When Heartburn Isn’t Just Heartburn

Why Some People Need Surgery for GERD

Almost everyone will experience heartburn from time to time. But when it becomes a regular part of daily life—causing discomfort, disrupting sleep, or interfering with meals—it could be a sign of gastroesophageal reflux disease, or GERD.

Many patients can manage GERD effectively with lifestyle changes and medication. But some may require surgery to find lasting relief.

Dr. Cathryn Coleman, a general surgeon on the medical staff at USMD Hospital in Arlington, Texas, explains when surgery becomes part of the conversation for reflux treatment—and why it’s sometimes the best option.

Medications First

“Surgery for reflux is less common nowadays, which is not a bad thing,” says Dr. Coleman. “It's because our medications have gotten so good. Most reflux symptoms can just be controlled with meds.”

Proton pump inhibitors (PPIs), H2 blockers, and antacids are commonly prescribed to reduce acid production and ease the discomfort of GERD. For many patients, these medications will effectively control symptoms such as heartburn, regurgitation, and bloating.

But not everyone finds long-term relief with these medications. Some may continue to experience breakthrough symptoms; others may worry about the risks and side effects of taking the drugs indefinitely. In some cases, the damage from reflux continues even if a patient feels fine.

When Doctors Recommend Surgery for GERD

So how do doctors decide when it’s time to move beyond pills and consider surgery?

According to Dr. Coleman, it typically comes down to three key scenarios:

1. Medications are no longer effective
   “Surgery becomes an option when those medications are not controlling the patient's symptoms,” she said. This includes patients who continue to feel significant heartburn or regurgitation despite taking the right medications at the right doses.
2. Patients are tired of taking daily meds
   For those who are managing their GERD well with prescriptions but dislike the idea of lifelong medication use, surgery can offer a path to medication-free living. “Some patients don’t want to take medications, or they get tired of taking their medications and they refuse to take them anymore,” Dr. Coleman said.
3. Signs of damage to the esophagus
   Perhaps the most important indicator of the need for GERD surgery is evidence of damage to the esophagus – which can occur silently, without noticeable symptoms. “If patients are taking medications but still have severe esophagitis—meaning that despite being on meds, they have inflammation and irritation from acid—that is an indication for surgery,” said Dr. Coleman. The concern? That persistent acid exposure can lead to Barrett’s esophagus, a condition where the lining of the esophagus changes and may eventually become cancerous.

That’s one of the most serious long-term risks of untreated GERD.

“If that esophageal tissue gets repeatedly insulted by acid, the cells may actually change into cancer of the esophagus,” Dr. Coleman said. “The body tries to become more tolerant of acid, but that’s not what we want that part of the body to do. As those cells mutate, there’s an increased risk of developing cancer.”

This is why diagnostic tests are so important. Even if a patient doesn't feel particularly ill, an upper endoscopy may reveal silent damage that warrants surgical intervention.

Diagnostic Steps Before Surgery

Before recommending surgery, most patients go through a series of tests to confirm a GERD diagnosis and assess the severity of reflux. These may include:

• Upper endoscopy, to check for esophagitis or Barrett’s esophagus
• pH monitoring, to measure acid levels in the esophagus
• Esophageal manometry, to evaluate how well the muscles in the esophagus are working
• Barium swallow studies, to detect structural problems like a hiatal hernia

“Most of these patients see a GI doctor before they see me,” says Dr. Coleman. “They get scoped and evaluated for esophagitis or a hiatal hernia. Then the GI doctor refers them to me for surgical evaluation.”

What Surgery Involves

If surgery is recommended, the most common procedure is fundoplication, where the top of the stomach is wrapped around the lower esophagus to strengthen the lower esophageal sphincter (LES) and prevent acid from backing up.

In many cases, patients who require GERD surgery also have a hiatal hernia—a condition where part of the stomach pushes into the chest through the diaphragm. In that case, the hiatal hernia is also repaired during the same procedure.

“With that scenario, part of the surgery involves fixing that hernia—bringing the stomach back into the abdomen and closing up part of the diaphragm,” said Dr. Coleman.

The Bottom Line

Surgery for GERD isn’t for everyone. But for patients with persistent symptoms, esophageal damage, or a desire to discontinue daily medications, the procedure can be life-changing.

If you are struggling with GERD, talk to your primary care provider or a gastroenterologist. An evaluation and a referral to a surgeon like Dr. Coleman may be the next step toward relief.

“Surgery isn’t our first step—but it’s a very good option for the right patient,” said Dr. Coleman.