Most people with mild acid reflux do very well on a proton pump inhibitor and a few lifestyle changes. But a small and growing group of patients spend years on these medications, increase the dose, add second drugs, and still live with burning chest pain, regurgitation, and disturbed sleep. For them, there is another option that is often under-discussed in primary care: surgery.

This article is for patients who have been living with reflux long enough to wonder whether there is something better than daily tablets.

Understanding GERD

Gastro-Oesophageal Reflux Disease, or GERD, happens when stomach contents travel upwards into the oesophagus more often than normal. A small ring of muscle called the lower oesophageal sphincter normally prevents this. When that sphincter becomes weak or relaxes too often, acid and partially digested food reach the lower oesophagus and sometimes the throat.

Common symptoms:

  • Burning behind the chest bone, especially after meals or at night
  • Sour or bitter taste at the back of the throat
  • Regurgitation of food or liquid, particularly on lying down
  • Chronic cough, hoarseness, or a feeling of something stuck in the throat
  • Disturbed sleep from nighttime symptoms

Many, though not all, patients with severe GERD also have a hiatus hernia, where a portion of the stomach slides up through the diaphragm into the chest. Hiatus hernias weaken the anti-reflux mechanism further.

Why PPIs stop working

Proton pump inhibitors like omeprazole, pantoprazole, and esomeprazole are excellent drugs. They block acid production at the stomach wall. For most patients, that is enough to heal the oesophagus and relieve symptoms.

Reasons PPIs may stop controlling symptoms over time:

  • The reflux is not primarily acid. Some reflux is bile, or weakly acidic, or simply volume. PPIs do nothing for these.
  • A hiatus hernia has worsened. As more stomach slides into the chest, the anti-reflux barrier fails mechanically, not chemically.
  • Motility has changed. The oesophagus may clear acid less efficiently, or the stomach may empty more slowly.
  • Medication compliance has drifted. Long-term daily tablets are hard to maintain perfectly for years.

There are also legitimate concerns about long-term PPI safety. Current evidence suggests small but real associations with reduced vitamin B12 and magnesium absorption, a modest increase in certain bone fractures, and some increased risk of gut infections. These risks are small for most people, but not zero, and they accumulate over decades.

When surgery is considered

Anti-reflux surgery is not a first-line treatment. It is considered when:

  • Symptoms are troublesome despite correctly taken PPIs for at least six to twelve months
  • A large or symptomatic hiatus hernia is present
  • The patient wants to come off long-term medication for lifestyle or medical reasons
  • Significant reflux damage is seen on endoscopy (erosive oesophagitis, Barrett's oesophagus in select cases)
  • Regurgitation and aspiration are a major part of the problem, surgery addresses these better than any drug

Before surgery, proper testing is essential. At minimum, most patients need an upper GI endoscopy, and often a 24-hour pH study and an oesophageal manometry to confirm that symptoms are genuinely due to reflux and to plan the correct operation.

What the procedure involves

The standard operation is laparoscopic fundoplication, usually the Nissen or Toupet variant. Through four or five small incisions, the surgeon:

  • Reduces any hiatus hernia by pulling the stomach back into the abdomen
  • Repairs the weakened diaphragmatic opening with sutures
  • Wraps the upper part of the stomach around the lower oesophagus to reinforce the anti-reflux barrier

Surgery takes 90 to 120 minutes under general anaesthesia. Most patients go home the next day. A liquid diet for a week and gradual transition to soft and then normal food over four to six weeks is standard.

Expected outcomes

Well-selected patients do very well. In large long-term studies:

  • About 85 to 90% of patients have significant, durable symptom relief
  • Most are able to stop or substantially reduce their PPI dose
  • Quality of life scores improve meaningfully, particularly for sleep and nighttime symptoms

Common short-term side effects include difficulty swallowing solid food for two to four weeks, which almost always resolves as the wrap settles, and early satiety. A small percentage of patients develop bloating or difficulty belching.

Outcomes are significantly better when surgery is performed by a surgeon with specific anti-reflux experience and after proper pre-operative testing. Poorly selected cases are the main reason for long-term failure.

If you have been on acid reflux medication for more than a year with incomplete relief, or if an endoscopy has shown a hiatus hernia, a surgical opinion is worth having. Send your endoscopy report on WhatsApp and we can talk about whether further testing or surgery would genuinely improve your quality of life.