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Digestive Health

When to consider anti-reflux surgery for heartburn

A young group of friends laughing and sharing pizza at a music festival.

08/15/2025

By, Shawn Liechty, MD Bariatric medicine and surgery, Nuvance Health part of Northwell Health

Heartburn is common, but if it becomes frequent and disrupts your life, it may be GERD. Lifestyle changes and medication help many, but if symptoms persist or you’re tired of daily treatments, it may be time to consider all options—such as anti-reflux surgery. For the right candidates, surgery can bring lasting relief and renewed energy. This guide will help you decide if surgical treatment could support your journey to better health. Learn more about Surgical Services at Nuvance Health part of Northwell Health

Understanding heartburn and GERD: more than just a burning sensation

Let's start by explaining what's happening inside your body when you experience heartburn and how it can progress to GERD.

What is heartburn, really?

At its core, heartburn is a symptom of acid reflux. This occurs when stomach acid, which is highly acidic and designed to break down food, flows backward into your esophagus. The esophagus is the tube that connects your mouth to your stomach. Unlike your stomach, your esophagus isn't built to withstand this strong acid, leading to the burning sensation you feel.

Think you have heartburn? Learn more about acid reflux and take a heartburn quiz.

A key player in preventing this backflow is the lower esophageal sphincter (LES). Think of the LES as a muscular valve at the bottom of your esophagus, just above your stomach. Normally, it opens to let food pass into your stomach and then closes tightly to keep stomach contents where they belong. When this valve weakens or relaxes inappropriately, acid can escape, causing reflux.

When heartburn becomes GERD (gastroesophageal reflux disease)

While occasional acid reflux is normal, if you experience heartburn or other reflux symptoms two or more times a week, or if your symptoms are severe, you may have GERD. This is a chronic condition that can significantly disrupt your life.

Common GERD symptoms extend beyond just heartburn. You might also experience:

Regurgitation: The sensation of stomach acid or food coming back up into your throat or mouth.
Chest pain: A non-cardiac chest pain that can sometimes be mistaken for heart issues.

Difficulty swallowing (dysphagia): A feeling that food is sticking in your throat.

Hoarseness or sore throat: Chronic irritation from acid can affect your vocal cords.

Chronic cough: A persistent cough, especially at night, can be a symptom of GERD.

Dental erosion: Acid can wear away tooth enamel over time.

Sleep disturbances: Symptoms often worsen when lying down, impacting sleep quality.

Living with these persistent symptoms can be exhausting, affecting your diet, sleep and overall enjoyment of life.

Common heartburn causes and contributing factors

Several factors can contribute to a weakened LES or increased acid reflux:

Weakened esophageal sphincter: This is often the primary culprit, allowing stomach acid to escape.
Hiatal hernia: This occurs when a portion of your stomach pushes up through the diaphragm (the muscle separating your chest and abdomen) into your chest cavity. A hiatal hernia can make it easier for acid to reflux into the esophagus.
Dietary triggers: Certain foods and drinks, like spicy foods, fatty meals, citrus, chocolate, caffeine and alcohol, can relax the LES or increase stomach acid production.
Lifestyle factors: Obesity, smoking, pregnancy and certain medications can also contribute to GERD.

Understanding these underlying mechanisms is the first step toward finding effective solutions.

Lifestyle changes and medications for GERD

Before considering surgical options, most people with heartburn and GERD begin with lifestyle adjustments and medication. These initial steps are often highly effective and can bring significant relief.

Lifestyle adjustments to manage GERD symptoms

Taking charge of your health often starts with simple, yet powerful, changes to your daily routine. For managing heartburn, these can include:

Dietary modifications: Pay attention to what triggers your symptoms and try to limit or avoid those foods. This might mean cutting back on fatty or fried foods, acidic fruits, tomato-based products, peppermint and carbonated beverages. Instead, focus on a balanced diet rich in whole foods.
Eating habits: Eating smaller, more frequent meals can prevent your stomach from becoming overly full, reducing pressure on the LES. Try to avoid eating within two to three hours of bedtime, giving your stomach time to empty before you lie down.

Weight management: If you are overweight or obese, losing even a small amount of weight can significantly reduce pressure on your abdomen and LES, leading to improved GERD symptoms.
Elevating your head during sleep: Raising the head of your bed by six to eight inches (using risers under the bedposts, not just extra pillows) can help gravity keep stomach acid down while you sleep.
Quitting smoking: Smoking weakens the LES and increases acid production, making it a major contributor to GERD. Quitting is one of the most impactful steps you can take.

Wearing loose-fitting clothing: Tight clothing around your waist can put pressure on your abdomen, pushing stomach acid upward.

These practical steps can make a real difference in managing your symptoms and improving your overall well-being.

When to consider anti-reflux surgery: signs it might be time

If you've diligently pursued lifestyle changes and consistently taken medication, yet your heartburn and GERD symptoms persist or significantly impact your life, it might be a sign that anti-reflux surgery might be a beneficial path for you. This isn't a decision to take lightly, but it's one that can lead to lasting freedom from discomfort.

Here are key indicators that suggest you might be a good candidate for anti-reflux surgery:

Persistent heartburn symptoms despite medication

This is perhaps the most common reason individuals explore surgical options. If you're taking proton pump inhibitors (PPIs) as prescribed, perhaps even at a high dose, but still experiencing significant GERD symptoms like:

Frequent, bothersome heartburn: The burning sensation continues to disrupt your day or night.

Regurgitation: You still experience stomach contents coming back up into your throat or mouth.

Chest pain: Non-cardiac chest pain persists, causing anxiety or discomfort.

Hoarseness or chronic cough: These "atypical" GERD symptoms continue to plague you.

If your quality of life remains significantly affected despite optimal medical management, it's a strong signal to discuss surgical alternatives with your doctor.

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Dependence on long-term medication

Many individuals find great relief with PPIs, but the prospect of taking medication every day, potentially for the rest of their lives, can be daunting. You might be considering surgery if:

You desire to reduce or eliminate daily medication: The idea of being free from daily pills is appealing.

You have concerns about long-term medication use: While PPIs are generally safe, some people worry about potential long-term side effects, such as nutrient deficiencies or bone density issues and prefer a more definitive solution.

Anti-reflux surgery can often allow patients to significantly reduce or even stop their GERD medications, offering a sense of freedom and peace of mind.

Potential complications of untreated GERD

Chronic, untreated GERD can lead to more serious health issues over time. If your diagnostic tests reveal any of the following complications, surgery may be recommended to prevent further damage:

Esophagitis: Persistent inflammation of the esophageal lining due to acid exposure. This can cause pain and difficulty swallowing.

Esophageal strictures: Repeated inflammation and healing can lead to scar tissue formation, narrowing the esophagus. This can make swallowing very difficult and may require endoscopic dilation.

Barrett's esophagus: This is a serious condition where the normal cells lining the esophagus are replaced by cells similar to those found in the intestine. Barrett's esophagus is considered a pre-cancerous condition, increasing the risk of esophageal cancer. Surgery can help prevent further acid exposure and potentially reduce the risk of progression.

Severe hoarseness, chronic cough or recurrent pneumonia: These can be signs of acid reflux affecting the airways and lungs and surgery may be considered to protect these vital organs.

Dental erosion: Chronic acid exposure can wear away tooth enamel, leading to dental problems.

Addressing these complications proactively through surgery can protect your long-term health.

Presence of a hiatal hernia

As mentioned earlier, a hiatal hernia occurs when part of the stomach pushes through the diaphragm. If a hiatal hernia is a significant contributor to your reflux and symptoms, surgical repair of the hernia is often performed alongside an anti-reflux procedure. In many cases, repairing the hernia is a crucial step in effectively treating the GERD.

A clear diagnosis of GERD

Before considering surgery, it's essential to have a clear and confirmed diagnosis of GERD. Your healthcare team will conduct a thorough evaluation to ensure that your symptoms are indeed caused by acid reflux and not another condition. This diagnostic process is vital for determining if you are a good candidate for anti-reflux surgery and for planning the most effective procedure.

In summary, if you're experiencing persistent GERD symptoms despite medication, are concerned about long-term medication use, have developed complications, or have a significant hiatal hernia, it's time to have an in-depth conversation with a specialist about whether anti-reflux surgery is the right next step for you.

The path to decision: Diagnostic evaluation for anti-reflux surgery

Deciding on anti-reflux surgery is a significant step and it's one that your healthcare team will guide you through with careful consideration. Not everyone with heartburn is a candidate for surgery. A comprehensive diagnostic evaluation is essential to confirm that GERD is indeed the cause of your symptoms, to assess the severity of the condition and to rule out any underlying issues that might affect the success of the procedure. This thorough assessment ensures that surgery is the most appropriate and effective treatment option for you.

Comprehensive GERD assessment: Why it's essential

Before any surgical treatment is considered, your doctor will want to:

Confirm the diagnosis of GERD: It's crucial to ensure that your symptoms are definitively caused by acid reflux and not by other conditions that might mimic GERD, such as certain heart conditions, esophageal motility disorders or other gastrointestinal issues.

Assess severity and complications: Understanding how severe your reflux is and if any complications (like esophagitis or Barrett's esophagus) have developed helps tailor the treatment plan.
Identify any contraindications: Certain conditions, such as severe esophageal motility disorders (where the esophagus doesn't move food properly), might make anti-reflux surgery less effective or even risky. A thorough evaluation helps identify these.

This detailed pre-operative evaluation is a cornerstone of successful anti-reflux surgery.

Understanding anti-reflux surgical procedures

Once a comprehensive evaluation confirms that anti-reflux surgery is a suitable option for you, it's important to understand the procedures themselves. The primary goal of these surgical treatments is to reinforce the LES and prevent stomach acid from flowing back into the esophagus, thereby alleviating reflux symptoms.

The principles of anti-reflux surgery

Anti-reflux surgery aims to create a new, stronger "valve" at the junction of your esophagus and stomach. This is typically achieved by wrapping a portion of the stomach (specifically the upper part, called the fundus) around the lower esophagus. This wrap acts as a barrier, preventing acid and stomach contents from refluxing upward. If a hiatal hernia is present, it is also repaired during the same procedure.

Laparoscopic fundoplication: the gold standard

The most common and effective type of anti-reflux surgery is fundoplication, which is almost always performed using a minimally invasive laparoscopic approach. This means the surgeon makes several small incisions (typically three to five) in your abdomen, rather than a large open incision. A laparoscope (a thin tube with a camera) and specialized surgical instruments are inserted through these incisions, allowing the surgeon to perform the procedure with precision while viewing it on a monitor.

The benefits of a laparoscopic procedure include:

Smaller incisions leading to less pain.
Reduced scarring.
Faster recovery times.
Shorter hospital stays.

There are different types of fundoplication, with the choice depending on your specific anatomy, esophageal function and the surgeon's recommendation:

Nissen fundoplication (360-degree wrap): This is the most common and often considered the "gold-standard" anti-reflux procedure, especially for people with severe reflux disease and heartburn. In a Nissen fundoplication, the surgeon wraps the entire (360-degree) upper part of the stomach (the fundus) around the lower esophagus. This creates a complete, tight valve that is highly effective at preventing reflux. It's particularly effective for those with significant acid reflux and a healthy esophageal motility.
Toupet fundoplication (270-degree partial wrap): In some cases, a partial wrap may be more appropriate. The Toupet fundoplication involves wrapping the fundus around the back of the esophagus for about 270 degrees. This partial wrap is often preferred for patients who have some degree of esophageal motility issues or who may be at higher risk for certain side effects like difficulty swallowing (dysphagia) or gas bloat syndrome (difficulty burping or passing gas). It still provides excellent reflux control while potentially being less restrictive than a full Nissen wrap.

The choice between a Nissen and Toupet fundoplication is a nuanced one, made in consultation with your surgical team based on your diagnostic test results, particularly esophageal manometry.

Other surgical and endoscopic options

While laparoscopic fundoplication is the most common, other procedures may be considered in specific circumstances:

LINX reflux management system: This is a minimally invasive procedure where a small, flexible ring of magnetic beads is placed around the lower esophagus. The magnetic attraction between the beads helps keep the LES closed, preventing reflux, but allows it to open for swallowing.
Transoral incisionless fundoplication (TIF): This is an endoscopic procedure, meaning it's performed through the mouth without any external incisions. Using a specialized device, the surgeon creates a partial fundoplication from inside the stomach. TIF is less invasive than laparoscopic surgery and may be an option for select patients with less severe GERD and no large hiatal hernia.

Learn more about the types of hernias our surgeons treat

Roux-en-Y gastric bypass: For individuals who are significantly obese and also suffer from severe GERD, gastric bypass surgery can be an effective treatment for both conditions. This procedure alters the digestive tract, often leading to significant weight loss and resolution of reflux symptoms.

Learn more about the Digestive Health Institute at Nuvance Health part of Northwell Health

Paraesophageal hernia repair: While often performed with a fundoplication, in some cases, a large paraesophageal hernia (where a significant portion of the stomach slides into the chest) may be the primary issue and its repair is the focus of the surgical treatment.

Learn more about Surgical Services at Nuvance Health part of Northwell Health

Your surgeon will discuss all appropriate treatment options with you, explaining the benefits and considerations of each, to help you make an empowered decision about your care.

Preparing for your anti-reflux procedure

Once you and your healthcare team have decided that anti-reflux surgery is the right path for you, preparing for the procedure is a crucial step. Being well-prepared can contribute to a smoother surgery and a more comfortable recovery.

Pre-operative consultations and tests

Your surgical team will guide you through all necessary pre-operative steps:

Detailed consultations: You'll have thorough discussions with your surgeon, anesthesiologist and potentially other specialists. This is your opportunity to ask any questions you have about the procedure, recovery, potential side effects and long-term expectations. Your surgeon will review all your diagnostic results (endoscopy, pH monitoring, manometry) to confirm the surgical plan.
Medical clearance: You may undergo additional tests, such as blood work, an electrocardiogram (ECG) or a chest X-ray, to ensure you are in good health for surgery.

Medication review: Discuss all medications, supplements and herbal remedies you are currently taking with your doctor. You may need to adjust or temporarily stop certain medications, especially blood thinners or even your PPIs, before surgery.

Understanding expectations: Your team will explain what to expect on the day of surgery, including arrival times, fasting instructions and the typical length of the procedure. They will also discuss potential complications, though these are rare with minimally invasive techniques.

Lifestyle adjustments before surgery

To optimize your health for surgery and recovery, your doctor might recommend certain lifestyle adjustments in the weeks leading up to your procedure:

Dietary changes: You may be advised to follow a specific diet, such as a liquid or soft diet, for a few days before surgery to ensure your stomach is empty.
Smoking cessation: If you smoke, you will be strongly encouraged to quit well in advance of your surgery. Smoking can impair healing and increase the risk of complications.

Weight management: If you are overweight, your surgeon might recommend losing some weight before surgery. Even a small amount of weight loss can make the procedure technically easier and improve outcomes.

Learn more about Comprehensive Weight Management programs at Nuvance Health now part of Northwell Health

Physical activity: Maintaining a moderate level of physical activity, if cleared by your doctor, can help improve your overall fitness and aid in recovery.

Being proactive in your preparation is a powerful way to contribute to a successful outcome and a positive recovery experience.

Life after anti-reflux surgery: recovery and long-term outlook

Undergoing anti-reflux surgery is a significant step toward reclaiming your comfort and well-being. Understanding what to expect during recovery and in the long term can help you feel confident and prepared for this exciting new chapter.

Immediate post-operative period

After your laparoscopic anti-reflux procedure, your hospital stay is typically short, often just one to two days.

Pain management: You will receive medication to manage any post-operative pain, which is usually mild to moderate due to the minimally invasive nature of the surgery.
Diet progression: Your diet will gradually progress. You'll likely start with clear liquids, then move to a full liquid diet, followed by a soft, pureed diet. This progression is crucial to allow your esophagus and the new fundoplication wrap to heal properly. You'll receive detailed instructions on what to eat and drink and for how long.
Mobility: You'll be encouraged to get up and walk around soon after surgery. This helps prevent complications like blood clots and aids in recovery.

Recovery at home: what to expect

Once you return home, your recovery will continue to progress. Most people can return to light activities within a week or two, with a full recovery taking several weeks.

Activity restrictions: You'll need to avoid heavy lifting and strenuous activities for several weeks to allow your incisions and the internal wrap to heal. Your surgeon will provide specific guidelines.
Managing common side effects: It's normal to experience some temporary side effects as your body adjusts to the new anatomy:

Dysphagia (difficulty swallowing): This is common in the initial weeks after surgery, especially with solid foods. It's usually temporary and improves as swelling subsides and your esophagus adapts. Following your prescribed diet progression is key.

Gas bloat syndrome: Some patients have trouble burping or passing gas, leading to a feeling of bloating. This is because the new wrap prevents gas from easily escaping the stomach. It often improves over time as the wrap settles.

Inability to vomit: The fundoplication wrap is designed to prevent reflux, which also means it can prevent vomiting. This is an expected outcome.

Dietary adjustments: You'll continue to follow a modified diet for several weeks, gradually reintroducing foods as tolerated. Chewing food thoroughly and eating slowly will be important.

Follow-up care: You'll have follow-up appointments with your surgeon to monitor your healing and progress.

Long-term potential benefits and considerations

The long-term outlook after anti-reflux surgery is generally excellent, with high rates of success in alleviating GERD symptoms.

Significant symptom reduction: Most people experience a dramatic reduction or complete elimination of heartburn, regurgitation and other GERD symptoms.
Reduced or no need for PPIS: Many people are able to significantly reduce or stop taking their proton pump inhibitors, achieving freedom from daily medication.

Improved quality of life: With symptoms under control, you may be able to enjoy a wider range of foods, sleep more soundly and participate in activities without the constant worry of heartburn. This leads to an improvement in overall well-being.

Prevention of complications: By effectively stopping reflux, surgery can help prevent the progression of complications like esophagitis and Barrett's esophagus.

Whileanti-reflux surgery offers lasting relief for many, it's important to remember that no procedure offers a "guarantee" of lifelong symptom absence. In some cases, a small percentage of people may experience a recurrence of symptoms over many years, which might require further evaluation or, rarely, revision surgery. However, for most, the benefits are long-lasting and life changing.

The bottom line: Making the decision to consider surgery is a personal one and it's a journey best taken with the guidance of a knowledgeable and compassionate healthcare team. If you've been struggling with persistent GERD symptoms, have concerns about long-term medication use or have developed complications, it's time to have an open and honest conversation with a specialist.

Reach out to a Nuvance Health surgeon today to discuss your symptoms, undergo a comprehensive evaluation and determine if anti-reflux surgery is the right choice to help you achieve lasting comfort and reclaim your vibrant life.

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