Acid Reflux and Hiatus Hernia: When Medication Is No Longer Enough

Acid reflux is extremely common, and for most people a course of medication, some dietary adjustment and weight loss resolves it. This article is not about those patients.

It is about the smaller group who have been taking a proton pump inhibitor daily for years, whose symptoms return within days of stopping it, and who have started to wonder whether taking a tablet every morning for the rest of their life is really the only option.

The mechanical problem behind the symptoms

At the junction of the oesophagus and the stomach there is a valve mechanism — partly the lower oesophageal sphincter, partly the way the diaphragm pinches the oesophagus as it passes through the hiatus, partly the angle at which the oesophagus meets the stomach.

When this mechanism fails, stomach contents reflux upward. A hiatus hernia — where the top of the stomach slides up through the diaphragm into the chest — disrupts all three components at once, which is why hiatus hernia and significant reflux so often occur together.

Acid-suppressing medication does not repair any of this. It reduces the acidity of what refluxes, which controls the burning very effectively. But the reflux itself continues, which is why some patients on adequate medication still have regurgitation, cough, or a sensation of fluid rising.

Symptoms beyond heartburn

• Regurgitation of food or sour fluid, especially on bending or lying down
• Chronic dry cough, particularly at night
• Hoarseness, throat clearing or a sensation of a lump in the throat
• Recurrent sore throat or dental erosion
• Asthma-like wheezing that is difficult to control
• Chest pain that mimics cardiac pain — always assessed for cardiac causes first
• Difficulty swallowing, which always requires investigation
• Disturbed sleep from night-time reflux

When surgery becomes a reasonable option

The candidates who do best are, somewhat counter-intuitively, those whose symptoms respond well to medication — because that demonstrates the symptoms genuinely are acid-related.

• Good response to medication, but unwillingness or inability to take it lifelong
• A large hiatus hernia, particularly a paraoesophageal one, which carries a risk of the stomach twisting
• Persistent volume regurgitation despite adequate acid suppression — medication reduces acidity, not volume
• Complications: stricture, ulceration, or Barrett’s oesophagus
• Respiratory complications from reflux — recurrent aspiration, difficult asthma
• Side effects from long-term proton pump inhibitors, or concerns about taking them for decades
• Young patients facing forty or fifty years of daily medication

Why the workup matters more than the operation

The difference between a good and a poor result from anti-reflux surgery lies largely in patient selection, and that depends on doing the investigations properly rather than operating on symptoms alone.

• Upper GI endoscopy: confirms oesophagitis, measures the hiatus hernia, and excludes ulcer, stricture, Barrett’s oesophagus or malignancy
• 24-hour pH study: objectively confirms that pathological acid reflux is actually occurring, and correlates it with symptoms. This is the test that most often changes management
• Oesophageal manometry: measures how well the oesophagus contracts. This is essential — a patient with poor oesophageal motility who receives a tight wrap will be left unable to swallow properly
• Barium swallow: useful for anatomy in large hernias
• Gastric emptying study: where delayed emptying is suspected

What the operation involves

Laparoscopic fundoplication is performed through four or five small ports and typically takes ninety minutes to two hours.

The stomach is reduced back into the abdomen from the chest. The hernia sac is dissected out. The opening in the diaphragm — the hiatus — is narrowed with sutures back to its normal size, sometimes reinforced with mesh in very large defects.

The top of the stomach, the fundus, is then mobilised and wrapped around the lower oesophagus and sutured in place, recreating a valve. A complete 360-degree wrap is called a Nissen fundoplication; a partial wrap, used where oesophageal motility is impaired, is a Toupet or Dor.

Most patients stay one to two days and return to desk work within one to two weeks.

Realistic expectations

It is important to be straightforward about outcomes rather than presenting surgery as a guaranteed cure.

In well-selected patients, around eighty-five to ninety percent are free of significant reflux and off daily acid suppression in long-term follow-up. That is a good result, but it is not a hundred percent.

Some patients need to restart medication over time. A proportion develop side effects of the wrap. And the wrap can loosen or the hernia recur over years, occasionally requiring revision.

The side effects to know about beforehand

• Difficulty swallowing in the early weeks — very common, expected, and settles in the great majority as the swelling resolves. A staged diet from liquids to soft to normal over four to six weeks manages it
• Inability to belch, which is why a modified diet and avoiding fizzy drinks is advised initially
• Increased flatulence — the gas that cannot be belched has to go somewhere
• Bloating, sometimes called gas-bloat syndrome, more common with a complete wrap
• Persistent dysphagia in a small minority, occasionally requiring endoscopic dilatation
• Recurrence of the hernia or loosening of the wrap over the longer term

Before considering surgery, do the basics properly

A surprising number of patients referred for anti-reflux surgery have never fully implemented lifestyle measures, and some improve enough that surgery becomes unnecessary.

• Weight loss — the single most effective non-surgical intervention for reflux
• Not eating within three hours of lying down
• Raising the head of the bed by fifteen to twenty centimetres, using blocks rather than extra pillows
• Smaller, more frequent meals
• Reducing alcohol, smoking, caffeine, chocolate, mint, and very fatty or spicy food
• Avoiding tight waistbands
• Taking the medication correctly — thirty to sixty minutes before food, which a large proportion of patients do not do