The initial therapy for GERD consisted in replacing the stomach to the abdomen and repairing and tightening the esophageal hiatus. Philip Rowland Allison (1908–1974) (Fig. 1.3), a British surgeon [10], initiated the modern era of antireflux surgery. He published in 1951 [11] a series of patients that, utilizing a transthoracic approach, the stomach were reduced to the abdomen and the crural fibers were closed behind the esophagus. He believed these crural fibers functioned as a pinchcock to prevent reflux. He had good long term results with over 80% of symptoms relieve after 20 years, with 49% of radiologic recurrence of the hernia [12], a rate below paraesophageal mesh-reinforced hiatoplasty and fundoplication in modern series [13]. Latter, it was acknowledged that GERD could exist without an associated HH and Allison procedure was also carried out successfully in these patients [14]. From this time, became clear that fixing the HH and performing a hiatoplasty were essential parts of the surgical treatment for GERD. In fact, modern authors learned that the absence of a hiatoplasty leads to much worse outcomes [15]. This fact culminated with the use of prosthetic reinforcement of the hiatus to make this part of the procedure even stronger, actually not a modern idea but dating back to experimental tries in 1957 and the first clinical experience in 1960 [16]. Some complications have been reported associated to the use of prosthetic hiatal reinforcement, but the rate of hernia recurrence seems to be lower forcing surgeons at present to face the dilemma of choosing between a risk of recurrence and the fear of complications [16]. Modernly, different devices were created in order to perform an endoscopic fundoplication using intraluminal suturing or plug [17]. Although the esophagus is wrapped, a hiatoplasty is obviously not performed. Not surprisingly, even in much selected patients, all published series show symptomatic improvement but some important complications, 40% of hernia recurrence and amelioration but not reestablishment to normal values of acid exposure measured objectively by pHmonitoring [18].

After experimenting on the diaphragm, surgeons focused on the His angle. Norman Rupert Barrett (Australia, 1903 – England, 1979), the famous surgeon that gives the name Barrett’s esophagus [19] pioneered the idea on restoration of the cardioesophageal angle as the critical element in the prevention of reflux [20]. In fact, latter studies showed that a fundoplication performed ex vivo in human stomachs is competent in preventing reflux to the point of gastric explosion, probably by accentuating the His angle [21]. Clinical experience; however, showed that the solely restoration of the His to an acute angle does not show good physiologic and clinical outcomes [22] as in patients submitted to a Lortat-Jacob antireflux repair [23].

Other natural antireflux mechanism that gained attention of surgeons was the length of the abdominal portion of the esophagus. In fact, historically, the length of the abdominal esophagus was a concern due to the necessity to reduce the herniated stomach and the chance of a short esophagus [9]. Latter, the length of the abdominal esophagus proved to be direct linked to GERD control based on clinical, in vitro [24], and experimental [25] studies. Currently, a segment of 2 centimeters is desirable when performing an antirreflux operation. Esophageal alongation may be achieved with extensive dissection of the organ in the mediastinum [26].

Rudolf Nissen (Fig. 1.4), the famous German surgeon (1896–1981) [27] developed in 1955 the most successful and widespread surgical therapy for GERD, the fundoplication [28]. He repeated a lesson learned from the past when he was reminded of an operation done in 1936 when the anastomosis of a cardia resection was protected by the stomach like a Witzel gastrostomy and the patient did not develop esophagitis. This operation suffered modification along time [27] and gained wild acceptance with close to 20,000 fundoplications performed annually in the US [29]. Excellent and good outcomes may be expected in over 90% of the patients [30, 31]. It is noteworthy that the first minimally invasive fundoplication occurred in 1991 [32], 4 years after the first laparoscopic cholecystectomy!

The Nissen fundoplication evoluted with several modifications (Fig. 1.5). First, different authors proposed a partial fundoplication, in which the gastric fundus wraps partially, not circumferentially, the esophagus, creating techniques and eponyms known as Toupet, Dor and Guarner [33]. These partial fundoplications were developed in order to minimize some of the side effects of a fundoplication, namely dysphagia and gas bloating. These techniques proved to be a good option to be added to a myotomy in the treatment of achalasia, since esophageal peristalsis is absent and a total fundoplication may cause dysphagia [34]. Good outcomes in achalasia patients lead some surgeons to tailor the fundoplication to match the strength of esophageal peristalsis as measured by esophageal manometry, so a total fundoplication was recommended for patients with normal peristalsis, and a partial fundoplication for those with impaired peristalsis [35]. Late follow-up; however, showed that better reflux control was obtained with a total fundoplication [36] and that esophageal motility may be restores after total fundoplication and GERD control [37].

Other important modification of Nissen’s fundoplication was the loosening of the wrap and the shrinking of the size of the valve, the so called “short-floppy” Nissen. The first technical amendment was developed by Donahue et al. [38] to avoid “gaseous eructations or vomiting (normal reflux) when appropriate”. This technique revoked the theory that a fundoplication would work solely as a pneumatic valve that should be applied close-fitting to the esophagogastric junction, since GERD control was achieved even with a loose valve. Latter, DeMeester et al. [39] showed that a 1 cm wrap was as effective as a 4 cm fundoplication to control GERD. Other modifications of the original technique also took place, such as the use or not of a calibrating intraesophageal bougie to perform the fundoplication; the need for short gastric vessels division and the anchoring of the fundoplication on the hiatus. There is not enough high quality evidence-based data to support the use or not of these topics; however.

Even though Nissen fundoplication proved to be an excellent operation for symptoms control [40] and increment in quality of life [41], with an irrelevant mortality [42] and sustained outcomes in a long-term follow-up [43], some authors looked for alternatives to this operation, some with procedures acting solely at the esophagogastric junction.

Angelchick and Cohen [44], in 1979, tried to reinforce the lower esophageal sphincter (LES) with silicon ring prosthesis around the esophagogastric junction. A great popularity was achieved with over 25,000 implants [45]. Years later, a strange body at this location showed to induce poor outcomes and a large number of complications related to unmanageable dysphagia and prosthesis erosion or migration [46, 47]. Most of the surgeons experienced with this device deemed the procedure not recommendable anymore [46, 47]. Fortunately, the device is not currently in use. Interestingly, other methods for GERD control tried to decrease the esophagogastric junction complacence by injecting foreign substances in the LES. Following previous experiences with foreign body, bad outcomes and significant complications made these methods to be withdrawn from market [48].

GERD has a complex and multifactorial genesis [49]. Parallel to the development of surgical techniques, surgeons also studied esophageal physiology and make significant progress on the understanding of GERD pathophysiology. Barrett was one of the first to acknowledge the fact that duodenal contents may also reflux and damage the esophagus [20]. Lately after, different tests were created to evaluate biliary or non-acid reflux [50]. The most significant was multichannel intraluminal impedance, a test that proved that non-acid reflux is able to produce symptoms [51] and that medical therapy for GERD is able to neutralize the pH of the refluxate but not the backflow of gastroduodenal contents to the esophagus [52]. Physiologic studies also showed that the simple restoration of the basal pressure of the LES to normal values is not enough to control GERD, since GERD may exist in the setting of sphincters with normal pressure [53] due to a defect in the other previously mentioned antireflux mechanisms or due to abnormal transient relaxations of the sphincter, identified since 1980 [54]. Thus, LES basal pressure must not be used alone as a primary endpoint to evaluate new antireflux procedures. It must be remembered as well that a fundoplication is able to restore all natural antireflux mechanisms [49] and decrease transient relaxations of the LES [55].