Are you considering hiatal hernia surgery? 
Did you know that acid reflux can come back even after surgery?

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The official medical guidelines for surgery specifically state that a small, sliding hiatal hernia (95% of them are sliding) is NOT an indication for surgery. Surgery is typically reserved for large, paraesophageal hernias, those with severe esophagitis, Barrett's disease and strictures.

It is also considered as an option when there is refractory relux - meaning you are taking medication (typically PPIs) and it isn't working to suppress your symptoms. It is this point I wish to address.

A critical point that's missed is that PPIs suppress acid, they don't prevent reflux. Read that sentence again. So reflux is still happening, it's just not very acidic. Now we need to ask what could continue to cause symptoms if it wasn't acid? Bile. Bile reflux can cause similar symptoms to acid reflux in how you feel, even though it's not acid causing it.

As a 2025 study that I list below stated: "consider bile reflux, don't just keep giving more PPIs". 

A 2024 study stated that up to 38% of refractory reflux is due to bile reflux. If you add in acid plus bile, the total is 64%. 

Let's look at another point. How well does hiatal hernia surgery do in eradicating reflux? It's not great. After 5 years, 44% of patients were again long-term PPI users. Another study found that recurrent heartburn post-surgery had an occurrence rate of 10 to 62% and was considered a post-operative complication.

This data is to give you knowledge that I find many patients considering surgery haven't been made aware of. Conservative measures are always preferred over surgery. Every surgeon would agree, barring obvious emergencies.

Finding a clinician who can address the often missed bile reflux and get to the root cause of what's causing it and acid reflux, could be of great benefit in improving your health.

If you'd like help we're here for you. The best next step is to contact us for a consultation and then we can determine if what we do is a good fit for you. Call 727-335-0400.

References:
Monaco L, Balletta A, Mazzarella G, et al. Combined pH and bilirubin monitoring of the esophagus improves the diagnostic yield of reflux disease in patients non-responsive to proton pump inhibitors. Scand J Gastroenterol. 2009;44(5):565-571.

Sugimoto M, Nishino S, Nishizawa T, et al. Importance of bile reflux in proton pump inhibitor-refractory gastroesophageal reflux disease. Digestive Endoscopy. 2024;36(3):390-399.

Armstrong D, Wong RKH, et al. Management of refractory reflux-like symptoms. Aliment Pharmacol Ther. 2025;61(7):505-522.

Naik RD, Vaezi MF. Treatment of refractory gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2020;18(2):343-351.

Wetscher GJ, Schwab G, Pointner R, et al. Long-term outcome after laparoscopic Nissen fundoplication: a systematic review and meta-analysis. Langenbecks Arch Surg. 2024;409(2):199-211.

Oor JE, Roks DJ, Broeders JA, et al. Reflux control 5 years after laparoscopic Nissen fundoplication: a prospective long-term study. World J Surg. 2025;49(4):1020-1029.

Engström C, Jamieson GG, Devitt PG, et al. Ten- to fifteen-year outcome of laparoscopic Nissen vs. Toupet fundoplication: a randomized trial. JAMA Surg. 2022;157(7):623-631.

Lundell L, Miettinen P, et al. Long-term outcome of antireflux surgery in randomized clinical trials: results at 20 years follow-up. Surg Endosc. 2024;38(1):112-120.

Broeders JA, Rijnhart-de Jong HG, Draaisma WA, et al. Ten-year outcome of laparoscopic and conventional Nissen fundoplication: randomized clinical trial. Ann Surg. 2013;258(5):870-877.

#hiatalhernia #acidreflux #r