Anti-Reflux Surgery Improves 90% of Refractory GERD Cases, Expert Says

Gastroesophageal reflux disease (GERD), which causes heartburn and pain when stomach acid flows back into the esophagus, affects one in ten Koreans. While many patients take acid-suppressing medications for years without improvement, anti-reflux surgery offers an alternative for refractory cases.

"Medication only reduces stomach acid; it has no mechanism to prevent reflux itself, which is the root cause of the disease," said Park Sung-soo, professor of gastrointestinal surgery at Korea University Anam Hospital and a leading authority on refractory GERD surgery. "For refractory patients, surgery is far more effective than medication, and the evidence supports this."

Park will appear on Seoul Economic TV's "Now, the Master Physician" program airing at 9 p.m. on the 7th to discuss anti-reflux surgery. Though established as standard treatment decades ago, the procedure has not been widely performed due to patient reluctance and perception as a "last resort."

Accurate Diagnosis First for Refractory GERD

GERD occurs when stomach acid and food flow back into the esophagus after meals, causing inflammation and symptoms. Proton pump inhibitors (PPIs) are commonly prescribed but only lower acidity without fundamentally blocking reflux.

"GERD is closely linked to lifestyle habits. Even when symptoms improve with medication, they easily recur with triggers like alcohol, overeating, or fatty foods," Park said. "That's why many patients feel it's a disease that won't get better."

Diagnosis relies heavily on patient symptoms, including typical ones like heartburn and acid regurgitation, as well as atypical symptoms such as chronic cough, hoarseness, and throat discomfort. For surgical candidates, precise tests including 24-hour esophageal pH monitoring and esophageal motility studies are essential.

"When we examine refractory patients with precise testing, about 30% don't actually have GERD," Park noted. He added that non-acid reflux—where stomach contents other than acid cause symptoms—may not respond to acid suppressants at all. Treatment approaches must distinguish between acid reflux, non-acid reflux, and functional (stress-related) symptoms.

Surgery Considered After 6-8 Weeks Without Improvement

Surgery is not recommended for all patients. "Patients who respond well to medication without side effects are not surgical candidates," Park said. "However, those who show insufficient improvement after 6-8 weeks of medication, or whose quality of life deteriorates significantly despite long-term use, can be considered for surgery as refractory GERD cases."

Candidates for anti-reflux surgery include those with persistent heartburn or acid regurgitation despite medication; those whose symptoms are controlled but cannot maintain dietary restrictions due to active social lives; and those who experience side effects such as intestinal infections or osteoporosis from long-term medication use.

Surgical Principle: Creating a Check Valve

Anti-reflux surgery uses the upper stomach (fundus) to wrap around the lower esophagus, creating a check-valve structure at the gastroesophageal junction. This physically blocks reflux while allowing food to pass downward—even when lying down or when abdominal pressure increases. German physician Nissen developed this technique in the 1950s, giving it nearly 70 years of clinical history.

"This isn't simply tightening the lower esophagus," Park explained. "It forms an internal valve at the gastroesophageal junction to fundamentally prevent reflux."

The procedure is typically performed laparoscopically. Post-operative symptoms like bloating and difficulty swallowing usually resolve within eight weeks, or at most three months, according to Park.

Anti-reflux surgery has gradually spread to university hospitals in Korea since the 2010s through research group activities and clinical accumulation. However, the shortage of precise diagnostic testing and experienced specialists remains a limiting factor.

90% Improvement in Heartburn, 70% in Atypical Symptoms

"Typical symptoms like heartburn and acid regurgitation improve approximately 90% after surgery," Park said. "Atypical symptoms such as throat discomfort and chronic cough also improve about 70%, leading to high patient satisfaction."

Recovery is relatively quick. Patients typically leave the hospital two days after surgery and are advised to consume mainly liquid foods for about six weeks to allow surgical site swelling to subside.

Regarding concerns about difficulty swallowing, Park said experienced surgeons design procedures to minimize this. "Adaptation time is needed for several weeks after surgery due to swelling, but lifelong persistence is rare."

Park emphasized proper patient selection: "Rather than immediately deciding on surgery for refractory GERD, patients should first confirm through precise testing whether they truly have GERD. After hearing about expected improvement rates, patients should make their own informed choice."

"Anti-reflux surgery is covered by national health insurance," he added. "Rather than reserving this effective option only as a last resort, it should be actively considered at the appropriate time."