Foregut Surgery

The foregut is the upper part of the digestive tract: the esophagus, stomach, and first part of the small intestine (duodenum), along with the diaphragm opening the esophagus passes through. Foregut surgery is well established for:

• GERD

• Achalasia

• Esophageal diverticula

• Barrett's esophagus

• Esophageal and stomach cancer

• Gastric outlet obstruction

• Obesity

(Chang, World Journal of Gastroenterology, 2019)

Foregut disease is extremely common.

• About 20% of U.S. adults have reflux symptoms at least weekly (Richter and Rubenstein, Gastroenterology, 2018).

• In a national survey, more than half of people taking a daily proton pump inhibitor (PPI) still had troublesome symptoms (Delshad et al., Gastroenterology, 2020).

• Obesity can triple the odds of GERD (Delshad et al., Gastroenterology, 2020).

The three most common benign foregut operations in the U.S. are hiatal hernia repair, fundoplication, and Heller myotomy (Teh et al., JAMA Surgery, 2022).

Today, almost all foregut surgery is minimally invasive. It is done laparoscopically, robotically, or endoscopically through the mouth. For paraesophageal hernia repair, 30-day mortality was 0.5% with laparoscopy vs 2.6% with open surgery in national data (Rattner, Journal of Medical Insight, 2024).

Major guidelines now govern this field:

• The SAGES hiatal hernia guidelines (2024)

• A multi-society GERD guideline endorsed by SAGES, ASMBS, ASGE, STS, SSAT, and EAES (2023)

• The EAES paraesophageal hernia guideline (2023)

• The SAGES POEM guideline update (2024)

(Mahmood et al., Surgical Endoscopy, 2026)

Symptoms that bring patients to a foregut surgeon

• Heartburn or regurgitation that persists despite medication, or that returns whenever medication is stopped
• Difficulty swallowing (dysphagia), food sticking in the chest, or pain with swallowing
• Chronic cough, hoarseness, throat clearing or a sour taste, which can signal laryngopharyngeal reflux
• Chest pressure, early fullness, or pain and vomiting after meals, common with large hiatal and paraesophageal hernias
• Unexplained iron-deficiency anemia or shortness of breath related to a large hernia
• Reflux or swallowing problems after a previous operation, such as a fundoplication or a sleeve gastrectomy

How foregut problems are evaluated

Testing comes before any recommendation, because the right operation depends on what the tests show:

• Upper endoscopy (EGD) to look for esophagitis, Barrett's esophagus, strictures, hernia size and stomach anatomy
• High-resolution esophageal manometry to measure how well the esophagus squeezes and how the lower sphincter relaxes, and to rule out achalasia and other motility disorders
• Reflux (pH) testing: a 24-hour catheter pH-impedance study or a 96-hour wireless Bravo capsule, to confirm whether reflux is really the cause of symptoms
• Barium swallow (esophagram) to show the hernia, the shape of the esophagus and how liquid empties
• CT scan when needed, for large or paraesophageal hernias, complex anatomy after prior surgery, or suspected vascular compression
• Gastric emptying study when nausea, bloating or vomiting raise concern for gastroparesis

Explore foregut conditions and procedures

GERD and anti-reflux surgery

• Anti-reflux surgery for GERD: fundoplication or LINX
• Nissen fundoplication, Toupet fundoplication and Dor fundoplication
• LINX magnetic sphincter augmentation
• Transoral incisionless fundoplication (TIF) and Stretta
• Gastric bypass (Roux-en-Y) for GERD and ligamentum teres cardiopexy for reflux after sleeve
• Conditions: GERD, refractory GERD, reflux after sleeve gastrectomy, erosive esophagitis and Barrett's esophagus

Hiatal and paraesophageal hernia

• Hiatal and paraesophageal hernia repair
• Hiatal hernia repair after sleeve gastrectomy and after gastric bypass
• Conditions: hiatal hernia and paraesophageal hernia

Revisional foregut surgery

• Revisional (redo) foregut and anti-reflux surgery
• Conditions: failed fundoplication and recurrent hiatal hernia

Esophageal motility and swallowing

• Achalasia: Heller myotomy, POEM and Dor partial fundoplication
• Esophageal diverticulum surgery
• Esophageal dilation for esophageal strictures
• Jackhammer esophagus, EGJ outflow obstruction (EGJOO) and diffuse esophageal spasm

Stomach, esophagus and ulcer surgery

• Gastrectomy, esophagectomy and Barrett's endoscopic therapy
• Bleeding ulcer surgery, perforated ulcer repair and endoscopic ulcer management
• Gastric outlet obstruction surgery

Vascular compression

• Median arcuate ligament release (MALS surgery) and SMA syndrome surgery

If you live in South Florida, our page on hiatal hernia and reflux surgery in Miami explains how evaluation and treatment are arranged at our practice.

Foregut operations restore anatomy and function in four main ways:

• Rebuilding the antireflux barrier.
  • Fundoplication wraps the top of the stomach around the lower esophagus. It blocks all refluxed material, acid and non-acid (Katz et al., ACG Clinical Guideline, 2022).
  • LINX places a ring of magnetic titanium beads that reinforces the valve but still lets you belch and vomit (Katz et al., ACG Clinical Guideline, 2022).
• Repairing the diaphragm.
  • Hiatal and paraesophageal hernia repair returns the stomach to the abdomen and closes the enlarged opening in the diaphragm.
  • A fundoplication is usually added, which controls reflux and helps anchor the stomach (Baiu and Lau, JAMA, 2019).
• Relieving obstruction.
  • Heller myotomy divides the tight muscle at the bottom of the esophagus in achalasia. Reducing that resistance is the mainstay of achalasia treatment (Mittal and Vaezi, New England Journal of Medicine, 2020).
  • Gastric outlet operations bypass or open a blocked stomach outlet.

• Releasing compression. Median arcuate ligament release frees the celiac artery and nerve plexus from a band of diaphragm tissue that compresses them (Kim et al., JAMA Surgery, 2016).

Choosing between operations

No single operation is right for everyone. Each option below suits a different kind of patient, and the recommendation is based on testing, anatomy, weight, prior surgery and personal priorities:

• Nissen fundoplication (360°): a full wrap with strong reflux control. Often considered when esophageal motility is normal and reflux is severe, with the trade-off of more gas-bloating and early swallowing difficulty.
• Toupet fundoplication (270°): a partial wrap that causes less swallowing difficulty and bloating, with possibly somewhat more reflux recurrence (Katz et al., ACG Clinical Guideline, 2022). Often chosen when esophageal contractions are weaker.
• Dor fundoplication (180°): an anterior partial wrap, usually paired with Heller myotomy for achalasia to limit reflux after the myotomy.
• LINX: a magnetic ring that reinforces the valve without wrapping the stomach, for patients with normal motility who want to keep the ability to belch and vomit.
• TIF: an incisionless partial wrap built through the mouth, for selected patients with a small or no hiatal hernia, or combined with laparoscopic hernia repair.
• Stretta: an endoscopic radiofrequency treatment for selected patients with milder reflux and no significant hernia who prefer to avoid surgery.
• Roux-en-Y gastric bypass for GERD: treats reflux and obesity together, and is often preferred when reflux occurs with obesity, after a sleeve gastrectomy, or after more than one failed wrap.
• Ligamentum teres cardiopexy: an option for selected patients with reflux after sleeve gastrectomy who want to keep their sleeve.

• Durable reflux control. In a meta-analysis of 1,334 patients followed more than 10 years after laparoscopic Nissen:
  • Heartburn fell from 94.2% to 33.7%
  • Regurgitation fell from 68.7% to 13.4%
  • Esophagitis fell from 61.7% to 7.4%
  • 87% were satisfied and would have the operation again

(Principe et al., Annals of Surgery, 2026)

• Better short-term control than medication. In a Cochrane review of randomized trials:
  • Heartburn persisted in 4.2% after fundoplication vs 22.2% on medication
  • GERD-specific quality of life was better after surgery

(Maret-Ouda et al., JAMA, 2020)

• Freedom from daily PPIs with LINX. At more than 5 years:
  • 90.4% were free of daily PPIs
  • 81.6% had at least a 50% improvement in quality of life

(Louie et al., Annals of Surgery, 2026)

• Effective achalasia relief. Heller myotomy succeeded in 81.7% and POEM in 83.0% at 2 years in a randomized NEJM trial (Werner et al., New England Journal of Medicine, 2019).

• Safer when done electively. For paraesophageal hernias, 88.1% of elective repairs had a complication-free "textbook" outcome vs 46.7% of emergency repairs. Emergency repairs carried 6.7% mortality (Crnkovic et al., Journal of the American College of Surgeons, 2026).

• Fast recovery. Many patients go home the same day or the next day (Teh et al., JAMA Surgery, 2022).

• Reflux patients with:
  • Symptoms that persist despite PPIs
  • Side effects from PPIs, or a preference to stop them
  • Severe regurgitation
  • A hiatal hernia larger than 5 cm
  • Symptoms from weakly acidic reflux

(Fass, New England Journal of Medicine, 2022)

• The strongest predictors of a good result after antireflux surgery:
  • Abnormal acid exposure on pH testing
  • Erosive esophagitis
  • Typical symptoms
  • A good response to PPIs
  • A hiatal hernia
  • A highly experienced surgeon

(Fass, New England Journal of Medicine, 2022)

• Paraesophageal hernias. Repair is recommended for all symptomatic type II and III paraesophageal hernias and all type IV hernias. This includes patients with iron-deficiency anemia or breathing symptoms (Callaway and Vaezi, Clinical Gastroenterology and Hepatology, 2018).

• Achalasia confirmed by high-resolution manometry and timed barium swallow. Myotomy suits all subtypes. Type III achalasia responds best to a tailored myotomy (Vaezi et al., ACG Clinical Guideline, 2020).

• Median arcuate ligament syndrome, especially in patients who get relief from a celiac plexus block. That response helps predict who will benefit from surgery (DeCarlo et al., Journal of Vascular Surgery, 2023).

• Complicated ulcer disease, gastric outlet obstruction, or stomach tumors.

Patients with obesity and reflux are evaluated for gastric bypass (Roux-en-Y) for GERD. Patients with reflux after sleeve gastrectomy are evaluated for conversion to Roux-en-Y gastric bypass, hiatal hernia repair after sleeve, ligamentum teres cardiopexy or LINX. Patients whose reflux or hernia has returned after a previous repair are evaluated for revisional foregut surgery.

Most foregut operations are performed laparoscopically or robotically under general anesthesia, through 5–6 small incisions:

1. Exposure. The left lobe of the liver is lifted to expose the junction of the esophagus and stomach.
2. Hiatal dissection. Any hernia sac is removed. The esophagus is mobilized until at least 3 cm lies below the diaphragm without tension (Schlottmann et al., JAMA Surgery, 2025).
3. Crural repair. The diaphragm opening is closed with sutures. Mesh is used selectively, because long-term studies show routine mesh does not reduce recurrence compared with sutures alone (Schlottmann et al., JAMA Surgery, 2025).
4. The functional step, matched to the condition:
   • Full wrap (Nissen)
   • Partial wrap (Toupet or Dor)
   • LINX placement
   • Myotomy
   • Gastropexy
   • Ligament release
5. Gastropexy when indicated. In a randomized trial of 240 patients, anterior gastropexy reduced paraesophageal hernia recurrence at 1 year (Petro et al., JAMA Surgery, 2025).
6. Intraoperative endoscopy. This confirms the anatomy and checks for leaks (Bougleux Gomes et al., Journal of Medical Insight, 2023).

Endoscopic options such as TIF, Stretta, and esophageal dilation are performed through the mouth, with no incisions.

• Mortality after laparoscopic fundoplication is 0.1–0.2% (Maret-Ouda et al., JAMA, 2020).
• 30-day complications occur in 4.1%. The most common are:
  • Infection (1.1%)
  • Bleeding (0.9%)
  • Esophageal perforation (0.9%)

(Maret-Ouda et al., JAMA, 2020)

• Side effects after fundoplication:
  • Gas-bloating and difficulty swallowing are common long-term. One 10-year meta-analysis reported them in 53% and 26%, and most were mild (Principe et al., Annals of Surgery, 2026).
  • Partial wraps cause less difficulty swallowing and bloating than a full Nissen, but may have somewhat higher reflux recurrence (Katz et al., ACG Clinical Guideline, 2022).

• Reoperation after fundoplication is needed in 4.6–6.9% within about 10 years (Maret-Ouda et al., JAMA, 2020).

• Hernia recurrence. Recurrence reaches up to 48% after repair of hernias larger than 5 cm. Most recurrences cause no symptoms (Callaway and Vaezi, Clinical Gastroenterology and Hepatology, 2018).

• LINX. 13% of devices were removed at more than 5 years, with erosion in 2% (Louie et al., Annals of Surgery, 2026).

• Reflux after achalasia treatment. Esophagitis at 2 years occurred in 29% after Heller with Dor vs 44% after POEM (Werner et al., New England Journal of Medicine, 2019).

• Hospital stay:
  • Most patients go home the same day or after one night.
  • A regional same-day recovery program for hiatal hernia repair, fundoplication, and Heller myotomy proved safe and effective (Teh et al., JAMA Surgery, 2022).
  • Large paraesophageal hernias may need 1–2 nights.
• Diet:
  • Liquids, then soft foods for 2–4 weeks after a fundoplication or hernia repair.
  • Patients often stay on a liquid or partly liquid diet for several days (Baiu and Lau, JAMA, 2019).

• Walking: starts the day of surgery.

• Desk work: most patients return in 1–2 weeks.

• Heavy lifting: avoided for about 4–6 weeks after hiatal repair.

• Early swallowing difficulty is expected and usually improves over 6–12 weeks.

• Fundoplication:
  • Symptom recurrence was 17% at a mean of 13 years
  • 24% used PPIs, often for symptoms other than reflux

(Principe et al., Annals of Surgery, 2026)

• LINX: 89% had normal acid exposure at 6–12 years (Ferrari et al., Scientific Reports, 2020).
• Heller myotomy:
  • More durable than balloon dilation. Treatment failure was about 20% vs more than 50% at 10 years (Sediqi et al., Surgical Endoscopy, 2021).
  • If symptoms return, repeat dilation, myotomy, or POEM are options (Vaezi et al., ACG Clinical Guideline, 2020).
• MALS release:
  • 58.8% had full relief and 24.4% partial relief
  • Symptoms can return, so follow-up matters

(DeCarlo et al., Journal of Vascular Surgery, 2023)

Surveillance: patients with Barrett's esophagus continue endoscopic surveillance.

Expected Symptom Outcomes

For foregut surgery, the main improvements patients can expect are in symptoms and function:

• Reflux symptoms and esophageal healing. The long-term Nissen results summarized under Benefits show large, lasting reductions in heartburn, regurgitation and esophagitis (Principe et al., Annals of Surgery, 2026).

• Normalized acid exposure. After LINX, median esophageal acid exposure fell from 9.1% to 3.2% (Louie et al., Annals of Surgery, 2026). 89% of patients had normal acid exposure at 6–12 years (Ferrari et al., Scientific Reports, 2020).

• Swallowing. About 4 of 5 achalasia patients had lasting relief 2 years after Heller myotomy or POEM (Werner et al., New England Journal of Medicine, 2019).

• Anemia and breathing. Iron-deficiency anemia and breathing symptoms caused by large paraesophageal hernias are recognized reasons for repair. Their improvement is a key goal of surgery (Callaway and Vaezi, Clinical Gastroenterology and Hepatology, 2018).

• After-meal pain and nausea. 88.7% of MALS patients had partial or complete relief at a median of 13 months (Boaz et al., Surgery, 2026).

• Nutrition and weight. Patients with achalasia, paraesophageal hernia, MALS, or gastric outlet obstruction often lose weight because eating hurts. Many regain healthy weight once they can eat comfortably again.

• Quality of life. 81.6% of LINX patients had at least a 50% improvement in reflux-related quality of life beyond 5 years (Louie et al., Annals of Surgery, 2026).

Preventing Recurrence

For foregut surgery, the focus is on preventing recurrence and failure:

• Confirm the diagnosis before operating. This includes:
  • Upper endoscopy
  • Ambulatory pH testing when endoscopy is normal
  • High-resolution manometry
  • Barium swallow when indicated
  The strongest predictors of a good result after antireflux surgery are abnormal pH testing, typical symptoms, and response to PPIs (Fass, New England Journal of Medicine, 2022).
• Match the operation to your physiology. For example:
  • Partial wrap (Toupet) when esophageal motility is weak
  • Dor fundoplication with Heller myotomy for achalasia
  • Gastric bypass for reflux with obesity
• Use evidence-based technique:
  • At least 3 cm of esophagus below the diaphragm without tension
  • Suture crural closure, with mesh only when needed (Schlottmann et al., JAMA Surgery, 2025)
  • Anterior gastropexy for paraesophageal hernias, which reduced 1-year recurrence in a randomized trial (Petro et al., JAMA Surgery, 2025)

• Protect the repair early. Avoid heavy lifting and straining for about 6 weeks, and treat chronic cough, constipation, and vomiting promptly.

• Manage weight. Obesity can triple the odds of GERD (Delshad et al., Gastroenterology, 2020), and higher BMI increases the strain on a hiatal repair.

• Evaluate early. Recurrent symptoms are checked with endoscopy and pH testing before medication is restarted long-term (Maret-Ouda et al., JAMA, 2020).

Dr. Nestor de la Cruz-Muñoz is a board-certified minimally invasive surgeon specializing in advanced foregut, anti-reflux, hiatal hernia and complex revisional surgery, with extensive experience in bariatric and metabolic surgery.

Antireflux and hiatal hernia surgery is his most frequently performed operation. His practice is a regional referral center for reflux, hiatal hernia, and median arcuate ligament syndrome. He is one of the first surgeons in Florida, if not the first, to perform minimally invasive median arcuate ligament (MALS) release, and he has presented his techniques to surgical audiences.

He has performed more than 15,000 minimally invasive procedures over more than 25 years in practice, including complex foregut, hernia, gallbladder and abdominal operations as well as bariatric surgery. He is also a diplomate of the American Board of Obesity Medicine, directed a bariatric surgery fellowship for 10 years, where fellows also trained in foregut and revisional operations, and has served as Principal Investigator for six bariatric endoscopic FDA pivotal trials.

Experience matters in this field. Foregut surgery outcomes depend on the surgeon and the center:

• Paraesophageal hernia repair. In 63,812 repairs, hospitals doing more than 20 a year had:
  • Complications of 12.7% vs 26.4% at low-volume hospitals
  • Mortality of 0.8% vs 2.9%
  • Laparoscopy far more often

(Schlottmann et al., Journal of Gastrointestinal Surgery, 2017)

• Antireflux surgery. In 75,544 operations, high-volume hospitals had lower morbidity, shorter stays, and lower costs (Schlottmann et al., World Journal of Surgery, 2018).

• Achalasia. The American College of Gastroenterology recommends that definitive achalasia therapy be performed at centers with adequate volume and expertise (Vaezi et al., ACG Clinical Guideline, 2020).

Why combining foregut and bariatric expertise matters: many reflux patients also have obesity, a prior sleeve gastrectomy, or a failed fundoplication. For these patients, the right operation is often a gastric bypass rather than another wrap. One surgeon, one team, one plan, including:

• Nissen and Toupet fundoplication

• LINX

• TIF

• Heller myotomy with Dor fundoplication

• Paraesophageal hernia repair

• Gastric Bypass (Roux-en-Y) for GERD

• Revisional foregut surgery

Reflux is the central disease in foregut surgery, and matching the operation to the patient is the most important decision:

• Nissen (360°) fundoplication. The most extensively studied antireflux operation, with strong, durable reflux control (Katz et al., ACG Clinical Guideline, 2022). See Nissen fundoplication.

• Toupet (270°) fundoplication. It causes less difficulty swallowing and bloating, with possibly slightly more recurrence (Katz et al., ACG Clinical Guideline, 2022). See Toupet fundoplication.

• LINX. It preserves the ability to belch and vomit. Normal esophageal function must be confirmed before implantation. See LINX magnetic sphincter augmentation.

• Incision-free options for selected patients with small or no hiatal hernias. See transoral incisionless fundoplication (TIF) and Stretta.

• Reflux with obesity, after sleeve gastrectomy, or after multiple failed fundoplications. Roux-en-Y gastric bypass is often the preferred operation in these settings. See gastric bypass (Roux-en-Y) for GERD, sleeve to gastric bypass conversion and ligamentum teres cardiopexy.

• Achalasia. A Dor or Toupet partial fundoplication with Heller myotomy limits reflux after myotomy. Reflux esophagitis at 2 years occurred in 29% after Heller with Dor vs 44% after POEM (Werner et al., New England Journal of Medicine, 2019).

• When surgery won't help. Functional heartburn and reflux hypersensitivity need careful testing, because surgery helps only when reflux is proven.

See also GERD / acid reflux, erosive esophagitis, nonerosive reflux disease, laryngopharyngeal reflux (LPR), Barrett's esophagus, reflux hypersensitivity and anti-reflux surgery (fundoplication or LINX).

About 6% of patients need reoperation over 10+ years after Nissen fundoplication (Principe et al., Annals of Surgery, 2026). Revisional options include:

• Redo fundoplication for a failed fundoplication: a wrap that has slipped, herniated, loosened, or become too tight

• Recurrent hiatal hernia repair. Recurrence is reported in up to 48% after repair of hernias larger than 5 cm. Most recurrences cause no symptoms and don't need surgery (Callaway and Vaezi, Clinical Gastroenterology and Hepatology, 2018).

• LINX removal or revision. For difficulty swallowing, recurrent reflux or erosion, the device can be removed, usually with a fundoplication at the same operation. 92.6% of patients whose devices were removed had their symptoms resolve (Louie et al., Annals of Surgery, 2026).

• Conversion to Roux-en-Y gastric bypass after multiple failed fundoplications, or for reflux with obesity or after a prior sleeve. See gastric bypass (Roux-en-Y) for GERD.

• Repeat myotomy, POEM, or dilation for recurrent achalasia. Esophagectomy is reserved for an esophagus larger than 8 cm that responds poorly to myotomy (Vaezi et al., ACG Clinical Guideline, 2020).

• Revisional hiatal surgery after bariatric operations. See hiatal hernia repair after sleeve gastrectomy and hiatal hernia repair after gastric bypass.

See revisional foregut and reflux surgery.

Most insurers cover medically necessary foregut surgery when the record documents:

• Symptoms and their duration

• Failed, inadequate, or poorly tolerated medical therapy, usually including PPIs

• Objective testing: endoscopy, pH monitoring, manometry, and imaging as appropriate

• A diagnosis that meets guideline criteria, for example a symptomatic paraesophageal hernia or manometry-confirmed achalasia

Coverage for LINX, TIF, and Stretta varies more by plan than coverage for fundoplication or hiatal hernia repair. Emergency operations, such as perforated or bleeding ulcer surgery or an incarcerated paraesophageal hernia, don't require prior authorization.

• Upper endoscopy to assess esophagitis, Barrett's esophagus, hernia size, and stomach anatomy

• Ambulatory pH or pH-impedance testing, off PPIs when indicated. This is required before repairing a small sliding hernia, because a type I hernia without proven reflux doesn't need repair (Callaway and Vaezi, Clinical Gastroenterology and Hepatology, 2018).

• High-resolution esophageal manometry to confirm adequate esophageal function and to rule out achalasia before any antireflux operation

• Barium swallow or CT for large hernias, suspected achalasia, or outlet obstruction

• CT angiography or duplex ultrasound and a celiac plexus block for suspected MALS (DeCarlo et al., Journal of Vascular Surgery, 2023)
• Medical optimization:
  • Stopping smoking
  • Correcting anemia
  • Controlling diabetes

• GLP-1 medications held as directed by the anesthesia team

• A short pre-operative liquid diet when instructed

• After fundoplication, hiatal hernia repair, and Heller myotomy:
  • Weeks 0–2: liquids, then purées
  • Weeks 2–4: soft, moist foods in small portions
  • After 4–6 weeks: gradual return to a regular diet (Baiu and Lau, JAMA, 2019)

• After LINX: start small, frequent meals right away. Regular swallowing keeps the device moving and helps prevent scar-related swallowing difficulty.

• Avoid early on: bread, dry or tough meats, raw vegetables, rice, and carbonated drinks

• Eat slowly, take small bites, and chew thoroughly.

• Report swallowing difficulty that persists beyond 6–12 weeks. It may need Esophageal Dilation.

• After gastrectomy or gastric bypass: follow procedure-specific meal plans and take lifelong vitamins.

Nutrition Before and After Surgery

Many foregut patients arrive underweight, protein-depleted, or anemic after months of painful or difficult eating. This is especially common with achalasia, large paraesophageal hernias, MALS, and gastric outlet obstruction. Care includes:

• Nutrition screening before surgery, including albumin, iron studies, and B12 when indicated

• Treating anemia in patients with hernia-related blood loss (Callaway and Vaezi, Clinical Gastroenterology and Hepatology, 2018)

• Protein-forward liquid and soft diets during recovery, often with protein supplements

• A gradual return to resistance training after the 6-week lifting restriction

• Long-term B12, iron, and vitamin monitoring after gastrectomy or gastric bypass

• Days 0–14: walk several times a day, starting the day of surgery.

• Weeks 2–6: light cardio. No lifting over 15–20 lbs and no core-straining exercises.

• After 6 weeks: gradually add resistance training.

• Long-term: aim for 150+ minutes a week of activity. Use good lifting technique to protect the hiatal repair.

• Avoid straining: treat constipation and chronic cough early.

Many foregut patients travel to Miami because specialized reflux, hiatal hernia and motility surgery is not available close to home. Most operations require about one week in Miami. Testing such as endoscopy, manometry and pH studies can often be done locally and reviewed virtually beforehand, so your trip is focused on treatment.