The physician/surgeon considering anti-reflux surgery for a patient must now put together the pieces of this diagnostic puzzle in order to identify the need for surgery. He must also utilize this diagnostic information in determining the most appropriate anti-reflux repair approach for the patient. Until recently, "open" surgical approaches were necessary to repair the defective lower esophageal sphincter mechanism. Repair was either accomplished through an upper abdominal incision or left-sided chest incision. When performed by experienced esophageal surgeons, these repairs have resulted in immediate and long-term control of reflux symptoms and reversal of the esophageal injury from the acidic gastric reflux in more than 90 percent of patients operated.

The basic tenets of all anti-reflux surgical interventions are noted in Table 4. These technical concepts are achieved through careful dissection of the gastroesophageal junction, mobilizing the "floppy" fundic portion of the stomach, and wrapping this part of the stomach around the distal esophagus so as to create a sort of "flutter valve" mechanism which retards gastric reflux when the stomach becomes distended (e.g., after eating or drinking). In general, these stomach wrapping procedures are termed fundoplications, as the floppy fundus is "pleated" about the distal esophagus to accomplish the creation of this "flutter valve" mechanism (Figure 3). The surgical approach chosen to repair the defective lower esophageal anti-reflux barrier depends upon the physiologic aberration present and the extent of the patient's disease process.

Figure 3 - The technical basis of fundoplication - the gold-standard for surgical repair of a refluxing gastroesophageal sphincter - is the flap-valve mechanism created by wrapping the fundus of the stomach around the distal esophagus. As the stomach becomes distended during a meal, the fundic wrap compresses the distal esopha-gus, preventing reflux.

Accordingly, patients with significant esophageal scarring and shortening will usually require an open surgical approach to adequately mobilize the distal esophagus and restore it to its intra-abdominal position following fundoplication. Likewise, patients who have undergone previous abdominal operations may require an open surgical approach to anti-reflux surgery as intra-abdominal adhesions may make laparoscopic techniques dangerous or impossible. This is certainly true when considering laporascopic approaches for a "re-do" repair of a failed anti-reflux operation.

Beyond the decision to utilize an "open" or "laparoscopic" approach to create the anti-reflux repair, the surgeon must consider which form of fundoplication is the most appropriate match for the patient's esophageal peristaltic motor function. Impairment in the strength of esophageal peristalsis can lead to unacceptable postoperative dysphagia when the 360-degree fundic wrap characteristic of the "Nissen" fundoplication is utilized. We and others have utilized partial fundoplication procedures (e.g., Hill gastropexy, Toupet procedure, Belsey "Mark IV") successfully through both open and laparoscopic approaches in lieu of total fundoplication procedures for patients identified with significant esophageal motor dysfunction. This "tailored" approach to reconstruction of the lower esophageal sphincter mechanism can result in the maximal opportunity to relieve the patient of GERD related symptoms/mucosal injury and keep the incidence of untoward postoperative complications of gas-bloats and dysphagia to a minimum.

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