Prof. Dr. med. Dr. Matthias Heuer is a highly respected specialist in surgery, particularly in the fields of hernia surgery, thyroid surgery, and reflux treatment. As the director of the surgical clinics at the Stiftungsklinikum PROSELIS, with locations in Recklinghausen and Herten, he brings not only extensive expertise but also an innovative approach to modern surgery.
He is especially renowned for his use of minimally invasive and robot-assisted surgical techniques, allowing him to perform highly precise and particularly gentle operations. Prof. Dr. med. Dr. Heuer has established himself as a specialist in hernia surgery, focusing on the treatment of inguinal and abdominal wall hernias with utmost precision and modern surgical methods.
In his certified center of excellence for hernia surgery, various innovative minimally invasive procedures are employed, aiming for the gentlest possible treatment and a rapid return to daily life. His focus also includes thyroid surgery, where he is considered one of the leading experts. Additionally, Prof. Dr. med. Dr. Heuer possesses extensive expertise in colorectal surgery, encompassing the treatment of diseases of the colon and rectum.
He has also established himself as an expert in reflux surgery, and his innovative methods for treating heartburn offer a promising solution for patients suffering from this condition. The clinics in Recklinghausen and Herten are dedicated to state-of-the-art surgery, providing patients with top-quality care.
In a conversation with Prof. Dr. med. Dr. Heuer, the editorial team of the Leading Medicine Guide gained further insights into reflux, the development of a hiatal hernia, and surgical intervention.
Reflux, also known as gastroesophageal reflux disease (GERD), is a widespread condition where stomach acid and other contents flow back into the esophagus. This leads to unpleasant symptoms such as heartburn, acid regurgitation, and occasionally chronic coughing or hoarseness. A common cause of this condition is the presence of a hiatal hernia.
A hiatal hernia influences the development and severity of gastroesophageal reflux disease (GERD) by altering the normal anatomy of the upper digestive tract and thereby disrupting the mechanisms that prevent the backflow of stomach acid into the esophagus.
“Fundamentally, it's important to understand that the esophagus transitions directly into the stomach. The chest cavity, housing the heart and lungs, is separated from the abdominal cavity by the diaphragm—a large, flat muscle that plays a crucial role in breathing. The diaphragm acts like a bellows: it supports respiration by relieving the lungs during inhalation and exhalation. Within this muscle is a natural opening—the so-called esophageal hiatus—through which the esophagus passes from the chest into the abdomen and ultimately to the stomach. Normally, the diaphragm fits snugly around the esophagus at this point, forming a kind of 'natural closure mechanism.' This helps prevent the backflow of stomach contents into the esophagus, especially when the stomach contracts to move food toward the small intestine. In patients with reflux (also known as gastroesophageal reflux disease), this closure mechanism is disrupted. The opening in the diaphragm is too wide, so the esophagus is no longer securely embedded—it essentially 'dangles' in the hiatus. As a result, the junction between the stomach and esophagus no longer closes reliably. Consequently, stomach contents can flow back unimpeded—particularly when the stomach contracts. This is referred to as reflux. It's not only unpleasant but can also be painful. The stomach produces acid to digest food. However, the esophagus is not designed to come into contact with this acid. When it does, it leads to heartburn—a burning pain behind the breastbone,” explains Prof. Dr. med. Dr. Heuer at the beginning of our conversation and then describes the initial symptoms:
“When stomach contents constantly flow back into the esophagus or even up to the throat, it often triggers a gag reflex. In medicine, we refer to this as regurgitation—the involuntary expulsion of undigested food or chyme from the stomach. We frequently see patients who have already been treated with medication or are undergoing treatment, yet still experience symptoms—such as frequent infections in the throat, nose, and pharyngeal areas. This is because, during reflux, bacteria can reach areas where they don't normally belong, leading to inflammation. These types of symptoms cannot be fully resolved with standard medications—usually proton pump inhibitors that reduce acid production in the stomach. The tablets address the acid but not the anatomical cause—the overly wide opening in the diaphragm. Therefore, the reflux itself can persist, albeit less acidic. This also means that some symptoms may not completely disappear despite medication. If this irritation of the esophagus occurs frequently or persistently, it can lead to inflammation. Repeated inflammation over time causes the esophageal lining to change as a protective measure. This results in what's known as Barrett's mucosa—a pathological transformation considered a precursor to esophageal cancer. Therefore, it's important to take reflux symptoms seriously and treat them promptly—not only to alleviate discomfort like heartburn but also to prevent long-term complications.”
The subtle closure between the esophagus and stomach can lose its function over time. The exact cause of this is not yet fully understood.
However, various theories exist. Often, a weakness in connective tissue is the underlying issue. Increased abdominal pressure, such as from heavy physical labor, chronic straining, or significant overweight, can also cause the hiatus—the natural opening in the diaphragm—to stretch permanently.
“Such a change leads to what's known as a hiatal hernia, where parts of the stomach shift upward through the diaphragm into the chest cavity. In addition to these physical causes, lifestyle also plays a crucial role. An unhealthy diet, excessive alcohol consumption, and lack of exercise can promote development. In most cases, the onset of this problem is gradual. Many affected individuals initially notice no symptoms. Over time, however, symptoms like heartburn become more frequent, often associated with specific triggers such as large meals, alcohol, or sweets. Typically, patients report that symptoms initially occurred occasionally, perhaps after a social evening, and then gradually became more frequent. Eventually, this leads to chronic irritation and inflammation of the lower esophagus. Another significant factor is overweight, which increases abdominal pressure and thus promotes reflux. Smoking also plays a central role, as it further stimulates acid production in the stomach. Both contribute to worsening symptoms,” says Prof. Dr. med. Dr. Heuer, who then explains the initial conservative treatment options:
“The first step is lifestyle modification: a conscious, stomach-friendly diet, avoiding alcohol, sweets, coffee, and late-night eating, as well as weight reduction, can significantly alleviate symptoms. Building on this, many cases involve medication treatment with proton pump inhibitors (PPIs) like omeprazole. These block acid production in the stomach, so while reflux doesn't disappear, it's significantly less aggressive. Some people also use alkaline home remedies like baking soda to chemically neutralize stomach acid. This remedy is widespread but can be problematic with long-term use. Strong bases like baking soda can, over time, impair the body's natural regulatory mechanisms and lead to kidney or liver damage. When all these measures are no longer sufficient, high-dose medications are not tolerated, or symptoms worsen despite therapy, many affected individuals eventually seek specialized consultations. The diaphragmatic opening doesn't heal on its own. On the contrary: if the hiatal hernia enlarges, the stomach can shift further into the chest cavity. This can not only worsen reflux symptoms but also lead to breathing difficulties because the lungs can no longer expand properly. At this stage, surgical correction often becomes necessary.”
The diagnosis of a hiatal hernia is usually made through a combination of clinical examination and imaging procedures.
Prof. Dr. med. Dr. Heuer explains: “In diagnosing and treating reflux symptoms, we work very closely with gastroenterologists—they are essentially our non-surgical partners in treatment. A central component of diagnosis is gastroscopy, which allows us to assess the lower esophagus very well. Many patients already come with a current finding. Additionally, we conduct special measurement procedures to analyze the function of the lower esophageal segment more precisely. These include pH-metry, which measures the acid content (pH value), and manometry, which determines the pressure conditions in the area of the lower esophageal sphincter. An additional procedure that I personally value highly is the so-called free swallow under fluoroscopy. Here, I observe how the liquid flows through the esophagus into the stomach—this not only allows an objective assessment of the passage but also helps explain the cause of the symptoms to the patient in a comprehensible way,” and adds:
“The findings obtained are then incorporated into a computer-assisted evaluation. Based on this, the so-called DeMeester score is calculated—a standardized point value for objectively assessing reflux, named after a Dutch researcher who developed the procedure in Los Angeles. If this score exceeds a threshold of 40, there is usually a clear indication for surgery. In many cases, the patients' suffering is already so great at this point that they themselves desire surgery. Nevertheless, it's important to emphasize that, unlike an acute condition like cancer, there is no immediate need for action here. It's more of a medical recommendation to be decided upon calmly together. I never schedule surgery appointments during the initial consultation but encourage patients to reflect on the matter again—possibly also in conversation with their primary care physician. After all, the procedure entails a change in physical balance. I often describe it vividly: someone who has comfortably lived in sweatpants for ten years may initially find switching to tight leggings uncomfortable. It's similar with the altered pressure conditions after surgery—the body needs time to adjust. The key is that patients are willing to take this step consciously. Many who have already been informed and prepared by their primary care physician or gastroenterologist are accordingly more decisive. Nevertheless, I believe it's important that every procedure is well thought out. In practice, about 90% of patients return after this reflection phase and ultimately decide on surgery.”
A surgical intervention, such as fundoplication, can be the best option for patients with reflux and a hiatal hernia when conservative treatment methods like medications and lifestyle changes are insufficient to control symptoms or when patients suffer from severe complications.
„We are a certified hernia center with extensive experience, particularly in the area of hiatal hernias – those diaphragm hernias in which parts of the stomach move through the natural opening in the diaphragm, the so-called hiatus, into the chest cavity. Since this “hole” in the diaphragm plays a central role in the development of reflux, interventions at this site are among our daily routine procedures. Our center operates at two locations, where we perform around 800 hernia surgeries per year together. Although this number does not refer exclusively to hiatal hernias, the PROSELIS Foundation Hospital is considered one of the leading institutions in this field – both regionally and nationwide – not only in terms of case numbers but also with regard to outcome quality. Our work is externally certified, which is personally very important to me. It is not enough to rely on one's own assessment; an objective, independent quality control ensures that our standards remain consistently high“, emphasizes Prof. Dr. med. Dr. Heuer, then discusses the various surgical procedures:
„The goal is always to narrow the hiatus – that is, the enlarged opening in the diaphragm – and to anatomically reconnect it to the esophagus. This aims to restore the original closure mechanism between the stomach and esophagus. A second important component of the surgery is the so-called fundoplication, in which the upper part of the stomach, the fundus, is formed into a cuff. This wraps around the esophagus and provides additional stability to effectively prevent reflux of stomach contents. The surgical procedure can be performed using one of three techniques: open surgery, laparoscopic, or robot-assisted. Open surgery is used only in rare exceptional cases, such as in patients who have had multiple prior surgeries and have significant internal adhesions. Our standard is the laparoscopic approach, which uses small incisions with a camera and fine instruments. This minimally invasive method is especially gentle, precise, and allows for rapid recovery“.
Studies have shown that fundoplication provides significant relief of reflux symptoms in about 80–90% of patients, with high patient satisfaction and a marked improvement in quality of life. Even years after the surgery, the positive results often persist. However, some patients may experience long-term symptoms such as bloating, swallowing difficulties, or trouble belching. In rare cases, reflux can recur, requiring further treatment or even a revision surgery.
Robot-assisted surgery is one of the most advanced developments in operative medicine. It combines the surgeon's experience and precision with the technical excellence of a highly sophisticated robotic system.
In this process, the robot does not perform the operation itself but is controlled by the surgeon via a console – with extremely fine movements that are transmitted to the patient in real time with high precision. Especially in complex procedures requiring millimeter-precise dissection in tight anatomical regions, robotics provides significantly improved visualization, finer maneuverability, and greater stability. It is thus a meaningful extension of minimally invasive surgery – particularly for selected patients where especially gentle and precise techniques are required.
„In our center, we work in the field of robotics with the Da Vinci Xi – a state-of-the-art surgical system that we use in cooperation with other departments such as urology, gynecology, and colorectal surgery. We have two of these systems, which we use interdisciplinarily to ensure optimal utilization and effective deployment. As head of surgery responsible for all surgical specialties, I place great importance on ensuring that the available technology is used efficiently and in a patient-oriented manner. However, the robot-assisted procedure is only considered for selected patients. To illustrate this, I like to use a common example: If you have a drip coffee maker at home that makes good coffee, that you're happy with, and that you can operate without much effort, why should you suddenly invest in an expensive fully automatic machine? Just because the market is heading that way? The coffee won’t necessarily taste better, and your morning routine won’t get shorter. But at some point, drip machines may no longer be available – and then you need to be prepared. The same applies to robotic surgery“, explains Prof. Dr. med. Dr. Heuer.
Robotics offers excellent three-dimensional imaging and high precision in very confined spaces.
Prof. Dr. med. Dr. Heuer comments: „These are definitely advantages we can make use of. But they do not automatically replace the experience and safety we’ve had for years with the laparoscopic standard technique. Handling the robot must be learned – there is a learning curve to go through. And once you’ve mastered a technique perfectly, you must ask yourself how much value a new technology truly adds. That’s why we use the robot in situations where the conditions are favorable – for example, in slim patients without previous abdominal surgeries who have ideal anatomical conditions. This allows us to achieve comparable outcomes to laparoscopy while continuously developing our expertise in this area. However, our standard procedure remains clearly the laparoscopic technique, with which we achieve excellent results. Robotics is a complementary tool for us – a step toward the future, but not necessary in every case“.
As with any surgical procedure, fundoplication carries certain risks. The most common postoperative complaints include temporary swallowing difficulties and the inability to belch, which may lead to bloating. In rare cases, infections, bleeding, or injury to adjacent organs can occur. Reflux may also recur if the fundoplication becomes loose. However, modern minimally invasive techniques, experienced surgeons, and careful aftercare help to significantly reduce these risks.
After fundoplication surgery, an important recovery phase begins during which the body adapts to the changes in the gastrointestinal tract. Most patients can be discharged after a few days, but careful aftercare and dietary adjustments are crucial for a swift and complication-free recovery.
„After the operation, the patient usually stays with us for three days. Admission takes place on the day of surgery, and on the third day – often already Friday after surgery on Wednesday – the patient can go home. A drain is not necessary because no complications like bleeding occur during surgery. The patient can eat again on the day of surgery. The medications previously taken to reduce stomach acid are stopped immediately. On the day of discharge, a contrast swallow is performed to check whether the hiatus is properly closed. This step serves as a baseline for postoperative follow-up. In an outpatient setting, especially after one to two weeks, I offer patients a follow-up visit to check their progress and assess for any ongoing issues. In the first weeks after surgery, especially within two to four weeks, patients adjust to the changed internal pressure dynamics. This may result in a sensation of swallowing against resistance – a so-called globus sensation. However, these symptoms usually subside within six months. After about half a year, we generally see very good outcomes. In most cases, such as last year when 60 patients were operated on, 58 of them feel well, no longer need medication, and have not experienced recurrences. There are no significant complaints. As for the question of whether a patient can drink a glass of sparkling wine on the day of surgery: it would be theoretically possible, but I would not recommend it for practical reasons. The carbonation and alcohol could lead to further issues. A glass of water would be more advisable. Nevertheless, we begin oral intake on the day of surgery, as we trust that the patient can eat normally again“, explains Prof. Dr. med. Dr. Heuer regarding the postoperative process.
A preventive recommendation primarily includes the basics of a healthy lifestyle:
„Fresh, balanced food instead of ready-made products, moderate alcohol consumption, and regular physical activity. It’s also important not to smoke and to avoid being overweight, as fat accumulation in the abdominal area can exert pressure on the stomach. Overall, it’s about living consciously and healthily. Of course, there’s no guarantee that one can completely prevent certain diseases, but an active lifestyle helps reduce the risk“, advises Prof. Dr. med. Dr. Heuer, and with that we conclude our conversation.
Many thanks, Professor Dr. Dr. Heuer, for this impressive insight into reflux treatment!
