Management of Refractory Gastroesophageal Reflux Disease (GERD) After Hiatal Hernia Surgery

Diagnostic Evaluation

The American Gastroenterological Association recommends endoscopy as the first diagnostic step in patients with inadequate response to proton pump inhibitors (PPIs), particularly in the post-surgical context where anatomical recurrence must be excluded 1, 2
A complete endoscopic evaluation should include the Los Angeles classification for erosive esophagitis, assessment of the diaphragmatic hiatus (Hill grade), measurement of the length of any recurrent axial hiatal hernia, and search for Barrett's esophagus 1, 2, 4

Verify correct intake of Dexilant: 30-60 minutes before the first meal of the day to optimize its efficacy 5, 3
Consider increasing the dose of Dexilant to 60 mg twice daily, as acid suppression with twice-daily PPIs is superior to once-daily dosing and more effective for refractory GERD symptoms 6, 1, 7, 5
Add alginate-containing antacids as adjunctive treatment for intercurrent symptoms, particularly effective in patients with known hiatal hernia, as they form a physical barrier and displace the postprandial acid pocket below the diaphragm 6, 4, 5, 8

If endoscopy shows no erosive esophagitis of grade B or higher according to Los Angeles and no Barrett's esophagus ≥3 cm, a prolonged wireless pH monitoring (96 hours if available) WITHOUT PPIs should be performed to confirm and phenotype GERD 1, 2, 3
In symptomatic patients with proven GERD, 24-hour pH-impedance monitoring ON PPIs can determine the mechanism of persistent symptoms (residual acid reflux, weakly acidic reflux, or reflux hypersensitivity) 6, 1, 4

Anti-reflux surgery (laparoscopic fundoplication, magnetic sphincter augmentation) is an effective therapeutic option in patients with objectively documented refractory GERD and optimized medical treatment failure, but only after objective confirmation of pathological reflux 6, 1, 4, 3
Note that lack of response to PPIs predicts lack of response to anti-reflux surgery, which should be integrated into the shared decision-making with the patient 7

Do not empirically increase the dose without diagnostic confirmation of GERD by endoscopy and possibly pH monitoring 3
Do not continue long-term PPI treatment without establishing a definitive diagnosis 2, 4, 3
Recognize that persistent symptoms may be due to non-GERD causes such as functional heartburn or reflux hypersensitivity, requiring different therapeutic approaches (neuromodulation, cognitive-behavioral therapy, hypnotherapy) 1, 4, 3