Reflux and Hiatal Hernia: Surgery When Medication Is Not Enough

Gastro-oesophageal reflux is commonly experienced as heartburn. Most patients improve with lifestyle changes and medication, but symptoms persist in some people or return as soon as treatment stops. In carefully selected patients, surgery can offer a durable solution.

What is reflux?

Reflux occurs when stomach contents and acid flow back into the oesophagus. This can cause burning behind the breastbone, sour fluid in the mouth, swallowing difficulty, chronic cough, hoarseness and symptoms that disturb sleep.

How is it related to a hiatal hernia?

In many patients, the upper stomach moves through the opening in the diaphragm into the chest. This hiatal hernia weakens the natural anti-reflux barrier. Repairing the hernia is therefore an important part of surgery.

What is tried first?

Initial treatment includes weight management, smaller meals, avoiding late eating, raising the head of the bed, stopping smoking and alcohol, and acid-suppressing medication. These measures are effective for many patients but may not provide a permanent solution.

When is surgery considered?

• Symptoms continue despite appropriate medication.
• Symptoms return immediately when medication stops.
• A significant hiatal hernia is present.
• Reflux has damaged the oesophagus or caused Barrett’s oesophagus.
• Chronic cough or hoarseness is proven to be reflux-related.

Endoscopy and, when needed, specialist physiological tests confirm the diagnosis before surgery.

How is Nissen fundoplication performed?

During laparoscopic Nissen fundoplication, the diaphragmatic opening is repaired and the upper stomach is wrapped around the lower oesophagus to reinforce the valve. In some patients a partial wrap is selected according to swallowing function.

Recovery

Patients generally leave hospital within one or two days. A liquid and soft diet is followed initially, then normal food is reintroduced gradually. Mild temporary swallowing difficulty and early fullness are common. After successful surgery, many patients can stop acid-suppressing medicines.

Reflux surgery is not for every patient, but it can be a lasting solution for carefully assessed people whose symptoms remain dependent on medication.