04 December 2025
If you have been diagnosed with acid reflux or gastro-esophageal reflux disease (GERD or GORD) and have been taking proton pump inhibitors such as omeprazole, lansoprazole, pantoprazole and similar medications, you will already know that for many people, PPIs work well. Symptoms settle, the esophageal lining heals, and daily life returns to normal.
But I see patients in my clinic at Fakeeh University Hospital every week for whom that story does not apply. They have been on PPIs for months, sometimes years, and they are still suffering. Night-time reflux wakes them. Regurgitation continues. A chronic cough has not resolved. They increase their dose and find temporary relief but the symptoms return as soon as they try to reduce.
The reason this happens is mechanical. PPIs suppress the acid your stomach produces, but they do not repair the underlying problem: a weakened valve at the base of the esophagus; the lower esophageal sphincter which allows stomach contents to travel back up. Reducing the acid reduces the reflux symptoms but it does not stop the reflux. For patients with a structural problem at the valve, medication will always have a ceiling.
There is a second, less well-recognized group: patients whose symptoms were never caused by acid reflux at all, but by an underlying disorder of how the esophagus moves. These patients are frequently placed on long-term PPIs with little benefit, because the diagnosis and the treatment was wrong from the start. I will return to this point; it matters significantly for anyone considering surgery.
This article focuses on what happens after PPIs stop being enough, the evaluation process, how surgical decisions are made, and what a patient in Dubai should understand before agreeing to any operation for reflux. If you would like broader background on GERD, hiatus hernia and acid reflux as conditions including what causes them and how they are initially managed, a full guide covering the wider topic is being published shortly as part of this section of the site.
Most patients who reach a surgical consultation already have a strong sense that something has shifted. The following patterns are what I hear most often, and any one of them is a reasonable reason to seek specialist review:
A consultation with me does not begin with a recommendation for surgery. It begins with investigation. Before any decision about an operation is made, I need a clear and objective picture of what is actually happening in your esophagus, not just what your symptoms suggest.
That picture comes from three investigations. An endoscopy examines the lining of the esophagus and stomach directly, looking for evidence of acid damage, Barrett’s Esophagus, or any other structural finding. A 24-hour pH study measures how much acid and non-acid reflux is occurring and at what times, giving an objective record of reflux events.
The third investigation is esophageal manometry and this one is not optional. Manometry measures the pressure and movement patterns of the esophageal muscle wall. It is the investigation that tells me whether the esophagus is moving normally, and it is also the investigation that prevents a serious clinical mistake.
In my practice, I am thorough about manometry studies because I have seen and managed the consequences when this step is skipped. Patients who have functional overlay, emotional issues, and non-specific symptoms such as chest pain, bloating and nausea are sometimes sent for fundoplication without this investigation having been done. What is missed is a hidden underlying motility disorder of the esophagus. If you subject these patients to fundoplication surgery without ruling out those motility issues, you will almost invariably come across serious problems, unacceptable outcomes that could have been avoided.
Manometry is is a key factor in determining whether anti-reflux surgery is safe for a particular patient.
The results of the three investigations will guide clinical decisions towards one of three outcomes.
pH testing confirms significant acid reflux. Manometry shows normal esophageal motility. The patient is otherwise fit for a laparoscopic procedure. This is the clearest surgical candidate profile, and the point at which I will discuss fundoplication in detail including the specific technique I use and why.
Where manometry reveals a motility disorder such as Achalasia Cardia, diffuse esophageal spasm (sometimes called corkscrew esophagus), nutcracker esophagus, or another dysmotility condition. These cause symptoms that closely resemble GERD: chest discomfort, difficulty swallowing, a sensation of food sticking but they require a completely different treatment pathway.
If I find any of these motility disorders, I do not proceed to fundoplication. Doing so would be likely to worsen the existing symptoms and introduce significant new side effects. Patients with motility disorders need to be assessed and managed on their own merits. Sometimes with medication to reduce esophageal spasm, sometimes with endoscopic dilatation using a pneumatic balloon, sometimes with Botox injection into the lower esophageal sphincter, and in some cases with a surgical procedure called Heller’s Cardiomyotomy combined with a partial fundoplication. This is a different operation from fundoplication for reflux, and it is the right treatment for the right condition.
This is exactly why manometry comes before any surgical conversation about reflux. The test protects patients from an operation that could harm them.
When endoscopy finds changes to the esophageal lining that may indicate Barrett’s Esophagus, a condition where the lining of the lower esophagus changes in response to long-term acid damage. In this case, specialist gastroenterology review and a surveillance program take priority before any surgical decision is made.
For patients confirmed as surgical candidates, I perform laparoscopic fundoplication at Fakeeh University Hospital, Dubai Silicon Oasis. Specifically, I perform Toupet Fundoplication and the reason is worth explaining, because patients are often told simply that “fundoplication” is the operation they need, without understanding that the technique matters.
The most widely performed anti-reflux operation has historically been Nissen Fundoplication, in which the upper portion of the stomach (the fundus) is wrapped fully around the lower esophagus to reinforce the sphincter. This 360-degree wrap is effective at controlling reflux. However, in my clinical experience, Nissen fundoplication gives more incidents of dysphagia or difficulty swallowing after surgery. And there has been a clear trend in surgical practice towards the Toupet approach for a long time now, for exactly this reason.
In Toupet fundoplication, the stomach wrap covers 270 degrees behind the esophagus rather than a full 360 degrees around it. This partial wrap still reinforces the lower esophageal sphincter effectively, but it preserves more natural movement during swallowing. In my practice, I have found it gives consistently lower rates of post-operative dysphagia, the temporary swallowing difficulty that is the most common complaint patients describe after this surgery.
I do not present this as a universal verdict on Nissen versus Toupet: different surgeons with different training and caseloads will have different experiences. What I can tell you is that this is my practice standard, based on my own outcomes over many years. If you see a different surgeon, ask them which technique they use and why, it is a reasonable question, and they should be able to give you a direct answer.I also see patients who have previously undergone fundoplication elsewhere and are still experiencing symptoms or who have developed new complaints since their surgery. This is a more complex clinical situation, and I want to address it honestly.
Sometimes going through fundoplication of any type, whether it is Nissen or Toupet, may not relieve the reflux-related symptoms. On the contrary, it might worsen existing symptoms, and a patient may develop new complications. When I see these patients, the starting point is always a thorough re-investigation including manometry, if it was not done before the first operation.
In many of these cases, what I find is that the original surgery was technically sound, but the selection of the patient for surgery was the problem. A motility disorder that was never investigated was present from the start. The operation did not fail it was not the right operation for that patient’s condition.
This is not a criticism of colleagues: missed esophageal motility disorders are genuinely difficult to identify without manometry, and the symptom overlap with GERD is substantial. But it is why I insist on this investigation before operating, and why I would encourage any patient who has been told they need fundoplication to confirm that manometry has been performed first.
If medication is no longer controlling your symptoms, a surgical consultation will clarify whether you are a candidate for fundoplication or whether another condition is driving your symptoms that has not yet been identified. I see patients at Fakeeh University Hospital, Dubai Silicon Oasis. You can verify my DHA license on the DHA Sheryan medical directory (License No: 50530660-001).
Book Your Consultation at Fakeeh University HospitalThis article is written for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Individual surgical decisions must be made in consultation with a qualified healthcare professional following full clinical assessment. Dr. Appou Tamijmarane is licensed by the Dubai Health Authority (DHA License No: 50530660-001) and practices as a Consultant General Surgeon at Fakeeh University Hospital, Dubai Silicon Oasis, UAE. Patient testimonials referenced elsewhere on this website are published with consent.
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