Dr. Solon Gonçalves Souza Menezes
Professor of Surgery — FAMED UFU · Robotic Surgery Certification (Intuitive / Albert Einstein Hospital) · Practices at Hospital UMC and Hospital Mater Dei Santa Genoveva, Uberlândia, Brazil · +55 (34) 99341-0915
Gastroesophageal reflux disease (GERD) happens when acid stomach contents frequently rise into the esophagus, causing heartburn, regurgitation, chest pain, cough or hoarseness. At the root of the problem are a weakened natural valve — the lower esophageal sphincter — and, very often, a hiatal hernia, which displaces the junction between esophagus and stomach into the chest. Most patients do well with lifestyle changes and proton pump inhibitors (omeprazole and similar drugs). Surgery comes in as a long-term alternative for a specific group.
According to the American College of Gastroenterology guideline (ACG 2022), antireflux surgery, performed by an experienced surgeon, is a long-term treatment option for patients with objective evidence of reflux — especially severe esophagitis (Los Angeles grades C or D), large hiatal hernias and persistent, troublesome symptoms despite treatment (strong recommendation). The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2021) also conditionally recommends surgical over medical treatment for chronic or refractory reflux. The decisive word is “objective”: in a study cited by the guideline, of 366 patients with heartburn that did not improve with medication, only 21% had truly refractory reflux — in the others, the cause was something else, and operating would have been a mistake.
The operation is called fundoplication: the upper part of the stomach (the fundus) is wrapped around the lower end of the esophagus, forming a new valve, and the hiatal hernia, when present, is repaired in the same procedure. In the Nissen technique the wrap is complete (360°); in the Toupet technique, partial and posterior (270°). A meta-analysis of 8 randomized trials (1,545 patients) found no difference in reflux recurrence between the two, but long-term dysphagia (difficulty swallowing) was significantly lower with Toupet — which is why the choice takes into account the preoperative manometry and each patient's characteristics. Everything is done through a minimally invasive approach, with five small incisions.
Dr. Solon Gonçalves performs fundoplication by laparoscopy and by robotic surgery, at Hospital UMC and Hospital Mater Dei Santa Genoveva in Uberlândia, Brazil. SAGES considers that patients may be treated by either route, in shared decision-making; the meta-analysis that pooled only randomized trials (160 patients) and the one that pooled 38 studies (more than 550,000 patients) found no difference in complications, dysphagia, reoperation, recurrence or medication use — robotics had longer operative time and higher cost. The robotic route, with articulated instruments and 3D vision, is chosen in selected cases, such as large hiatal hernias or reoperations, always together with the patient.
Book a consultationWho has an indication for antireflux surgery.
The indication requires objective proof of the disease. Before any antireflux procedure, the ACG 2022 guideline recommends high-resolution esophageal manometry, to rule out achalasia and absent contractility (which, for most patients, contraindicates fundoplication), and, when there is still no objective proof of reflux, 24-hour pH monitoring off medication.
Proven, poorly controlled reflux
Persistent, troublesome symptoms despite optimized treatment, with reflux documented by endoscopy (grade C or D esophagitis, Barrett's esophagus) or pH monitoring. This is the group in which surgery carries a strong recommendation in ACG 2022.
Predominant regurgitation
Volume of contents rising to the mouth, especially when lying down, responds poorly to medication and very well to surgery: in the LOTUS trial, 2% of operated patients still had regurgitation at 5 years, versus 13% of those treated with esomeprazole.
Large hiatal hernia
Large or paraesophageal hernias associated with reflux are an indication for surgical repair with fundoplication, according to ACG 2022 and SAGES 2024. See the hiatal hernia page.
Those who prefer not to depend on medication
Young patients with objective reflux and a good response to medication, who do not want to take it for decades, may choose surgery in shared decision-making — knowing that a proportion of operated patients need medication again over the years.
Surgery or medication: what the clinical trials show.
The best long-term data come from the LOTUS randomized trial (554 patients in 11 countries, 5 years of follow-up) and from a Swedish registry study of 2,655 operated patients. They show that fundoplication controls acid more completely than medication, but also that surgery has side effects of its own and that reflux can come back.
| Outcome | Laparoscopic fundoplication | Continuous esomeprazole |
|---|---|---|
| Remission at 5 years (LOTUS) | 85% (95% CI 81–90) | 92% (95% CI 89–96) |
| Regurgitation at 5 years | 2% | 13% |
| Esophageal acid exposure (pH monitoring) | From 8.6% to 0.7% of the time | From 8.8% to 1.9% of the time |
| Dysphagia at 5 years | 11% | 5% |
| Bloating / flatulence | 40% / 57% | 28% / 40% |
| Serious adverse events | 28.6% | 24.1% |
| Reflux recurrence after surgery (Swedish registry, 5.6 years) | 17.7% (84% of these controlled with medication; 16% reoperated) | — |
| Medication use after surgery | 28% of operated patients report some use (SAGES review) | 100% |
On a phone, drag the table sideways to see all the columns.
What to expect before and after surgery.
Preoperative preparation
The preoperative work-up defines whether surgery is the right choice and which technique to use: upper endoscopy, high-resolution esophageal manometry (essential to choose between Nissen and Toupet and to rule out achalasia) and, when there is still no objective proof, 24-hour pH monitoring performed off medication. Blood tests and an anesthetic assessment complete the preparation, in addition to fasting and the guided suspension of some medications. In patients with significant obesity, the 2022 multi-society consensus advises discussing gastric bypass as an alternative, because it treats both reflux and excess weight — see the bariatric surgery page.
Recovery and postoperative care
The hospital stay is 1 to 2 days. In the first weeks the diet is liquid and then soft, gradually progressing to solids, because the new valve is swollen — some difficulty swallowing during this period is expected and usually improves. Bloating and difficulty belching or vomiting may occur, especially after a Nissen. A meta-analysis of 12 trials showed that the laparoscopic route shortens the hospital stay by almost 3 days and the return to activities by about 8 days compared with open surgery. Work without effort is usually resumed in 1 to 2 weeks and intense exercise after 4 to 6 weeks, with individual guidance.
What can go wrong — and how often.
Fundoplication is safe, but it has characteristic side effects that the patient needs to know before deciding. The numbers come from the LOTUS trial, the SAGES systematic review and the meta-analyses cited in the references.
- Dysphagia (difficulty swallowing) — common and transient in the first weeks; persistent in about 11% at 5 years in LOTUS (vs 5% with medication). It is lower with partial fundoplication (Toupet) than with total fundoplication (Nissen).
- Gas-bloat syndrome — bloating, difficulty belching and flatulence: in LOTUS, 40% reported bloating and 57% flatulence at 5 years, versus 28% and 40% with medication.
- Reflux recurrence — 17.7% at 5.6 years in the Swedish registry, most controlled with medication; about 3% need reoperation. Slippage or migration of the wrap are causes of recurrence and of further surgery.
- Major surgical complications — perforation of the esophagus or stomach, bleeding, splenic injury: rare; in the SAGES analysis, serious complications were about 2.9% more frequent in the surgical arm than in the medical arm.
- General risks — anesthesia, venous thrombosis, infection and hernia at the incisions, with low frequency.
Common questions about this procedure.
When is reflux surgery necessary?+
When reflux is proven by tests (endoscopy with severe esophagitis or abnormal pH monitoring) and symptoms persist despite optimized treatment, when regurgitation is the main symptom, or when there is a large hiatal hernia. It can also be the choice of those with objective reflux who do not want to depend on medication for decades. Before operating, manometry is essential to rule out diseases that mimic reflux.
Does reflux surgery solve the problem? Is it worth it?+
For the well-selected patient, yes: surgery reduces esophageal acid exposure more completely than medication and controls regurgitation much better. But it is important to know that, at 5 years, 85% of operated patients were in remission in the LOTUS trial, that about 18% have some degree of recurrence in just over 5 years and that dysphagia and bloating are more frequent than with medication. It is worth it when these points are discussed honestly before the decision.
I had reflux surgery and still have heartburn. Is that normal?+
In the first weeks, symptoms may fluctuate while the valve settles. Persistent heartburn months later deserves investigation: it may be recurrence due to migration or loosening of the wrap (which affects about 18% at 5 years and generally responds to medication), or another cause, such as esophageal hypersensitivity. A minority need further surgery.
What is the difference between Nissen and Toupet fundoplication?+
In the Nissen the stomach fundus wraps completely (360°) around the esophagus; in the Toupet the wrap is partial and posterior (270°). Reflux control is similar in clinical trials, but the Toupet causes less long-term dysphagia; on the other hand, some studies suggest slightly more medication use after the partial technique. Manometry helps decide: when esophageal contraction is weak, the partial wrap is preferred.
Is the surgery laparoscopic or robotic? Which is better?+
Both. Fundoplication is done by laparoscopy or with the robot, through the same five small incisions. The meta-analyses, including the one pooling only randomized trials, found no difference in complications, dysphagia, reoperation or recurrence — robotics takes longer and costs more. SAGES considers both routes acceptable in shared decision-making; robotics is reserved for selected cases, such as large hernias or reoperations.
How long do the surgery and the hospital stay take?+
Fundoplication usually takes one to two hours, under general anesthesia, and the hospital stay is 1 to 2 days. The time can be longer when there is a large hiatal hernia or previous surgery in the upper abdomen.
How long does the result of fundoplication last?+
Most patients keep reflux under control for many years: 85% in remission at 5 years in the LOTUS trial. In the Swedish registry, 17.7% had recurrence in just over 5 years, the vast majority controlled with medication. The result tends to last longer in those with well-documented disease and in those who keep their weight under control.
How many days of rest and sick leave?+
Generally 1 to 2 weeks for work without physical effort and 4 to 6 weeks for intense exercise and lifting. The progressive diet (liquid, then soft) in the first weeks is an important part of recovery. Sick leave is defined case by case.
Does reflux surgery make you lose weight?+
Losing weight is not the goal of fundoplication. Some weight loss may occur in the first weeks because of the liquid and soft diet, and tends to stabilize. For those with obesity and reflux, the indicated operation may be a different one — gastric bypass, which treats both conditions.
Will I be able to belch and vomit after surgery?+
The new valve makes belching and vomiting harder, especially after a Nissen; this explains the bloating and flatulence reported by some patients (40% and 57% at 5 years in LOTUS). With the partial technique (Toupet) these effects are smaller. Most people adapt, and advice such as eating slowly and avoiding carbonated drinks helps.
Is reflux surgery dangerous? What are the risks?+
It is a safe surgery when well indicated. The most common side effects are dysphagia and bloating; major complications, such as perforation or bleeding, are rare. The detailed numbers are in the risks section of this page.
Do you operate through the SUS, the Brazilian public health system?+
I do operate through the SUS. I am a Professor of Surgery at the School of Medicine of the Federal University of Uberlândia and I operate on patients at the university hospital, HC-UFU. The route, however, does not go through my private practice: to be operated on through the SUS you must go to the health post or Basic Health Unit nearest your home, be assessed by a doctor and, if surgery is indicated, be placed in your municipality's regulation queue. The surgeon does not choose who gets operated on through the SUS — the queue is followed strictly, according to SUS rules.
Hospital facilities in Uberlândia, Brazil.
Hospital Mater Dei Santa Genoveva
Av. Vasconcelos Costa, 967 — Martins, Uberlândia-MG
Open in Google Maps →Content reviewed by Dr. Solon Gonçalves Souza Menezes — CRM-MG 79366, RQE 60355 (GI Surgery), RQE 44656 (General Surgery). Professor of Surgery at FAMED-UFU and Supervisor of the General Surgery Medical Residency Program at HC-UFU. ORCID. Last reviewed: October/2026.
- Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538
- Slater BJ, Dirks RC, McKinley SK, et al. SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD). Surg Endosc. 2021;35(9):4903-4917. doi:10.1007/s00464-021-08625-5
- Slater BJ, Collings A, Dirks R, et al. Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). Surg Endosc. 2023;37(2):781-806. doi:10.1007/s00464-022-09817-3
- Galmiche JP, Hatlebakk J, Attwood S, et al. Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial. JAMA. 2011;305(19):1969-1977. doi:10.1001/jama.2011.626
- Hatlebakk JG, Zerbib F, Bruley des Varannes S, et al. Gastroesophageal Acid Reflux Control 5 Years After Antireflux Surgery, Compared With Long-term Esomeprazole Therapy. Clin Gastroenterol Hepatol. 2016;14(5):678-685. doi:10.1016/j.cgh.2015.07.025
- Maret-Ouda J, Wahlin K, El-Serag HB, Lagergren J. Association Between Laparoscopic Antireflux Surgery and Recurrence of Gastroesophageal Reflux. JAMA. 2017;318(10):939-946. doi:10.1001/jama.2017.10981
- Peristeri DV, Room H, Tsironis D, et al. Long-term efficacy of total versus posterior partial fundoplication in patients with gastro-oesophageal reflux disease: a systematic review and meta-analysis. Ann R Coll Surg Engl. 2024;106(7):569-575. doi:10.1308/rcsann.2023.0046
- Mirza W, Khan ME, Uneeb M, et al. Da Vinci-assisted vs laparoscopic Nissen fundoplication for GERD: a systematic review and meta-analysis of randomized controlled trials on patient-reported outcomes, dysphagia, and long-term failure. J Robot Surg. 2025;19(1):678. doi:10.1007/s11701-025-02869-2
- Xiao X, Zhang C, Li H, et al. Robotic-assisted versus laparoscopic esophageal hiatal hernia and anti-reflux surgery: a comprehensive systematic review and meta-analysis. Hernia. 2026;30(1). doi:10.1007/s10029-026-03770-z
- Gonçalves-Costa D, Barbosa JP, Quesado R, et al. Robotic surgery versus laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis. Langenbecks Arch Surg. 2024;409(1):175. doi:10.1007/s00423-024-03368-y
- Peters MJ, Mukhtar A, Yunus RM, et al. Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery. Am J Gastroenterol. 2009;104(6):1548-1561. doi:10.1038/ajg.2009.176