Anti-reflux and benign foregut care covers the surgical treatment of three related conditions of the upper digestive tract. The first is chronic acid reflux (GERD). The second is a hiatal hernia, including the more serious paraesophageal variant. The third is achalasia, a swallowing disorder in which the lower esophageal sphincter fails to relax.
For most patients with these conditions, medications or endoscopic treatments are tried first. Surgery becomes the right answer when those treatments do not control the problem, or when the anatomy itself calls for a mechanical repair. This page describes the three conditions and the four operations Dr. Jabbar performs to address them.
Reflux, hiatal hernia, and achalasia each present differently, but they share the same anatomic neighborhood at the bottom of the esophagus and the top of the stomach. The sections below cover each on its own, including when surgery becomes part of the conversation.
GERD is what happens when stomach acid repeatedly flows backward into the esophagus — often enough, or strongly enough, to damage the lining or interfere with daily life. The valve at the bottom of the esophagus (the lower esophageal sphincter) is supposed to keep acid in the stomach. In GERD, the valve relaxes when it should not, allowing acid to move the wrong way.
The classic symptom is frequent heartburn, especially after meals or at night. Other common symptoms include regurgitation of food or sour liquid into the throat, difficulty swallowing, the sensation of a lump in the throat, chronic cough, worsening asthma, hoarseness, and chest pain that worsens when lying down.
Several factors contribute to GERD. The most common are a weak or inappropriately relaxing lower esophageal sphincter, a hiatal hernia (which physically pulls the sphincter out of position), obesity, pregnancy, smoking, and delayed stomach emptying. Certain foods reliably trigger episodes in many people, including fatty or fried foods, spicy foods, citrus, tomato products, coffee and caffeine, alcohol, carbonated drinks, peppermint, and chocolate.
Diagnosis often starts with the symptom pattern alone. Confirmatory testing is indicated when the diagnosis is unclear, symptoms are severe, or surgery is being considered. Upper endoscopy looks for inflammation of the esophagus (esophagitis), strictures, or Barrett’s esophagus (a precancerous change in the esophageal lining). Ambulatory 24-hour pH monitoring measures how much acid actually reaches the esophagus and is considered the gold standard for confirming GERD. Esophageal manometry measures esophageal muscle function and is performed before any anti-reflux operation, because the choice of operation depends on how well the esophagus contracts.
Treatment is individualized and may combine targeted lifestyle changes with medication: weight loss when relevant, smaller meals, no late-night eating, raising the head of the bed, avoiding foods that reliably trigger an individual patient’s symptoms, and quitting smoking. Over-the-counter antacids and H2 blockers come next, followed by proton pump inhibitors (PPIs) at over-the-counter or prescription strength.
Anti-reflux surgery may be considered when testing objectively confirms GERD and symptoms, complications, anatomy, medication response, or informed patient preference support an operation. The surgical options Dr. Jabbar performs are Nissen and Toupet fundoplication, described below.
A hiatal hernia is an anatomic problem. The diaphragm (the muscle that separates the chest from the abdomen) has a small opening called the hiatus, through which the esophagus passes on its way to the stomach. In a hiatal hernia, that opening has become large enough that part of the stomach pushes up through it and bulges into the chest cavity.
There are different types of hiatal hernia, and the distinction matters clinically.
A sliding (Type I) hiatal hernia is the most common. The upper part of the stomach slides up through the hiatus, taking the gastroesophageal junction with it. Most sliding hernias are small and cause no symptoms beyond reflux. They are managed primarily as a reflux problem, and surgery is considered only when reflux symptoms are severe and not controlled by medication.
A paraesophageal hernia (Types II, III, and IV) is the more serious version. Part of the stomach — and sometimes other organs, such as the colon, spleen, or small bowel — ends up sitting in the chest next to the esophagus. This creates a real anatomic problem and a real risk of complications, including incarceration (the herniated stomach gets stuck), strangulation (blood flow to the stuck portion is cut off), gastric volvulus (the stomach twists on itself), bleeding, obstruction, and breathing difficulty when a large portion of the stomach occupies space in the chest.
Symptoms can include heartburn and regurgitation, but also chest or upper abdominal pain, difficulty swallowing, feeling full after small meals, shortness of breath after eating, and — with bleeding — vomiting blood or passing black, tarry stools. Sudden severe pain, the inability to keep food or liquid down, or signs of bleeding are an emergency.
Diagnosis is usually made with upper endoscopy, a barium swallow X-ray (which gives the best anatomic picture of the hernia), or CT imaging. Esophageal manometry is checked before any planned surgical repair.
Small, asymptomatic sliding hernias do not require treatment. Symptomatic sliding hernias are managed first with the same medications and lifestyle changes used for GERD. Any paraesophageal hernia causing symptoms (chest pain, obstruction, severe reflux, bleeding, aspiration, shortness of breath) is repaired surgically. Urgent or emergency repair is required for incarceration, strangulation, gastric volvulus, perforation, or uncontrolled bleeding.
Achalasia is a motility disorder of the esophagus. The nerves that coordinate swallowing stop working normally, the lower esophageal sphincter (the valve at the bottom of the esophagus) fails to relax when a person swallows, and the esophagus loses its ability to push food downward in coordinated waves. The result is that food and liquid sit in the esophagus rather than moving into the stomach.
Symptoms develop gradually over months or years. The hallmark is difficulty swallowing both solids and liquids (most other esophageal problems start with solids alone). Other symptoms include regurgitation of undigested food or saliva (especially at night), chest pain, heartburn, coughing at night from regurgitation, unintended weight loss, and recurrent pneumonia from aspiration.
The cause of most cases of achalasia is unknown. The leading theory is an autoimmune attack on the esophagus’s nerves, possibly triggered by a viral infection in genetically susceptible people. A rare inherited form exists, and in endemic regions, Chagas disease can cause a similar picture.
Diagnosis is made by combining tests. High-resolution esophageal manometry is the gold standard; it measures the muscle pressures along the length of the esophagus and at the sphincter. A barium swallow X-ray can show the classic “bird’s beak” narrowing at the lower esophagus, with dilation above it. Upper endoscopy is performed to rule out cancer or other causes of obstruction.
Treatment options include pneumatic balloon dilation, Botox injection into the sphincter (mostly for patients too frail for surgery), Heller myotomy (the operation that cuts the sphincter muscle), and peroral endoscopic myotomy (POEM, an endoscopic alternative to Heller myotomy). Heller myotomy with partial fundoplication and peroral endoscopic myotomy are established options; the best choice depends on achalasia subtype, anatomy, local expertise, and patient preferences.
The operations below treat reflux, hiatal hernias, and achalasia. Several of them are performed in combination during the same operation, since the anatomy overlaps and repairing one problem often addresses another.
A Nissen fundoplication is an anti-reflux operation that reconstructs the valve at the bottom of the esophagus. The surgeon takes the upper part of the stomach (the fundus), wraps it a full 360 degrees around the lower esophagus, and sutures it into place. The wrap acts like a one-way valve, reinforcing the weak lower esophageal sphincter and preventing stomach acid from flowing back into the esophagus.
Nissen fundoplication is an established option for selected patients with objectively confirmed GERD, particularly when esophageal motility is appropriate. It is often performed with hiatal hernia repair. The choice should account for expected benefits and risks such as swallowing difficulty, gas-bloat symptoms, and possible recurrent reflux.
The operation is performed laparoscopically or robotically through small abdominal incisions. The hiatus (the opening in the diaphragm) is first closed back to a normal size. The fundus is mobilized so it can be brought behind the esophagus and wrapped around to the front. The wrap is kept short (typically 2 centimeters) and “floppy,” so that food can still pass through. Open Nissen is reserved for reoperative cases or patients with unusual anatomy.
Hospital stay is typically one to three days. A liquid-to-soft diet is followed for the first few weeks while the wrap heals, and return to normal activity usually takes two to three weeks.
A Toupet fundoplication is a partial version of the wrap. The fundus is wrapped 270 degrees around the back of the lower esophagus, leaving the front of the esophagus uncovered. The valve is reconstructed enough to control reflux, and the partial wrap leaves more room for food to pass through.
The Toupet is generally chosen when the esophagus is not contracting strongly enough to push food through a full 360-degree Nissen wrap. Esophageal manometry performed before surgery identifies these patients. A Toupet is also chosen in some cases to reduce the risk of post-operative side effects such as difficulty swallowing or trouble belching.
The operation is similar to a Nissen up to the wrap itself. The hiatus is closed, the fundus is mobilized, and the wrap is sutured to the sides of the esophagus rather than completed across the front. The procedure is performed laparoscopically or robotically through small incisions.
Hospital stay and recovery look like a Nissen: one to three days in the hospital, with a graduated diet and a return to normal activity in two to three weeks.
A hiatal hernia repair returns the herniated stomach (and any other displaced organs) from the chest back into the abdomen, closes the enlarged opening in the diaphragm with sutures, and commonly adds a fundoplication (Nissen or Toupet) to prevent reflux after the repair. Mesh may be considered selectively for some large or complex defects; evidence does not support routine use in every paraesophageal hernia repair. In select cases, the stomach is anchored in the abdomen with additional sutures (a gastropexy).
This operation is indicated for symptomatic paraesophageal hernias, hiatal hernias with severe reflux not controlled by medication, hernias causing obstruction or chest pain, and hernias causing anemia from chronic bleeding (Cameron lesions on the stomach folds at the hiatus). Emergency repair is needed for gastric volvulus, incarceration, strangulation, perforation, or uncontrolled bleeding.
Most repairs are performed robotically or laparoscopically through small abdominal incisions. The robotic approach has become increasingly common for large paraesophageal hernias, because the magnified view and precise instruments help with the dissection deep in the chest. Open repair (through either the abdomen or the chest) is reserved for reoperations, very complex anatomy, or emergencies where time matters more than incision size.
Hospital stay for laparoscopic or robotic repair is typically two to four days; open repair generally takes longer. After surgery, a soft diet is followed for several weeks while the repair heals.
A Heller myotomy is the surgical treatment for achalasia. The operation cuts the muscle fibers of the lower esophageal sphincter (the valve at the bottom of the esophagus) along the front of the esophagus, so that food and liquid can finally pass into the stomach. It is almost always paired with a partial fundoplication (Dor or Toupet), in which a small portion of the stomach is wrapped around the lower esophagus to prevent acid reflux after the sphincter has been cut.
Heller myotomy is the operation chosen when achalasia is significantly affecting eating, weight, and quality of life, and when balloon dilation or Botox has not provided durable relief. POEM (peroral endoscopic myotomy) is an endoscopic alternative performed by gastroenterologists or surgeons at some centers and may be preferred in certain achalasia subtypes.
Heller myotomy is performed laparoscopically or robotically. The robotic approach offers enhanced precision during the muscle dissection along the lower esophagus, which matters because the cut must be deep enough to relieve the obstruction without perforating the underlying esophageal lining. Open Heller myotomy is rarely needed today.
Hospital stay is typically one to two days, and some centers perform Heller myotomy as a same-day or overnight procedure. Recovery involves a graduated diet over a few weeks.
