, and offer the true promise of minimally invasive surgery, incisionless surgery through a natural orifice. This review will provide an assessment of the three existing categories of procedural interventions, laparoscopic, robotic assisted, and endoscopic, and outline the key advantages and disadvantages of each method for the treatment of GERD.