Expert Interview with Prof. Dr. med. Dr. Matthias Heuer - Reflux, Hiatal Hernia, and Fundoplication

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 departments at the PROSELIS Foundation Hospital, with locations in Recklinghausen and Herten, he brings not only in-depth expertise but also an innovative approach to modern surgery.

He is particularly well-known for his use of minimally invasive and robot-assisted surgical techniques, which enable him to perform surgeries with high precision and minimal trauma. Prof. Dr. med. Dr. Heuer has established himself primarily as a specialist in hernia surgery, where he relies on the highest precision and modern surgical techniques in the treatment of visceral hernias and abdominal wall hernias.

In his certified center of excellence for hernia surgery, various innovative minimally invasive procedures are used, aimed at providing the gentlest possible treatment and a rapid return to daily life. He also focuses on thyroid surgery, a field in which he is considered one of the leading experts. In addition, Prof. Dr. med. Dr. Heuer brings extensive expertise in coloproctological surgery, which encompasses 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, located in Recklinghausen and Herten, are focused on state-of-the-art surgery, providing patients with first-class care.

In an interview with Prof. Dr. med. Dr. Heuer, the editorial team of the Leading Medicine Guide learned more about reflux, the development of a hiatal hernia, and surgical intervention.

Reflux, also known as gastroesophageal reflux disease (GERD), is a common condition in which stomach acid and other stomach contents flow back into the esophagus. This leads to unpleasant symptoms such as heartburn, acid regurgitation, and occasionally chronic coughing fits 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 reflux of stomach acid into the esophagus. 

“It’s important to understand that the esophagus connects directly to the stomach. The chest cavity, which contains the heart and lungs, is separated from the abdominal cavity by the diaphragm—a large, flat muscle that plays a vital role in breathing. The diaphragm acts like an air pump: it supports breathing by relieving pressure on the lungs during inhalation and exhalation. This muscle contains a natural opening—known as the esophageal hiatus—through which the esophagus passes from the chest cavity into the abdominal cavity and ultimately to the stomach. Normally, the diaphragm fits tightly against 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 push food toward the small intestine. In patients with reflux (also known as gastroesophageal reflux disease), it is precisely this closure mechanism that is disrupted. The opening in the diaphragm is too wide, so the esophagus is no longer securely anchored—it literally “dangles” in the hiatus. As a result, the junction between the stomach and the esophagus no longer closes reliably. As a result, stomach contents can flow back unimpeded—especially when the stomach contracts. This is referred to as reflux. It is not only unpleasant but can also be painful. This is because the stomach produces stomach acid to digest food. However, the esophagus is not designed to come into contact with this acid. If this happens nonetheless, 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 as far as the throat, it often triggers a gag reflex. In medicine, we refer to this as regurgitation—the involuntary pushing up of undigested food or chyme from the stomach. We often see patients who have already been treated with medication or are currently being treated, yet still experience symptoms—for example, frequent infections in the throat, nose, and nasal passages. This is because reflux can also carry bacteria into areas where they do not normally belong, which can lead to inflammation there. This type of symptom cannot be completely resolved with standard medications—usually so-called proton pump inhibitors, which reduce acid production in the stomach. This is because the pills treat the acid but not the anatomical cause—namely, the opening in the diaphragm that is too wide. Reflux itself can therefore continue to occur, though it is less acidic. However, this also means that some symptoms do not completely disappear despite medication. If this irritation of the esophagus occurs frequently or persistently, it can lead to inflammation. Over time, repeated inflammation causes the esophageal lining to change as a protective measure. This results in what is known as Barrett’s esophagus—a pathological change considered a precursor to esophageal cancer. That is why it is important to take reflux symptoms seriously and treat them promptly—not only to relieve symptoms such as heartburn, but also to prevent long-term complications.”

The delicate sphincter between the esophagus and the stomach can lose its function over time. Exactly how this happens is not yet fully understood. 

However, there are various theories. Often, a weakness in the connective tissue is the underlying cause. Increased pressure in the abdominal cavity—such as from heavy physical labor, chronic straining, or severe obesity—can also cause the hiatus—that is, the natural opening in the diaphragm—to become permanently stretched. 

“Such a change leads to what is known as a hiatal hernia, in which parts of the stomach shift upward through the diaphragm into the chest cavity. In addition to these physical causes, lifestyle also plays a decisive role. An unhealthy diet, excessive alcohol consumption, and a lack of exercise can contribute to its development. In most cases, this condition develops gradually. Many people affected do not notice any symptoms at first. Only over time do symptoms such as heartburn—which is often associated with certain triggers, such as large meals, alcohol, or sweets—become more frequent. Typically, patients report that the symptoms initially occurred only occasionally—for example, after a social evening—and then gradually became more frequent. This often eventually leads to chronic irritation and inflammation of the lower esophagus. Another important contributing factor is obesity, which increases pressure in the abdominal cavity and thus promotes reflux. Smoking also plays a key role, as it further stimulates acid production in the stomach. Both factors contribute to the worsening of symptoms,” says Prof. Dr. med. Dr. Heuer, who then goes on to explain the conservative treatment options:

“First and foremost is a lifestyle change: a conscious, stomach-friendly diet, avoiding alcohol, sweets, coffee, and late-night meals, as well as weight loss, can significantly alleviate symptoms. Building on this, in many cases medication is prescribed in the form of so-called proton pump inhibitors (PPIs) such as omeprazole. These block acid production in the stomach, which does not eliminate reflux but makes it significantly less aggressive. Some people also turn to alkaline home remedies such as baking soda, which is said to chemically neutralize stomach acid. This remedy is widely used, but can be problematic with long-term use. This is because strong alkalis like baking soda can, over time, disrupt 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 treatment, many affected individuals eventually seek out specialized clinics. This is because the hiatal hernia does not 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, at the latest, surgical correction is often necessary.”

A hiatal hernia is typically diagnosed through a combination of clinical examination and imaging techniques. 

Prof. Dr. med. Dr. Heuer explains: “In the diagnosis and treatment of reflux symptoms, we work very closely with gastroenterologists—they are, so to speak, our non-surgical partners in treatment. A key component of the diagnostic process is gastroscopy, which allows us to assess the lower esophagus in particular very effectively. Many patients already come to us with recent test results. In addition, we perform specialized measurement procedures to analyze the function of the lower esophagus more precisely. These include pH monitoring, which measures acidity (pH level), and manometry, which determines pressure conditions in the area of the lower esophageal sphincter. A supplementary procedure that I personally value highly is the so-called free swallow under fluoroscopy. During this procedure, I observe how the liquid flows through the esophagus into the stomach—this not only allows for an objective assessment of the passage but also helps me clearly explain the cause of the patient’s symptoms,” he adds:

“These findings are then incorporated into a computer-assisted analysis. Based on this, the so-called DeMeester score is calculated—a standardized scoring system for the objective assessment of reflux, named after a Dutch researcher who developed the method in Los Angeles. If this score exceeds a threshold of 40, there is generally a clear indication for surgery. In many cases, the patients’ distress is already so severe at this point that they request surgery on their own initiative. Nevertheless, it is important to emphasize that, unlike an acute condition such as cancer, there is no immediate need for action here. Rather, it is a medical recommendation that is decided upon jointly and calmly. As a rule, I do not schedule surgery appointments during the initial consultation; instead, I encourage patients to give the matter further thought—and, if necessary, to discuss it with their primary care physician. After all, the procedure involves a change in the body’s balance. I often describe this using an analogy: If you’ve lived comfortably in sweatpants for ten years, switching to tight leggings will feel uncomfortable at first. It’s much the same with the changes in pressure after surgery—the body has to get used to it first. The key is that patients are ready to take this step consciously. Many who have already been informed and prepared by their family doctor or gastroenterologist are correspondingly more decisive. Nevertheless, I believe it’s important that every procedure be carefully considered. In practice, about 90% of patients return after this reflection period and ultimately decide to undergo the surgery.”

A surgical procedure such as fundoplication may be the best option for patients with reflux and a hiatal hernia if conservative treatment methods—such as medication and lifestyle changes—do not sufficiently control symptoms or if patients suffer from serious complications. 

“We are a certified hernia center with extensive experience, particularly in the field of hiatal hernias—that is, hernias of the diaphragm in which parts of the stomach protrude into the chest cavity through the natural opening in the diaphragm, known as the hiatus. Since this very ‘hole’ in the diaphragm plays a central role in the development of reflux, procedures at this site are part of our daily routine surgeries. Our center operates at two locations, where together we perform approximately 800 hernia surgeries per year. Even though this figure does not refer exclusively to hiatal hernias, the PROSELIS Foundation Hospital ranks among the leading institutions in this field both regionally and nationwide—not only in terms of case numbers but also in terms of the quality of outcomes. Our work is externally certified, which is very important to me personally. It is not enough to rely on our own assessment; objective, independent quality control ensures that our standards remain consistently high,” emphasizes Prof. Dr. med. Dr. Heuer, before going on to discuss the various surgical procedures:

“The goal is always to narrow the hiatus—that is, the excessively wide opening in the diaphragm—and to reattach it anatomically correctly to the esophagus. This is intended to restore the original closure mechanism between the stomach and the esophagus. A second important component of the surgery is what is known as fundoplication, in which the upper part of the stomach, the fundus, is shaped into a cuff. This cuff wraps around the esophagus and provides additional stabilization to the area, effectively preventing the reflux of stomach contents. The surgery can be performed using three different techniques: open surgery, laparoscopic surgery, or robot-assisted surgery. Open surgery is used only in rare, exceptional cases, such as in patients who have undergone multiple previous surgeries and have severe internal adhesions. Our standard procedure is laparoscopic surgery, in which we work through small incisions using a camera and fine instruments. This minimally invasive procedure is particularly gentle, precise, and allows for a quick recovery.”

Studies have shown that fundoplication provides significant relief from reflux symptoms in approximately 80–90% of patients, with high patient satisfaction and a marked improvement in quality of life. In many cases, these positive results persist for years after surgery. However, some patients may experience long-term symptoms such as bloating, difficulty swallowing, or trouble belching. In rare cases, reflux may recur, which may require further treatment or even a revision of the surgery.

Robot-assisted surgery represents one of the most advanced developments in surgical medicine. It combines the experience and precision of surgeons with the technical excellence of a highly sophisticated robotic system. 

The robot does not perform the surgery itself, but is controlled by the surgeon via a console—with extremely precise movements that are transmitted to the patient in real time and with high accuracy. Especially in complex procedures where millimeter-precise dissections in tight areas of the body are critical, robotics offers significantly improved visibility, finer maneuverability, and greater stability. It is thus a valuable extension of minimally invasive surgery—especially for selected patients who require a particularly gentle and precise technique.

“At our center, we use the Da Vinci Xi in the field of robotics—a state-of-the-art surgical system that we share with other specialized departments such as urology, gynecology, and coloproctology. We have two of these systems, which we use on an interdisciplinary basis to ensure optimal utilization and effective deployment. As Chief of Surgery, with shared responsibility for all surgical specialties, I place great importance on ensuring that the available technology is used efficiently and in a patient-centered manner. However, we only consider robot-assisted surgery for select patients. To illustrate this, I like to use an everyday example: If you have a drip coffee maker at home that brews good coffee, that you’re satisfied with, and that you can operate with minimal effort, the question arises: why would you suddenly buy an expensive fully automatic machine? Just because the market is moving in that direction? The coffee won’t necessarily taste any better, and your morning routine won’t be any shorter either. But at some point, there might no longer be any drip coffee makers—and then you have to be prepared. It’s exactly the same with robotic surgery,” explains Prof. Dr. med. Dr. Heuer.

Robotics offers an excellent three-dimensional camera image and high precision in very confined spaces. 

Prof. Dr. med. Dr. Heuer comments: “These are definitely advantages we can leverage. But they don’t automatically replace the experience and confidence we’ve gained over the years with the standard laparoscopic procedure. Operating the robot is a skill that must be learned—there’s a certain learning curve that must be navigated. And once you’ve mastered a procedure perfectly, the question always arises as to how much you actually gain from a new technology. That’s why we use the robot in situations where the conditions are favorable—for example, with slim patients who have not undergone previous abdominal surgery and who offer an ideal anatomical starting point. This allows us to achieve results with robotics comparable to those of laparoscopy while continuously developing our expertise in this field. Nevertheless, our standard procedure remains quite clearly the laparoscopic technique, with which we achieve excellent results. For us, robotic surgery is a complementary tool—a step toward the future, but not necessary for every case.”

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As with any surgical procedure, fundoplication also carries certain risks. The most common postoperative complaints include temporary difficulty swallowing and an inability to burp, which can lead to bloating. In rare cases, infections, bleeding, or injury to adjacent organs may occur. Reflux may also recur if the fundoplication loosens. However, modern minimally invasive techniques, experienced surgeons, and careful postoperative care help to significantly reduce these risks.

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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 follow-up care and dietary adjustments are crucial for a quick and complication-free recovery.

“After surgery, the patient typically stays with us for three days. Admission takes place on the day of surgery, and on the third day—often as early as Friday following a Wednesday surgery—the patient can go home. A drain is not necessary, as no complications such as bleeding occur during the procedure. The patient can start eating again on the day of the surgery. They should stop taking the medications they were previously taking to stimulate hydrochloric acid production immediately. On the day of discharge, a barium swallow is performed to check, using a contrast agent, whether the hiatus is properly closed. This step serves as a baseline for postoperative monitoring. In an outpatient setting, especially after one to two weeks, I offer to see patients again to assess their progress and determine whether they are still experiencing any symptoms. In the initial period after surgery, particularly within two to four weeks, patients adjust to the changed pressure conditions in their bodies. This can lead to a sensation as if the patient is 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 results. In most cases—as was the case last year with the 60 patients who underwent surgery—58 of them feel well, no longer require medication, and have had no relapses. There are also no longer any significant symptoms. As for whether a patient can drink a glass of sparkling wine on the day of surgery: It would be theoretically possible, but for practical reasons, I would not recommend it. The carbonation and alcohol could lead to further problems. A glass of water would be a better choice instead. “However, we begin allowing the patient to eat immediately on the day of surgery, as we are confident that the patient is able to resume a normal diet,” explains Prof. Dr. med. Dr. Heuer regarding the post-operative procedure.

Preventive advice primarily covers the basics of a healthy lifestyle: 

“Fresh, balanced meals instead of processed foods, moderate alcohol consumption, and regular exercise. It’s also important not to smoke and to avoid being overweight, as fat deposits in the abdominal cavity can put pressure on the stomach. Overall, it’s about living a conscious and healthy life. Of course, there’s no guarantee that certain diseases can be completely prevented, but an active lifestyle helps reduce the risk,” recommends Prof. Dr. med. Dr. Heuer, and with that, we conclude our conversation.

Thank you very much, Professor Dr. Dr. Heuer, for this insightful look into the treatment of reflux!