• laparoscopy
• gastro-oesophageal reflux disease
• antireflux surgery
• fundoplication

Surgical treatment of gastro-oesophageal reflux disease (GORD) has previously been limited to chronic complicated reflux in patients with very longstanding severe symptoms. There is now an increasing tendency in many countries to utilise surgery in the earlier stages of the disease.¹ This change in clinical practice is partly due to advances in surgical technique (laparoscopic approach) but paradoxically is also probably due to improvement in medical therapy.^2,3 With the efficacy and availability of modern medical therapy, the focus, as well as the opportunities of therapy in GORD, have changed but also the recognition of the magnitude of the impairment in quality of life of GORD patients who are not adequately treated.⁴ This increased awareness may be the most pregnant cause of the suggested increase in prevalence of the disease in the adult population.

An important background factor for the significant but not eminent strategic decisions to be taken in the long term management of GORD patients is the fact that there are shortcomings and drawbacks with pharmacological maintenance therapy. GORD is a disease of a chronic nature where medical therapies are entirely targeting the control of acid reflux and not correcting the underlying motor abnormalities of the upper alimentary canal.⁵ Low dose proton pump inhibitor (PPI) therapy and full dose H₂ receptor antagonists insufficiently interfere with food stimulated acid production and the latter also have a significant tachyphylaxis problem.^6–,⁸ A profound and sometimes prolonged acid rebound phenomenon is perhaps a greater problem after PPI therapy in Helicobacter pylori negative subjects than previously recognised. Furthermore, in patients with severe reflux disease, twice daily dosing of PPI is often necessary. In addition, there is sometimes insufficient control of volume reflux, nocturnal symptoms, and retrosternal pain. Acid breakthrough during the night has recently been …