GORD — Surgical Management (Antireflux Surgery)

Definition and burden — proven GORD is a testing diagnosis

GORD for the surgeon means proven gastro-oesophageal reflux disease in an adult who has failed, cannot tolerate, or refuses lifelong acid suppression: the global pooled prevalence is 13.98% across 102 studies in 37 countries — 12.88% in Latin America and the Caribbean to 19.55% in North America, 4.16% in China to 22.40% in Turkey — roughly 1.03 billion people.^[1] Lyon 2.0 frames every candidate as proven or unproven disease with a modern definition of actionable GORD: testing evidence that supports revising, escalating or personalising management — not heartburn alone.^[5] Unproven disease is studied off antisecretory medication with prolonged wireless or catheter-based pH monitoring, while proven disease with persisting symptoms is studied on optimised therapy with pH-impedance monitoring.^[5]

Pathophysiology and the hernia-size ladder

Reflux is multifactorial: low lower-sphincter resting tone, transient sphincter relaxations, hiatus hernia, acid and pepsin plus bile-trypsin refluxate, poor clearance, delayed emptying and impaired mucosal defence — with lifestyle, obesity, genetics, pregnancy and stress modifying onset and complications.^[2] Hernia size grades everything: in 175 pH-proven patients (43 no hernia, 86 under 3 cm, 34 at 3–5 cm, 12 over 5 cm), larger hernias meant lower sphincter pressure, weaker peristalsis, more distal and proximal acid reflux and more severe oesophagitis — and half of hernias over 5 cm harboured Barrett's oesophagus.^[3] That ladder drives the operation: small hernias keep endoscopic options open, large ones force crural repair with a wrap.^[3][6]

Diagnosis — Lyon thresholds and the endoscopy gate

Memorise the Lyon lines. Conclusive evidence means advanced erosive oesophagitis (Los Angeles grades C or D), long-segment Barrett's mucosa, peptic stricture, or acid exposure time above 6% on ambulatory pH or pH-impedance monitoring.^[4] The refuting combination is a normal endoscopy with exposure under 4% and fewer than 40 reflux episodes off proton pump inhibitors — though a normal endoscopy alone never excludes disease.^[4] Since Lyon 2.0, Los Angeles grade B oesophagitis counts as conclusive evidence, and weak criteria are retired.^[5] The ASGE adds the endoscopy gate: alarm symptoms, multiple Barrett's risk factors, or a post-sleeve history earn upper endoscopy with landmark photo-documentation of the junction — and keeps medicine honest by recommending PPIs at the lowest dose for the shortest duration while long-term options are discussed.^[6]

Preoperative workup — manometry, pH and the IRP red flag

Confirm the diagnosis, rule out a major motility disorder, then select the candidate: high-resolution manometry plus pH testing are the key studies, with straight-leg-raise and multiple-rapid-swallow manoeuvres probing for hidden hernia and testing peristaltic reserve before surgery.^[7] The single most examinable number is the integrated relaxation pressure: elevated basal IRP predicts worse post-Nissen dysphagia severity (correlation 0.572, significance below 0.0001, sensitivity and negative predictive value both 100%) with poorer quality of life to 3 years.^[8] Preoperative dysphagia independently predicts postoperative dysphagia at short and long follow-up, while higher wave amplitude and contractile integral inversely correlate with post-Nissen dysphagia.^[8] The viva conclusion writes itself: a resistant sphincter or absent peristalsis means partial wrap or no wrap — never a 360-degree total wrap.^[7][8]

LOTUS — the surgery-versus-PPI equipoise

LOTUS randomised 554 patients with chronic GORD (288 to standardised laparoscopic total fundoplication with crural repair, 266 to esomeprazole 20–40 mg daily, dose-adjustable).^[9] At 3 years, remission was 90% after surgery against 93% on medicine in the intention-to-treat analysis (90% against 95% per-protocol, non-significant) with no major unexpected surgical complications — but postfundoplication complaints remained a problem after surgery.^[9] Mucosal healing does not pick a winner either: histology severity scores fell identically on both arms (0.95 to 0.57 to 0.49 on esomeprazole; 0.91 to 0.56 to 0.52 after surgery, all highly significant with no between-group difference), and severe changes fell from about half to 11%.^[10] Even with Barrett's oesophagus (60 of 554 patients), only 4 of 60 failed either strategy over 3 years: pH was better controlled after surgery, symptom and quality-of-life scores were identical, and surgical success matched optimised medical therapy with or without Barrett's.^[11]

Nissen 360 — the reflux-control anchor and its price

The 360-degree Nissen remains the reflux-control standard — and every late randomised follow-up prices it the same way: better reflux, worse venting. At 15 to 20 years (79 of 107 followed), heartburn scores (3.2 against 1.4) and PPI use (41.7% against 17.1%) were higher after anterior-180 wrap, offset by less solid dysphagia (1.8 against 3.3) and better belching (84.2% against 65.9% able) — with satisfaction identical (8.4 against 8.0) and 6 against 7 revisions.^[12] At 10 years against the anterior-90 wrap, dysphagia favoured partial (2.03 against 3.18) while heartburn (1.90 against 2.83) and PPI use (22% against 39%) favoured Nissen, satisfaction again identical.^[13] At 12 years against anterior-180, heartburn, dysphagia, gas symptoms, satisfaction and reintervention were all equivalent — but acid suppression (8% against 29%) and absent-or-mild symptoms (90% against 74%) favoured Nissen.^[14] Counsel with that trade, not with a winner: Nissen buys the driest oesophagus at the highest venting price.^[12][13][14]

Toupet 270 versus Nissen — the posterior-partial compromise

When the examiners ask for the wrap with Nissen-level control and less dysphagia, answer Toupet. Across 8 randomised trials (605 Nissen against 607 Toupet), the posterior partial wrap produced lower sphincter pressure, less dysphagia and inability to belch in both short and long term, and less short-term gas bloat — with reflux recurrence, heartburn, satisfaction, reoperation, DeMeester scores and PPI use all equivalent.^[19] The three-way long-term network meta-analysis (13 randomised trials, 2,063 patients, beyond 5 years) agrees: Toupet dysphagia odds were 0.285 against Nissen, Toupet-against-Dor and Dor-against-Nissen showed no difference, and every other outcome was comparable across all three wraps.^[20] Posterior partial is therefore the default compromise when a total wrap's side effects are the worry — matched control, cheaper swallowing.^[19][20]

Anterior 180 versus Nissen — level-1a partial, and the 90-degree warning

The anterior-180 wrap carries the strongest partial-wrap endorsement in the set: 5 randomised trials (227 against 231) show 1-year Dakkak dysphagia scores of 2.8 against 4.8, gas bloat risk ratio 0.59, flatulence 0.57 and inability to belch 0.63 — with acid exposure, oesophagitis, heartburn, satisfaction, dilatation and reoperation similar at 1 and 5 years, stated as level-1a support for the 180-degree anterior operation.^[18] The 4-trial 5-year pool (461 patients) adds the critical qualifier: anterior wraps leave fewer side effects with equal satisfaction, but only the 180-degree wrap matches Nissen on reflux — the 90-degree wrap is inferior.^[15] A 5-year randomised trial confirms control in 84.38% with DeMeester scores falling from 106.89 to 12.67 (anterior) and 109.51 to 10.81 (Nissen), plus less flatulence after anterior wrap.^[16] But quote the objective sting at 14 years: acid, weakly-acidic, liquid and mixed episodes all run higher after anterior-180 with lower sphincter pressures — while gas reflux, belching and satisfaction stay identical.^[17] Anterior-90 for reflux control is the examinable error; anterior-180 is the defensible partial.^[15][17]

Partial versus partial — no winner on satisfaction

Pushed to choose between partials, both randomised answers say satisfaction is a draw. Toupet-270 against anterior-180 (94 patients, double-blind): 12-month Dakkak 5.9 against 6.4 (non-significant), no difference in reflux control, symptoms, satisfaction, or pH-metry acid exposure.^[21] Anterior-180 against posterior-270 (47 patients): heartburn higher after anterior (2.7 against 0.8) while belch inability clusters after posterior (56% against 16% at 3 months; 43% against 9% at 6 months) — satisfaction 85% against 86%.^[22] Posterior trades fewer symptoms for more side effects; choose by the patient's priority (reflux control against venting) and the manometry, not by brand loyalty.^[21][22][8]

Magnetic sphincter augmentation — venting preserved, explant priced

MSA trades a wrap for a magnetic bead collar — and the randomised-era evidence prices that trade precisely. Against Nissen (688 patients), belching is preserved in 95.2% against 65.9% and vomiting in 93.5% against 49.5%, with gas/bloat, dysphagia and PPI elimination (81.4% against 81.5%) all equivalent.^[23] Across 7 cohorts (686 MSA against 525 fundoplication) there was no mortality; dilatation-requiring dysphagia ran 9.3% against 6.6% (non-significant), gas/bloat odds ratio 0.39 with vomit 10.10 and belch 5.53 favouring MSA, and quality of life, PPI suspension and reoperation were similar.^[24] Durability at 5 years (136 of 200 in the FDA study): at least 50% quality-of-life gain in 81.6% (median score 26 to 4), freedom from daily PPIs in 90.4%, acid-exposure time 9.1 to 3.2 with DeMeester 29 to 11 — priced at 5% dysphagia, 13% explantation and 2% erosion, with 92.6% symptom resolution after removal, conversion or replacement.^[25] The explant ledger (397 patients, 2007–2021): 12.4% removed at median 39.5 months, mostly for dysphagia (43.2%), heartburn (25%) or epigastric pain (13.6%), with 2.5% erosion — concentrated in small 12- and 13-bead devices, and modern oversizing with posterior hiatoplasty cut explants from 23% to 5%.^[26] After sleeve gastrectomy, where bypass conversion may be refused or contraindicated, MSA with hiatoplasty (109 patients, 14 studies) improved quality-of-life scores from 38 to 10 and cut daily PPI use from 97.4% to 25.3%, with mostly self-limiting device events and 0.9% erosion explantation.^[27]

TIF 2.0 — real effect, defined selection, a ceiling

Transoral incisionless fundoplication has sham-proof efficacy: 44 chronic PPI-dependent patients, remission days 197 against 107 with 59% (13 of 22) in remission at 6 months and all secondaries favouring TIF2, no safety signal.^[28] The 2.0-only randomised meta-analysis (233 patients) holds that effect to 3 years: improved oesophageal pH, decreased PPI use, improved quality of life against PPI or sham in chronic refractory disease.^[29] But the network meta-analysis (7 trials, 1,128 patients) sets the ceiling: TIF ranks first on quality-of-life probability (0.96) while Nissen dominates physiology (pH-under-4 time 0.99, sphincter pressure 0.78) — and TIF is not recommended as a long-term alternative to PPI or Nissen treatment.^[30] Select by the ASGE rule: confirmed GORD with hernia 2 cm or under and Hill grade I or II may be evaluated for TIF instead of chronic medication; persistent disease with hernia over 2 cm and Hill III or IV gets combined hiatal repair with TIF or surgery.^[6]

Mesh cruroplasty — the large-hernia split

For large hernias (over 30% stomach intrathoracic, defect over 5 cm, surface over 10 cm²), three meta-analyses disagree instructively — quote all three. The large-hernia analysis (1,670 patients): mesh halves total recurrence (odds ratio 0.44) but not recurrences over 2 cm (0.94) nor reoperations (0.64), with erosions confined to synthetic meshes.^[31] The mesh-type network (8 randomised trials, 766 patients): non-absorbable mesh cuts early recurrence (odds ratio 0.225) with no late difference; absorbable mesh never differs; major complications are similar.^[32] The sceptical analysis (1,472 patients, randomised plus prospective): recurrence odds ratio 0.51 with a prediction interval spanning 0.08 to 3.35 (non-significant), complications and reoperation equivalent — heterogeneity demanding better trials.^[33] The viva synthesis: mesh trims early and small recurrences, not late, large or reoperation-grade ones — and permanent mesh needs an erosion-risk consent.^[31][32][33]

Failed fundoplication — mechanisms, then redo or bypass

First name the failure: slipped fundoplication, unrecognised short oesophagus, or wrap disruption — remediable by redo fundoplication with hernia repair, Roux-en-Y conversion (high success in selected patients), or oesophagectomy as a last resort.^[34] Then choose by patient: in 165 reoperations (120 redo wraps, 38 bypass conversions), reflux improved most with bypass (89.5% to 10.5% with reflux), and conversion protected against persistent reflux on multivariable analysis — at the cost of longer operation and stay with the most complications in heavier, multiply-redone patients (12.1% overall).^[35] The conversion meta-analysis (22 studies, 1,523 patients) sets expectations: symptom resolution 71.6% with heartburn recurrence 15.6%, dysphagia 20.7%, PPI use 29.6%, morbidity 39.5% and mortality 2.2% — equivalent to redo fundoplication except body-mass index falls 6.1 kg/m² further.^[36] Rule of thumb: obese or multiply-failed patients convert; lean first-failures redo — both after full re-workup.^[34][35][36]

Obese GORD — bypass versus fundoplication, matched to goals

At body-mass index 35 or above (95 patients, 72 fundoplication against 23 bypass), both operations improve symptoms and quality of life with identical symptom, dysphagia and short-form scores and identical DeMeester and acid-exposure results — but quality-of-life scores favour fundoplication to 5 years while weight loss favours bypass to 5 years: match the operation to the patient's goal, not to dogma.^[37] For massive paraoesophageal hernias over 5 cm in obesity (40 fundoplication against 16 antireflux bypass), resolution is similar with non-significantly lower recurrence after bypass and superior weight and excess-weight loss — bypass is an acceptable option here.^[38] And where bypass conversion is contraindicated or refused after sleeve, MSA with hiatoplasty is the fallback with quartered PPI use.^[27]

Barrett's oesophagus — operate, then keep scoping

About 20% of the US population has GORD and 10–15% of those develop Barrett's along the reflux-injury to columnar-metaplasia sequence toward adenocarcinoma.^[40] Surgery earns its place — antireflux surgery relieves symptoms, induces regression and resists progression — but never ends surveillance: follow-up with endoscopy is essential.^[39] Dysplasia or early neoplasia belongs to endoscopic resection plus ablation, now standard over oesophagectomy in most cases, with resection reserved for a minority of selected candidates.^[39] LOTUS reassures the Barrett's consent discussion: surgery and optimised medicine failed equally rarely (4 of 60), with better pH but identical symptoms either way.^[11]

Complications — gas-bloat and dysphagia, honestly priced

Price the standard Nissen honestly from a standardised 350-patient series at median 4 years: persistent dysphagia 2%, gas-bloat syndrome 12.7%, endoscopic dilatation 2%, revision surgery 5% — with quality-of-life scores falling from 19 to 2.^[42] Dysphagia risk is foreseeable (high IRP, preoperative dysphagia) — quote the dilatation-requiring dysphagia numbers (9.3% MSA against 6.6% fundoplication) and the explant ledger above rather than promising resolution.^[8][24][25]

Revision summary

Proven GORD (Lyon lines, grade B now conclusive) in a worked-up patient (manometry plus pH, IRP checked) meets LOTUS equipoise (90% against 93%) — then the wrap menu: Nissen for maximal control at maximal venting cost; Toupet and anterior-180 for matched satisfaction with less dysphagia; anterior-90 never for control. MSA preserves belch and vomit at a 13% explant price; TIF 2.0 suits small hernias with a physiological ceiling; mesh trims early recurrence only; failed wraps redo or convert by patient; Barrett's always stays under surveillance.^{[4][5][8][9][12][19][18][25][30][31][35][39]}

HRQL 38→10 with PPI use 97.4%→25.3% (both punder 0.01), device AEs 31.8% mostly self-limiting, erosion explant 0.9% — an option where conversion to bypass is refused or contraindicated (PMID 39402392).^[27]

References42ShowHide

1. [1]Nirwan, Hasan, Babar, et al. Global Prevalence and Risk Factors of Gastro-oesophageal Reflux Disease (GORD): Systematic Review with Meta-analysis. Sci Rep, 2020.PMID 32242117
2. [2]Usai, Oppia, Cabras, et al. Overview of pathophysiological features of GERD. Minerva Gastroenterol Dietol, 2017.PMID 28251844
3. [3]Schlottmann, Andolfi, Herbella, et al. GERD: Presence and Size of Hiatal Hernia Influence Clinical Presentation, Esophageal Function, Reflux Profile, and Degree of Mucosal Injury. Am Surg, 2018.PMID 29981634
4. [4]Gyawali, Kahrilas, Savarino, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut, 2018.PMID 29437910
5. [5]Gyawali, Yadlapati, Fass, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut, 2024.PMID 37734911
6. [6]Desai M, Ruan W, Thosani NC, et al. American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: summary and recommendations. Gastrointest Endosc, 2025.PMID 39692638
7. [7]Yodice, Mignucci, Shah, et al. Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing. World J Gastroenterol, 2021.PMID 33967555
8. [8]Kapadia, Osler, Lee, et al. The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication. Surg Endosc, 2018.PMID 29234939
9. [9]Lundell, Attwood, Ell, et al. Comparing laparoscopic antireflux surgery with esomeprazole in the management of patients with chronic gastro-oesophageal reflux disease: a 3-year interim analysis of the LOTUS trial. Gut, 2008.PMID 18469091
10. [10]Fiocca, Mastracci, Engström, et al. Long-term outcome of microscopic esophagitis in chronic GERD patients treated with esomeprazole or laparoscopic antireflux surgery in the LOTUS trial. Am J Gastroenterol, 2010.PMID 19904246
11. [11]Attwood, Lundell, Hatlebakk, et al. Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience. J Gastrointest Surg, 2008.PMID 18709511
12. [12]Rudolph-Stringer, Bright, Irvine, et al. Randomized Trial of Laparoscopic Nissen Versus Anterior 180 Degree Partial Fundoplication - Late Clinical Outcomes at 15 to 20 years. Ann Surg, 2022.PMID 33214480
13. [13]Hopkins, Irvine, Jamieson, et al. Long-term follow-up of two randomized trials comparing laparoscopic Nissen 360° with anterior 90° partial fundoplication. Br J Surg, 2020.PMID 31502659
14. [14]Roks, Broeders, Baigrie, et al. Long-term symptom control of gastro-oesophageal reflux disease 12 years after laparoscopic Nissen or 180° anterior partial fundoplication in a randomized clinical trial. Br J Surg, 2017.PMID 28158901
15. [15]Broeders, Roks, Jamieson, et al. Five-year outcome after laparoscopic anterior partial versus Nissen fundoplication: four randomized trials. Ann Surg, 2012.PMID 22418004
16. [16]Cao, Cai, Qin, et al. Randomized clinical trial of laparoscopic anterior 180° partial versus 360° Nissen fundoplication: 5-year results. Dis Esophagus, 2012.PMID 21883656
17. [17]Broeders, Broeders, Watson, et al. Objective outcomes 14 years after laparoscopic anterior 180-degree partial versus nissen fundoplication: results from a randomized trial. Ann Surg, 2013.PMID 23207247
18. [18]Broeders, Roks, Ahmed, et al. Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. Ann Surg, 2013.PMID 23470572
19. [19]Li, Jiang, Chendaer, et al. Laparoscopic Nissen Versus Toupet Fundoplication for Short- and Long-Term Treatment of Gastroesophageal Reflux Disease: A Meta-Analysis and Systematic Review. Surg Innov, 2023.PMID 36998190
20. [20]Lee, Tahir, Tessier, et al. Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials. Surg Endosc, 2023.PMID 37308760
21. [21]Roks, Koetje, Oor, et al. Randomized clinical trial of 270° posterior versus 180° anterior partial laparoscopic fundoplication for gastro-oesophageal reflux disease. Br J Surg, 2017.PMID 28295217
22. [22]Daud, Thompson, Jamieson, et al. Randomized controlled trial of laparoscopic anterior 180° partial versus posterior 270° partial fundoplication. ANZ J Surg, 2015.PMID 24286198
23. [23]Skubleny, Switzer, Dang, et al. LINX(®) magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis. Surg Endosc, 2017.PMID 27981382
24. [24]Aiolfi, Asti, Bernardi, et al. Early results of magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: Systematic review and meta-analysis. Int J Surg, 2018.PMID 29471155
25. [25]Louie, Woldu, Bell, et al. Long-term (>5 Years) Outcomes after Magnetic Sphincter Augmentation. Ann Surg, 2026.PMID 42117783
26. [26]Froiio, Aiolfi, Bona, et al. Safety profile of magnetic sphincter augmentation for gastroesophageal reflux disease. Front Surg, 2023.PMID 38026489
27. [27]Cammarata, Novia, Aiolfi, et al. Magnetic Sphincter Augmentation for Gastroesophageal Reflux After Sleeve Gastrectomy: A Systematic Review. Obes Surg, 2024.PMID 39402392
28. [28]Håkansson, Montgomery, Cadiere, et al. Randomised clinical trial: transoral incisionless fundoplication vs. sham intervention to control chronic GERD. Aliment Pharmacol Ther, 2015.PMID 26463242
29. [29]Gerson, Stouch, Lobonţiu, et al. Transoral Incisionless Fundoplication (TIF 2.0): A Meta-Analysis of Three Randomized, Controlled Clinical Trials. Chirurgia (Bucur), 2018.PMID 29733015
30. [30]Richter, Kumar, Lipka, et al. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis. Gastroenterology, 2018.PMID 29305934
31. [31]Rajkomar, Wong, Gall, et al. Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis. Hernia, 2023.PMID 37010656
32. [32]Temperley, Davey, O'Sullivan, et al. What works best in hiatus hernia repair, sutures alone, absorbable mesh or non-absorbable mesh? A systematic review and network meta-analysis of randomized clinical trials. Dis Esophagus, 2023.PMID 36563005
33. [33]Kitsou, Mela, Saliaris, et al. The controversial impact of mesh augmentation on surgical outcomes in hiatal hernia repair: A Systematic Review and Meta-analysis. J Gastrointest Surg, 2026.PMID 42744186
34. [34]Grover BT, Kothari SN Reoperative antireflux surgery. Surg Clin North Am, 2015.PMID 25965135
35. [35]Castillo-Larios, Gunturu, Cornejo, et al. Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better? Surg Endosc, 2023.PMID 37130984
36. [36]Bhat, Dubey, Gan, et al. Efficacy and safety of laparoscopic Roux-en-Y gastric bypass in symptomatic patients following fundoplication failure: a meta-analysis. Esophagus, 2023.PMID 36348250
37. [37]Joseph, Vandruff, Amundson, et al. Roux-en-Y gastric bypass versus fundoplication for gastroesophageal reflux disease in patients with obesity results in comparable outcomes. Surgery, 2024.PMID 38154997
38. [38]DuCoin, Wasselle, Kayastha, et al. Massive Paraesophageal Hernia Repair in the Obese Patient Population: Antireflux Gastric Bypass Versus Fundoplication. J Laparoendosc Adv Surg Tech A, 2022.PMID 35333616
39. [39]Peyre CG, Watson TJ Surgical Management of Barrett's Esophagus. Gastroenterol Clin North Am, 2015.PMID 26021205
40. [40]Oh DS, Demeester SR Pathophysiology and treatment of Barrett's esophagus. World J Gastroenterol, 2010.PMID 20698038
41. [41]Sarici, Eriksson, Nguyen, et al. Gas Bloat Syndrome after Nissen Fundoplication: Association with Anatomical Failure and Revisional Operation. J Am Coll Surg, 2026.PMID 41738617
42. [42]Nikolic, Schwameis, Semmler, et al. Persistent dysphagia is a rare problem after laparoscopic Nissen fundoplication. Surg Endosc, 2019.PMID 30171395