From
Dr. Jeffrey Ponsky
Gastroesophageal Reflux Disease
With Dr. Michael Rosen · hosted by Dr. Jeffrey Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
BOB in Ped Surg 2023 - PAPSA Winner - Mohamad Mahmoud Qinawy, MD
16 min · Published Feb 2023
Video
SAGES/ALACE Symposium: Integrating New Technologies, Old Tricks, and Operative Approaches
Jeffrey Ponsky · 12 min · Published Mar 2012
Podcast
Case-Based Journal Review: G-Tube & Fundoplication for GERD 2023
18 min · Published Sep 2023
Podcast
Pediatric Gastroesophageal Reflux Disease
81 min · Published Aug 2018
Video
Gastoesophageal Reflux: Update Course 2015
30 min · Published Nov 2018
Video
BOB Ped Surg 2023 - Mohamad Qinawy, PAPSA - Presentation
8 min · Published Feb 2023
Video
Best of the Best Gen Surg - Predictors of Low and High Opioid Tablet Consumption after Inguinal Hernia Repair – an ACHQC Opioid Reduction Task Force Analysis - Dr. Warren
11 min · Published Sep 2022
Podcast
Inguinal Hernia: Adult
31 min · Published Jan 2017
Podcast
Gastroesopheal Reflux Disease
33 min · Published Dec 2016
Podcast
Inguinal Hernia With M. Rosen
Jeffrey Ponsky · 31 min · Published Oct 2015
Podcast
The invention of the PEG tube with Dr. Jeffrey Ponsky
Jeffrey Ponsky · 33 min · Published Jul 2026
Podcast
Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024
Jeffrey Ponsky · 3 min · Published Aug 2025
Video
ACS Icons in Surgery | Jeffrey L. Ponsky, MD, FACS
Jeffrey Ponsky · 20 min · Published Jul 2024
Video
SAGES Stories Episode 11 – Jeff Ponsky, MD
Jeffrey Ponsky · 61 min · Published Jun 2024
Video
From Idea to Ubiquity - the PEG Journey
Jeffrey Ponsky · Published Nov 2023
Podcast
Innovations in Surgery: PEG Tube
Jeffrey Ponsky · Published Aug 2023
What the experts said
Surgery for gastroesophageal reflux disease should be far down the treatment line after appropriate medical management and workup
Initial trial of 20 mg daily Prilosec (omeprazole) for 6 weeks is appropriate first-line therapy for GERD symptoms
There is mounting data that a lifetime of proton pump inhibitors has consequences associated with it
Endoscopy is needed at minimum to assess esophagitis and in particular to rule out Barrett's esophagus in patients with persistent reflux symptoms
In 2016, for a patient without esophagitis, hiatal hernia, or Barrett's, more workup is warranted before keeping them on PPIs indefinitely, especially in young active persons due to concerns about osteoporosis and other issues
A pH study is needed to confirm the diagnosis of gastroesophageal reflux disease when endoscopy does not show evidence of esophagitis
The Bravo test should be done off PPIs to provide symptom correlation, which is important for setting patient expectations about what surgery will improve
Manometry is essential before any surgical discussion and should be part of the preoperative workup for patients potentially going down the operative road
The basic reason for manometry is number one to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function
Manometry findings consistent with reflux include total relaxation of the lower esophageal sphincter with swallowing and low resting pressure of the LES
Distal esophageal amplitudes on manometry can be used to tailor the fundoplication, with discussion about the difference between a floppy Nissen and a Toupet based on esophageal motility
A patient with normal peristalsis (amplitude of 30 mmHg or higher), total LES relaxation, DeMeester score of 28, and a 2 cm hiatal hernia should receive a full Nissen fundoplication
One disadvantage of laparoscopic fundoplication is that it does not create much scar tissue; full mediastinal dissection helps reduce recurrences by creating ability for the area to scar down and provides more esophageal length
Taking down the short gastric vessels makes it easier to avoid twisting the wrap and to see exactly what is being brought around during fundoplication
The way a Nissen is created is highly variable and one of the downsides of this operation is lack of standardization, making it hard to reproduce data
The geometry of the wrap is the most important part of the operation; surgeons should take time to ensure proper geometry and not be afraid to take down and reestablish the wrap if it does not look right
A common mistake is making the Nissen wrap too long, which adds to dysphagia; the wrap should be about 2 centimeters with typically 3 sutures
The first stitch in a Nissen should be stomach to stomach so the knot can be used to move the wrap and ensure proper positioning before placing additional sutures
A bougie is not routinely needed during crural closure in experienced hands; the esophagus should have a little V-shaped triangle of air below it
In patients with weak peristalsis (amplitude below 20 mmHg) and weak LES, the best operation to prevent reflux is still a Nissen, but the esophageal pump does not work well enough to overcome that barrier, necessitating a Toupet to avoid creating dysphagia
A Toupet fundoplication is a posterior 270-degree wrap that is about 2.5 to almost 3 centimeters long with 3 sutures on either side through esophagus to stomach
The hardest transition of becoming an attending doing foregut surgery is managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues
Fundoplication changes the way patients swallow, the way their stomach works, and the way acid moves from their body; patients must be counseled preoperatively about these changes
The fundoplication is tightest right after surgery and gets looser over time; early dysphagia is expected and the patient who has no dysphagia at 2 weeks likely has a wrap that is too loose
Dysphagia should not be a concern for the first 6 weeks postoperatively, even if the patient maintains a liquid diet, and endoscopic intervention should not be considered until 3 months with no progression and inability to tolerate anything besides liquids
For persistent dysphagia at 6-8 months, workup should include upper GI to rule out hernia recurrence and look for anatomic causes, followed by endoscopy with dilation if the wrap appears too tight
Pseudoachalasia after fundoplication presents with dilated esophagus, retained fluid, tight GE junction on endoscopy, and manometry showing lack of peristalsis and non-relaxing LES; this likely occurs when the wrap is too tight and prolonged dysphagia causes the esophagus to burn out
For pseudoachalasia, nutrition should be optimized before reoperation, with consideration of PEG tube feeding if needed
For complex reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though sometimes dividing it and leaving half a wrap (Toupet) may be acceptable if the wrap cannot be fully taken down
For morbidly obese patients with BMI over 35 and reflux, gastric bypass should be considered instead of fundoplication as the primary operation because Nissen does not work well in morbidly obese patients
For symptomatic herniated wrap, reevaluation should include 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study especially if nausea and vomiting are prominent symptoms
Nausea and vomiting as a large component of foregut patients' complaints are red flags to put the brakes on rushing to surgery and to understand what is going on, particularly regarding gastric emptying
In reoperative fundoplication, the first goal is to reach the right crus to identify where the cava is and avoid injury; the liver and wrap often obliterate the right crus and drifting off the wrap can lead to caval injury
When taking the liver off the wrap in reoperative surgery, sharp dissection with hook or scissors accepting bleeding is preferred over harmonic to avoid injuring the wrap that will be used later
Most surgeons do not take the dissection low enough to the base of the crus; getting the crus at the base provides a choice of going right or straight up with known anatomy to avoid the cava
Many fundoplications recur because there is not enough scar tissue in the chest; if struggling with dissection below, getting up in the chest and working back down is a useful strategy
In reoperative surgery, the key is identifying named structures and digging them out in a systematic fashion rather than trying to make a space without proper dissection, or the surgeon will get lost quickly
If the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is intact, no acute intervention is needed in the operating room; postoperative upper GI on day 1 or 2 should assess gastric emptying, and early Botox of the pylorus is preferred over pyloroplasty if delayed emptying is a concern
PPIs are preferred over H2 blockers because they are more effective at reducing gastric acid secretion and require less frequent dosing
Bravo study is preferred over traditional pH probe because it is easier for the patient (no nasal tube) and provides 48 hours of pH data
Patients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus
Treatment options for pseudoachalasia include taking down the Nissen, performing a Heller myotomy with Dor fundoplication, or taking down the Nissen, doing a long Heller, and converting to a Toupet