GERD (Gastroesophageal reflux disease) is becoming more and more common, and the prevalence in China is also on the rise. Since Rudolf Nissen started the first anti-reflux surgery in 1936, the anti-reflux surgery (ARSAntireflux surgery) has evolved through hundreds of surgical procedures over the past 80 years, and has been basically fixed into two major categories: fully encapsulated fundoplication surgery and semi-encapsulated fundoplication surgery, and the controversy about the anti-reflux surgery procedure has never stopped. The choice of anti-reflux surgery is more based on clinical experience or reference to foreign guidelines. The people of Xinjiang Uygur Autonomous Region have carried out laparoscopic antireflux surgery (LARS laparoscopicAntireflux surgery) in more than 800 cases since 2005, and have conducted a series of studies on common antireflux surgery, and have gained some experience, which we will share with you. I. Historical evolution of anti-reflux surgery Bowditch first reported the anatomical defect of hiatalhernia in 1853, but the concept of GERD did not exist until 1919, when Soresi reported the first case of elective surgery to repair HH. In 1934, Winkelstein, an American physician, recognized that GERD caused a series of signs and symptoms and introduced the concept of GERD for the first time, which is still used today. It is this discouraging clinical study that played an important role in the future invention of anti-reflux surgery. In 1928 Harrington of the Mayo Clinic reported 27 cases of successful repair of HH, however, 17 years later Harrington published a paper reporting Almost at the same time, Dr. Nissen performed the first successful anti-reflux surgery in 1936, but it was 20 years before Dr. Nissen published the Nissen anti-reflux procedure, which was refined after long-term follow-up and became the most successful and classic procedure in anti-reflux surgery today. In the era of open anti-reflux surgery, there is another classic procedure with good surgical results, which is the Belsey type I-IV procedure that Professor Belsey improved continuously in 1030 patients from 1940 to 1967, opening up another era of anti-reflux surgical procedures. In the mid-20th century, surgeons around the world were keen to innovate various anti-reflux procedures. 1957 Collis published the Collis procedure for GERD of the short esophagus. These surgical scholars are all giants in the field of anti-reflux surgery. It is exciting to note that the work of Dallemagne and Geagea brought us to the era of laparoscopic anti-reflux surgery before the 21st century. Currently, laparoscopic antireflux surgery is undergoing a period of rapid development in China, but controversy continues to surround both the indications for antireflux surgery and the variety of surgical options available. There is no expert consensus and guidelines for anti-reflux surgery in China, and in 2014, the Chinese Society of Gastroenterology formulated the 2014 consensus opinion on GERD in China: there is no clear recommendation for surgical indications in the consensus opinion, but it is mentioned that anti-reflux surgery is a safe and effective method that can be used as a proton pump inhibitor ( proton pumpinhibitor (PPI) therapy is effective, but requires long-term medication as an alternative treatment option. If reflux monitoring suggests the presence of symptom-related acid reflux in refractory GERD, anti-reflux surgery may be performed after weighing the pros and cons. Anti-reflux surgical treatment is not recommended for non-acid reflux patients. However, in clinical practice there are many patients with GERD whose condition requires surgical anti-reflux surgery, and patients with non-acid reflux have excellent surgical results with anti-reflux surgery, because surgery is “anti-reflux” surgery, not just “anti-reflux surgery The surgery is an “anti-reflux” surgery, not just an “anti-acid reflux surgery”. Based on more than 800 cases of anti-reflux surgery, the People’s Hospital of Xinjiang Uygur Autonomous Region firstly performed a comprehensive design of individualized surgery based on clinical symptoms + GERDQ score quantification criteria + imaging (gastroscopy, upper gastrointestinal barium meal, CT) + pathological histology (LA standard reflux esophagitis) + esophageal high-resolution manometry + 24-hour esophageal PH monitoring. protocol. (1) Patients with GERD who are effectively treated with PPI and who cannot tolerate long-term medication; (2) Symptomatic GERD combined with esophageal hiatal hernia for which medical medication is ineffective; (3) Surgery is not recommended for asymptomatic type I esophageal hiatal hernia; elective surgery is recommended for asymptomatic type II and III esophageal hiatal hernia; and surgery should be considered for all type IV esophageal hiatal hernia. (4) GERD patients with complications such as esophagitis, esophageal stricture, etc. Barrett’s esophagus is present in GERD patients, but endoscopic treatment of Barrett’s is recommended before anti-reflux surgery; (5) GERD combined with esophageal hiatal hernia with anemia; (6) GERD patients with chest pain that seriously affects the quality of life, excluding cardiac disorders. (7) GERD extra-esophageal symptoms such as reflux asthma, reflux cough, reflux pneumonia, reflux sleep disorder, etc. seriously affect the quality of life situation. (8) Patients with acute gastric torsion and intestinal obstruction should have emergency surgery. (9) GERD combined with simple obesity requiring weight loss surgery. III. Choice of anti-reflux surgery In retrospect, there are many kinds of anti-reflux surgery, but they are mainly divided into total fundoplication (Total fundoplication), represented by Nissen 360° surgery, and partial fundoplication (Partial fundoplication), which is a surgery that partially wraps around the esophagus. fundoplication), the latter is mainly represented by Dor fundoplication (180° anterior) and Toupet fundoplication (270° posterior), and the current laparoscopic anti-reflux surgery is basically fixed to Nissen, Toupet and Dor fundoplication. However, different LARS procedures have their own advantages and disadvantages. There is no unified standard on how to choose partially or fully encapsulated fundoplication, and there is a lack of research results on the procedure in China, so the choice of various fundoplication procedures still needs further standardization and quantitative criteria. However, unpredictable postoperative dysphagia has always troubled surgeons and patients, because the fundus of the Nissen procedure is too long and too tight, causing persistent dysphagia. Nissen”), which ensures an anti-reflux effect while reducing the incidence of postoperative dysphagia. The Toupet fundoplication, which is a technique that partially wraps around the esophagus, also has a good anti-reflux effect, as it wraps the fundus around the esophagus at 270° from the posterior, theoretically leaving a 90° peristaltic margin in front of the esophagus and accomplishing a good anti-reflux effect. Fold procedure is more often used for anti-reflux surgery after esophageal myotomy for cardia achalasia, but the results of recent studies have shown that in experienced centers Dor procedure anti-reflux surgery results can be almost equal to Nissen and Toupet, and we found that severe postoperative dysphagia also occurs with Dor procedure, which suggests that the anti-reflux procedure is not the cause of postoperative Preoperative esophageal dysmotility is also an important factor in postoperative dysphagia. Many authors believe that if a 360° fundoplication is given to a patient with significant ineffective esophageal peristalsis, there is empirically a higher incidence of postoperative dysphagia and some degree of outflow tract obstruction at the level of the gastroesophageal junction. However, the theory of “tailor-made” fundoplication based on esophageal motility, such as partial fundoplication in those patients with esophageal motility disorders, has been shown to be incomplete. fundoplication. They concluded that laparoscopic Toupet fundoplication is not adequate for patients with severe GERD. After studying 48 patients undergoing anti-reflux surgery with gastroscopy, esophageal manometry, and pH monitoring, they found that at a mean follow-up of 22 months (18-37 months), the procedure failed in 22 cases. Specifically, 77% of patients had reappearance of GERD symptoms and 64% resumed PPI. Horvath et al. also found that a DeMeester score greater than 50 had 86% sensitivity predicting possible surgical failure and that all patients who underwent a fully encapsulated fundoplication had good anti-reflux results, thus suggesting that partial fundoplication in patients with severe GERD may not be a superior option. Subsequent literature by Oleynikov et al. 2002 demonstrated that complete fundoplication also appears to be safe in patients with GERD with esophageal peristaltic disorders. They studied 39 patients with partial fundoplication and 57 patients with Nissen fundoplication and found that both types of folding were effective in controlling GERD symptoms and acid reflux, but some patients with total fundoplication seemed to have more control of acid reflux. Patti et al. further showed the theory that total fundoplication is superior to “tailored” fundoplication, and that total fundoplication provides more durable control of reflux than partial fundoplication, even in those patients with esophageal dysmotility. It does not cause more dysphagia in patients with esophageal motility disorders. Two recent studies provide important information on the long-term results of the Nissen and Dor fundoplication procedures. The first study analyzed pH outcomes in 18 patients (8 with Dor folding and 10 with Nissen fundoplication) in a prospective randomized controlled trial that lasted 14 years. Notably, the results of this study showed higher clinical heartburn scores and lower dysphagia scores after the Dor procedure relative to the Nissen procedure. The second study evaluated 2261 patients (53.5% of patients with Nissen fundoplication and 43.2% who underwent Dor fundoplication) at a mean follow-up of 7.6 years found that the anti-reflux effect was slightly lower after the Dor procedure than the Nissen procedure, while dysphagia was lower, and the authors concluded that both Nissen and Dor fundoplication were providing good long-term outcomes at 10 The authors concluded that both Nissen and Dor fundoplication provide good long-term results, with nearly identical control of anti-reflux and dysphagia rates over 10 years for both procedures. Therefore, the choice of anti-reflux procedure for esophageal manometry and 24-hour esophageal Ph monitoring becomes a critical selection criterion. The choice of anti-reflux procedure can be based on esophageal manometry and 24-hour esophageal PH monitoring, and can be selective based on the change in lower esophageal sphincter pressure (LES) before surgery. 24-hour esophageal PH monitoring can reflect the number and duration of reflux in patients, whether reflux is associated with cough or other related symptoms, and the relationship between body position and reflux. The DeMeester score is also used to objectively determine whether the patient’s reflux is physiologic or pathologic, and to reduce subjective factors that may cause over-surgical treatment. It is important to determine which patients undergo 360° full wrap-around fundoplication and partial wrap-around folding. And the position of the LES after anti-reflux surgery can be precisely calculated. Of course the different fundoplication procedures are more than mere technical issues, the key to a successful anti-reflux surgery is to fully understand the important technical elements and even the psychological elements provided in these different anti-reflux procedures. There has been a consensus among national and international scholars that good results can be achieved in experienced centers regardless of the type of anti-reflux procedure, so it is particularly important that multicenter studies in this country are being conducted, and happily these efforts are in order.