It is paradoxical that recently the number of operations for gastro-oesophageal reflux and hiatus hernia has increased dramatically even though extremely effective medication for these conditions is now available in many, if not all, Western countries.1a The traditional indications for antireflux surgery still exist but they have been impacted upon by cultural factors, cost, and associated serious disease; so why do more people require surgery?

The most common indication for surgery used to be the failure of medical treatment in severely symptomatic disease; however, so effective are proton pump inhibitors (PPIs) at controlling the major symptom of reflux—namely, heartburn, that this is a less common reason for performing surgery today. Indeed, the failure of a patient to get some degree of symptomatic relief from an adequate dosage of PPIs should alert the surgeon to other problems—for example, bile reflux, irritable colon, functional dyspepsia, or gallstones. Yet, successful medical treatment is often indefinite in duration and many patients do not wish to be on medication for the rest of their lives; such patients are often considered for surgery. Lifelong medication is also costly, and surgery may be the cheaper option in the long term.1

Stricture formation used to be another common indication for surgery, but PPI treatment has proved so successful that this is now rarely seen. Many patients are elderly and their predominant problem is dysphagia, which is usually effectively treated with PPIs and dilatation. A further indication for surgery—that is, regurgitation or high volume reflux, is now seen more often. It is possible that the successful treatment of heartburn through the use of PPIs has decreased awareness of reflux and the patient has thus allowed more fluid to regurgitate; as a consequence more patients are presenting with volume regurgitation as their main problem.

Surgery as a …