Is anti-reflux surgery safe for my mother, aged 65?

Question

Hello doctor,

My 65-year-old mother has chronic reflux, and a recent upper GI endoscopy showed grade B erosive esophagitis and a small hiatal hernia. Her main complaints are hoarseness in the morning and a burning sensation in the throat, even with twice-daily Pantoprazole.

Her chest X-ray was normal. Should we consider esophageal pH monitoring or manometry? Is surgery like LINX or Nissen safe for someone her age?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I am deeply concerned about your worries.

It confirms ongoing acid or non-acid reflux despite proton pump inhibitor (PPI) therapy. It correlates reflux episodes with throat symptoms. It helps distinguish among true refractory gastroesophageal reflux disease (GERD), non-acid reflux, and functional throat symptoms that are not reflux-related.

The best option is 24-hour impedance pH monitoring while on PPI therapy. This is especially important for hoarseness and throat burning, as it detects acid, weakly acidic, and non-acid reflux. It directly determines whether anti-reflux surgery would be beneficial.

Esophageal manometry is required if anti-reflux surgery (Nissen fundoplication or LINX) is being considered or if there is concern about swallowing coordination.

What manometry tells us: esophageal motility (rules out achalasia or severe dysmotility) and lower esophageal sphincter (LES) pressure. It helps determine full Nissen versus partial fundoplication and eligibility for LINX. Manometry is mandatory before anti-reflux surgery but it is not a diagnostic test for reflux itself.

Why PPIs may not be helping her throat symptoms: several possibilities exist, including non-acid reflux (PPIs do not prevent this), reflux hypersensitivity, laryngopharyngeal reflux (LPR) often responds incompletely to PPIs, and weak LES due to a hiatal hernia. Morning hoarseness is a classic symptom of supine reflux.

Is anti-reflux surgery safe at her age (64 to 65)? Age alone is not a contraindication. Outcomes depend more on physiologic age and comorbidities than chronological age.

Safety data in general, patients in their 60s to 70s routinely undergo Nissen procedures. Mortality is less than 0.1 percent in experienced centers. Complication rates are similar to those in younger patients when appropriately selected.

Pros include less gas-bloat, faster recovery, and reversibility. Cons include less data for severe LPR symptoms, usually not ideal with hiatal hernias larger than 2 to 3 centimeters, and requires normal manometry.

Nissen fundoplication pros: strongest reflux control, best evidence for extra-esophageal symptoms, and allows simultaneous hiatal hernia repair. Cons include risk of gas-bloat and dysphagia if patient selection is poor.

In older patients with documented erosive disease and throat symptoms, laparoscopic Nissen fundoplication or a partial wrap if motility is weak is often preferred if testing confirms reflux.

I hope this helps.

Please follow up if you have any further concerns.

Thank you.