Medium-term efficacy of laparoscopic Dor fundoplication combined with the reconstruction of angle of His in the treatment of gastroesophageal reflux disease

Medium-term efficacy of laparoscopic Dor fundoplication combined with the reconstruction of angle of His in the treatment of gastroesophageal reflux disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medium-term efficacy of laparoscopic Dor fundoplication combined with the reconstruction of angle of His in the treatment of gastroesophageal reflux disease Xing Du, Hongyi Dong, Haijun Du, Diangang Liu, YinPeng Ren This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6924682/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Gastroesophageal reflux disease (GERD)is currently one of the most common digestive tract diseases. There is no report on laparoscopic fundoplication combined with reconstruction of angle of His (RAH) in the treatment of GERD. Thus, this study aimed to investigate the medium-term efficacy of laparoscopic Dor fundoplication combined with RAH for GERD patients. Methods Clinical data of GERD patients who underwent Dor fundoplication combined with RAH (Dor+RAH group, 116 cases) or Dor fundoplication (Dor group, 107 cases) in Department of General Surgery, Xuanwu Hospital, Capital Medical University from January 2019 to June 2022 were retrospectively analyzed. Esophageal and extraesophageal symptom scores, functional complications, and patient satisfaction were compared between the two groups after two years postoperatively. Results There was no significant difference in esophageal and extraesophageal symptom scores between the two groups before surgery (all P >0.05). At 2 years postoperatively, esophageal and extraesophageal symptom scores of both two groups decreased significantly compared with those preoperatively (all P <0.01). In the 2-year postoperative symptom scores, the scores for regurgitation and heartburn in the Dor+RAH group were lower than those in the Dor group, with statistically significant differences ( P 0.05). The incidences of postoperative functional complications (including dysphagia, abdominal distension, difficulty to belch, increased flatus, and chronic abdominal pain) were similar in both groups, and all were significantly relieved by conservative treatment. The patient satisfaction rate with surgical treatment was 92.2% (107/116) in the Dor+RAH group, showing no significant difference from 90.7% (97/107) in the Dor group ( P =0.671). Conclusions: Both Dor fundoplication combined with RAH and pure Dor fundoplication demonstrate good anti-reflux effects in treating GERD, with few surgical complications and high patient satisfaction. Compared with Dor fundoplication, Dor fundoplication with RAH has a better effect in controlling regurgitation and heartburn symptoms, indicating it may have a better therapeutic effect for GERD patients. Gastro-esophageal reflux disease Fundoplication Angle of His Reconstruction Efficacy Figures Figure 1 Background Gastro-esophageal reflux disease (GERD) refers to the reflux of gastric and duodenal contents into the esophagus, throat, mouth, respiratory tract and other sites, causing a series of uncomfortable symptoms, signs and complications[ 1 – 5 ]. It is currently one of the most common digestive tract diseases[ 6 , 7 ]. As a global disease, GERD is characterized by high incidence rate and high misdiagnosis and mistreatment rate. The course of the disease can last for months to decades, seriously affecting patients' life and work, and has become a major public health problem [[ 8 – 10 ]]. In recent decades, laparoscopic antireflux surgery has received increasing attentions. The first laparoscopic Nissen fundoplication was performed and reported by GEAGEa in 1991[ 11 ]. Since then, this surgical procedure has gradually become popular in European and American countries and has become the "gold standard" for the treatment of GERD[ 12 , 13 ]. When the surgical indications are strictly controlled and appropriate cases are selected, laparoscopic Nissen fundoplication can achieve definite and good antireflux effects. However, the surgery itself may cause some complications related to digestive tract functions, such as dysphagia, abdominal distension, difficulty to belch, etc. On the premise of not reducing the surgical efficacy, in order to reduce the occurrence of postoperative complications, domestic and foreign scholars have continuously tried new antireflux surgical procedures[ 14 ]: (1) modifying the Nissen procedures, such as the Nissen-Rossetti procedure that preserves the short gastric vessels; (2) reducing the circumferential wrapping of the esophagus, that is, partial fundoplication[ 15 , 16 ], such as the posterior Toupet (270°), the anterior Dor (180°) and 90° fundoplication. Studies have shown that compared with the Nissen procedure, laparoscopic Dor fundoplication can achieve similar antireflux effects, while reducing postoperative complications such as dysphagia and abdominal distension[ 17 , 18 ]. Angle of His is the angle between the lower esophagus and the gastric fundus, which is involved in the formation of the gastroesophageal valve and is one of the important antireflux structures. When hiatal hernia (HH) occurs, the structure the angle of His will be damaged, leading to the reduction or disappearance of its antireflux function. Therefore, theoretically, reconstructing the angle of His, meaning restoring the function of the gastroesophageal valve, can play a role in anti-reflux and improving the symptoms and complications of GERD. At present, there is no report on laparoscopic Dor fundoplication combined with reconstruction of angle of His (RAH) in the treatment of GERD in the international literatures. Since January 2019, Department of General Surgery, Xuanwu Hospital, Capital Medical University has explored this surgical procedure, followed up the patients, analyzed the data, and now reports the medium-term follow-up results as follows. Methods Subjects A retrospective analysis was performed on GERD patients who were hospitalized in the General Surgery Department of Xuanwu Hospital of Capital Medical University from January 2019 to June 2022 and received laparoscopic anterior Dor fundoplication combined with RAH (Dor + RAH group, 116 cases) or pure Dor fundoplication (Dor group, 107 cases). All patients underwent pre-operative examinations, such as symptom scoring, upper gastrointestinal endoscopy, high-resolution esophageal manometry (HRM), 24-hour multichannel intraluminal impedance pH (24-h MII-pH) monitoring, and upper gastrointestinal barium meal radiography. This study was approved by the hospital ethics committee, and all patients were informed and signed informed consent forms. Inclusion criteria: ① Age ≥ 18 years; ② GERD-related symptoms for ≥ 6 months, such as regurgitation, heartburn (burning sensation behind the sternum), non-cardiac chest pain, subxiphoid distension and fullness, cough, wheezing, and pharyngeal foreign body sensation, etc.; ③ GERD was diagnosed by preoperative objective examinations; ④ Achalasia and nutcracker syndrome were excluded by HRM; ⑤ The informed consent form was provided by all patients. Exclusion criteria: ① History of surgery in the esophagus, stomach and other parts; ② patients with esophageal and gastrointestinal malignant tumors; ③ those complicated with severe central nervous system diseases, fibromyalgia, severe coagulation disorders and other diseases; ④ those who could not tolerate surgery due to severe cardiovascular and cerebrovascular diseases, etc.; ⑤ those who refused to participate in the study. Preoperative Examinations Positive diagnostic criteria for esophageal 24-h MII-pH monitoring (Sandhill Scientific, Highlands Ranch, CO, USA) [ 19 ]: DeMeester scores ≥ 14.72, or acid exposure time (AET) ≥ 4.2%, or percent bolus exposure time (BET) ≥ 1.4%, or total number of reflux episodes ≥ 73. HRM examination: The resting pressure of the lower esophageal sphincter (LES) < 13 mmHg was defined as reduced LES pressure (normal reference value: 13–43 mmHg). HH was diagnosed when the LES pressure zone was separated from the diaphragmatic pressure zone. Upper gastrointestinal endoscopy: Reflux esophagitis was classified into LA-A、LA-B、LA-C and LA-D according to the Los Angeles (LA) classification criteria. Endoscopic diagnostic criteria for HH: With the patient in the left lateral decubitus position during quiet breathing (avoiding nausea or vomiting), the gastroesophageal junction (Z-line or dentate line) was clearly observed. The distance from the Z-line to the incisors and the distance from the diaphragmatic indentation to the incisors were measured, and the difference between the two distances was calculated. A distance difference ≥ 2.0 cm was defined as HH. The diagnostic criteria for GERD: Positive diagnosis was made with 24-h MII-pH monitoring indicated GERD, or reflux esophagitis was found with gastroscopy. The diagnostic criteria for HH: The diagnosis of HH could be made if HH was found in either HRM or gastroscopy. Surgical procedure All surgeries were performed by the same surgical team. The patient was placed in a supine position with a head-high and foot-low (Split-leg) position at an angle of 30° to 45°. The chief surgeon stood between the patient's legs, the first assistant was on the patient's left side, and the endoscope holder was on the patient's right side. After successful tracheal intubation anesthesia, a conventional five-port method was used to establish observation and operation ports. Once the light source entered the abdominal cavity, the size and type of HH could be roughly observed. The hepatogastric ligament and lesser omentum were transected with a ultrasonic scalpel, the hernia sac was dissected, the esophageal was fully mobilized, the hernia contents were reduced, and the length of the abdominal segment of the esophagus was ensured to be ≥3 cm without tension. Care was taken to protect the anterior and posterior branches of the vagus nerve. The right and left of diaphragmatic crura were sutured together with 2 − 0 non-absorbable sutures to narrow the hiatus to an appropriate degree without compressing the esophagus. If the anteroposterior diameter of the hiatus was ≥ 5 cm or the diaphragmatic cruras were obviously weak, a patch (Covidien, 8 cm×8 cm) was placed at the diaphragmatic crura and fixed with an absorbable stapler. Anterior Dor Fundoplication with the reconstruction of angle of His: Gastric fundus was mobilized fully and the short gastric vessels could be transected if necessary. The fundus was pulled from the anterior side of the esophagus to the right side of the esophagus, and abdominal segment of the esophagus was wrapped with the fundus with the degree of 180–200. The folded fundus was sutured and fixed to the esophagus and diaphragm with 3 − 0 non-absorbable sutures for 3–4 stitches, and the Dor fundoplication was created. On the left side of the esophagus, the folded fundus was sutured and fixed to the diaphragm with 3 − 0 non-absorbable sutures, avoiding the inferior phrenic vessels, to complete the reconstruction of angle of His, as shown in Fig. 1 . Observation indicators Symptom scoring: Patients were surveyed using a self-developed questionnaire-based grading symptom scoring system before surgery and 2 years after surgery. Attack frequency score (0–5 points): 0 points: asymptomatic; 1 point : attack frequency < 1 day/week; 2 points : attacks 1–2 days/week; 3 points : 3–4 days/week; 4 points: 5–6 days/week; 5 points: ≥6 days/week. Symptom severity score (0–5 points): 0 points: asymptomatic; 1 point: mild symptoms; 2 points: mild discomfort, not affecting daily life or work; 3 points: moderate, affecting daily life and work; 4 points: severe discomfort, causing partial inability to care for oneself; 5 points: extremely severe, life-threatening, causing loss of self-care ability, with a history of one or more rescues. The score of each symptom was the sum of the symptom severity score and the frequency score. Esophageal symptoms included regurgitation, heartburn, non-cardiac chest pain, and a feeling of subxiphoid distension and fullness. Extraesophageal symptoms included cough, wheezing, and pharyngeal foreign body sensation. Postoperative functional complications: dysphagia, abdominal distension, difficulty to belch, increased flatus, chronic abdominal pain, as well as postoperative recurrence and reoperation. The severity of postoperative dysphagia was classified into none, mild, moderate and severe. None dysphagia: no choking sensation when eating solid foods, no need for water; mild dysphagia: obvious choking sensation when eating solid foods, requiring water to relieve symptoms; moderate dysphagia: only able to eat liquid or soft foods, unable to eat solid foods; severe dysphagia: unable to drink water and other liquid food. Satisfaction survey: At 2 years postoperatively, outpatient or telephone follow-up was conducted to assess patients’ overall satisfaction with surgical efficacy, classified as satisfied, neutral, or dissatisfied. Statistical analysis The SPSS 26.0 statistical software package (IBM, Armonk, NY) was used for data processing. Continuous data were summarized as Mean ± SD if normally distributed and as median (interquartile rang, IQR) otherwise, and categorical variables were summarized as counts and frequencies. For measurement data that follow a normal distribution, an independent two-sample t-test was used for comparisons between groups. For paired non-normally distributed measurement data, the Wilcoxon signed-rank test was used for comparisons. For two independent samples of non-normally distributed measurement data, the Mann-Whitney U test was used for comparisons. Chi-squared test was used for categorical parameter. All tests of significance were 2-sides, with P < 0.05 considered statistically significant. Results Patient characteristic A total of 223 patients were included in the analysis, among whom 116 were in the Dor + RAH group (52 male and 64 female; mean age, 53.98±11.68 years) and 107 were in the Dor group (46 male and 61 female; mean age, 54.87±11.98 years). There were not significant differences in the ages, body mass index, sex distribution of subjects, distribution of reflux esophagitis, parameters of 24-h MII-pH monitoring and HRM, and implantation rate of patches among two groups ( P >0.05 for all) (Table 1 ). Table 1 Comparison of baseline data between two groups of patients Clinical Variables Dor + RAH group ( N = 116) Dor group ( N = 107) Z/χ 2 P Gender, (M/F), n (%) 52/64 46/61 0.216 0.782 Age (yr), mean±SD 53.98±11.68 54.87±11.98 0.431 0.811 BMI (kg/m 2 ), mean±SD 24.4±3.6 26.1±4.2 0.521 0.53 Reflux esophagitis, n(%) 83(71.5) 76(71.0) 0.158 0.782 24-h MII-pH monitoring Demeester score, median (IQR) 25.4 (14.6, 43.1) 23.4 (14.6, 41.1) 2.332 0.153 AET (%), median (IQR) 9.3 (4.2, 12.6) 8.1 (4.1, 11.1) 2.098 0.423 BET (%), median (IQR) 2.3 (0.8, 41.8) 2.2 (0.6, 3.3) -2.413 0.156 Number of all reflux episodes, median (IQR) 70 (52, 79) 76 (56, 86) -3.180 0.207 HRM Resting LES pressure (mmHg), median (IQR) 8.1 (3.6, 13.2) 8.8 (4.1, 12.2) -4.045 0.185 Resting UES pressure (mmHg), median (IQR) 56.1 (32.1, 83.2) 58.8 (39.8, 80.3) -2.371 0.595 Application of Mesh (%) 81(69.8) 72(67.3) 0.166 0.683 Abbreviations: M/F male/female, BMI body mass index, SD standard deviation, 24-h MII-pH 24-hour multichannel intraluminal impedance pH, IQR interquartile rang, AET acid exposure time, BET bolus exposure time, HRM high resolution manometry, LES lower esophageal sphincter, UES upper esophageal sphincter, Dor + RAH Dor fundoplication combined with reconstruction of angle of His. Comparison of reflux symptom scores There was no significant difference in the preoperative esophageal symptoms (regurgitation, heartburn, chest pain, and subxiphoid distension and fullness) and extraesophageal symptoms (cough, wheezing, and pharyngeal foreign body sensation) between the two groups (all P > 0.05), as shown in Table 2 . At 2 years postoperatively, the scores of esophageal symptoms and extraesophageal symptoms in both groups were significantly lower than those before surgery (all P < 0.05), as shown in Table 3 . The scores of postoperative regurgitation and heartburn symptoms in the Dor + RAH group were lower than those in the Dor group, with significant differences (Z=-3.735, P < 0.001; Z=-2.736, P = 0.006). However, there was no significant difference in the scores of other symptoms (chest pain, subxiphoid distension and fullness, cough, wheezing, and pharyngeal foreign body sensation) between the two groups (all P > 0.05), as shown in Table 4 . Table 2 Comparison of preoperative GERD symptom scores between two groups Symptom scores, median (IQR) Dor + RAH ( N = 116) Dor group ( N = 107) Z Z P P Esophageal symptoms Regurgitation 7(6, 8) 7(6, 7) -1.255 0.209 Heart burn 7(6, 8) 7(6, 8) -1.753 0.08 Chest pain 4(0, 6) 3(0, 5) -0.567 0.571 Subxiphoid distension and fullness 3.5(0, 6) 2(0, 5) -0.256 0.798 Extraesophageal symptoms Cough 2(0, 5) 0(0, 5) -0.997 0.319 Wheezing 4(0, 5) 0(0, 5) -1.776 0.076 Pharyngeal foreign body sensation 4(0, 5) 3(0, 5) -1.124 0.261 Abbreviations: GERD gastro-esophageal reflux disease, IQR interquartile rang, Dor + RAH Dor fundoplication combined with reconstruction of angle of His. Table 3 Symptom scores of patients in both groups before and after antireflux surgery Symptom scores, median (IQR) Before surgery After surgery Z P Dor + RAH group Esophageal symptoms Regurgitation 7(6, 8) 0.5(0, 1) -13.298 <0.001 Heart burn 7(6, 8) 1(0, 2) -13.029 <0.001 Chest pain 4(0, 6) 0(0, 2) -5.276 <0.001 Subxiphoid distension and fullness 3.5(0, 6) 0(0, 1) -5.851 <0.001 Extraesophageal symptoms Cough 2(0, 5) 0(0, 1.75) -4.814 <0.001 Wheezing 4(0, 5) 0(0, 2) -4.820 <0.001 Pharyngeal foreign body sensation 4(0, 5) 0(0, 2) -5.970 <0.001 Dor group Esophageal symptoms Regurgitation 7(6, 8) 2(0, 2) -11.794 <0.001 Heart burn 7(6, 8) 1(0, 2) -5.811 <0.001 Chest pain 3(0, 5) 0(0, 2) -4.734 <0.001 Subxiphoid distension and fullness 2(0, 5) 0(0, 2) -4.104 <0.001 Extraesophageal symptoms Cough 0(0, 5) 0(0, 1) -3.604 <0.001 Wheezing 0(0, 5) 0(0, 1) -3.974 <0.001 Pharyngeal foreign body sensation 3(0, 5) 0(0, 2) -3.298 <0.001 Abbreviations:IQR interquartile rang, Dor + RAH Dor fundoplication combined with reconstruction of angle of His. Table 4 Comparison of postoperative GERD symptom scores between two groups Symptom scores, median (IQR) Dor + RAH group ( N = 116) Dor group ( N = 107) Z P Esophageal symptoms Regurgitation 0.5(0, 1) 1(0, 2) -3.735 <0.001 Heart burn 1(0, 2) 2(0, 2) -2.736 0.006 Chest pain 0(0, 2) 0(0, 2) -0.88 0.379 Subxiphoid distension and fullness 0(0, 1) 0(0, 2) -0.592 0.554 Extraesophageal symptoms Cough 0(0, 1.75) 0(0, 1) -0.927 0.354 Wheezing 0(0, 2) 0(0, 1) -1.77 0.077 Pharyngeal foreign body sensation 0(0, 2) 0(0, 2) -0.02 0.984 Abbreviations: GERD gastro-esophageal reflux disease, IQR interquartile rang, Dor + RAH Dor fundoplication combined with reconstruction of angle of His. Comparison of the occurrence of functional complications Within 2 weeks after surgery, 93.3% of patients experienced dysphagia. The incidence was 92.2% (107/116) in the Dor + RAH group and 94.3% (101/107) in the Dor group, with no significant difference between the two groups (χ²=0.411, P = 0.522). With dietary guidance, all patients showed significant improvement in dysphagia symptoms, and all patients were able to transition to a semi-liquid diet at 2 months postoperatively. At 2 years postoperatively, no moderate dysphagia was observed in either group, and all patients could eat soft food smoothly. None of the patients required endoscopic esophageal dilation or secondary surgery. At 1 month postoperatively, the incidence rates of abdominal distension, difficulty to belch, increased flatus, and chronic abdominal pain were 11.2%, 10.2%, 6.2%, and 2.1%, respectively. With dietary guidance, lifestyle modifications, and medication, all of the above symptoms were significantly alleviated in patients at 2 years postoperatively. Comparison of of satisfaction At 2 years postoperatively, 106 patients in the Dor + RAH group were satisfied with the overall surgical efficacy, 7 had neutral opinions, and 3 were dissatisfied. In the Dor group, 96 patients were satisfied, 7 had neutral opinions, and 4 were dissatisfied. The satisfaction rate with surgical treatment was 91.4% (106/116) in the Dor + RAH group and 89.7% (96/107) in the Dor group, with no significant difference between the two groups (χ² =0.18, P = 0.672). Comparison of perioperative mortality, severe complications, and reoperation rates All patients had no conversion to laparotomy, and no severe complications such as massive hemorrhage, gastrointestinal perforation, hepatic or splenic rupture, or death occurred. All patients successfully weaned from the ventilator, had their tracheal intubation removed, and were safely transferred back to the general ward after surgery. At 2 years postoperatively, all patients had no symptomatic or anatomical recurrence, and no reoperation was performed. Discussion Since the clinical application of laparoscopic fundoplication in 1991, numerous studies have confirmed its effectiveness, safety, and long-term efficacy in treating GERD[ 20 , 21 ]. The ultimate goal of modifying and evolving anti-reflux surgical procedures is to reduce the occurrence of postoperative complications such as dysphagia while ensuring surgical efficacy. BROEDERS et al. [ 22 ]reported that laparoscopic anterior Dor fundoplication achieved similar 5-year anti-reflux effects compared to the Nissen procedure, while reducing the incidence of postoperative complications. The results of our study showed that anti-reflux surgery could significantly improve both esophageal and extra-esophageal symptoms in GERD patients, significantly improve quality of life, and achieve an overall satisfaction rate of approximately 90% with surgical efficacy, consistent with other research findings[ 23 – 24 ]. It is important to note that this study adopted subxiphoid distension and fullness as an symptom parameter. This symptom is often a clinical manifestation of HH, caused by the compression of the gastric fundus or body by the bilateral diaphragmatic crura during HH formation. It has a high incidence in HH patients and causes significant distress, but has not been mentioned in previous studies.In this study, the incidence of dysphagia during the perioperative period (within 2 weeks postoperatively) was 93.3% (208/223), with similar rates in both groups (92.2% vs. 94.3%, P = 0.522). All patients showed significant improvement in dysphagia symptoms through dietary guidance. At 2 months postoperatively, all patients could transition to a semi-liquid diet, and at 2 years postoperatively, there was no moderate dysphagia, with all patients able to eat soft food smoothly. During the follow-up period, none of the patients underwent endoscopic esophageal dilation or reoperation due to dysphagia. Postoperative dysphagia is one of the most common postoperative complications. In addition to considering different surgical procedures (Nissen, Toupet, Dor), selection of width of fundoplication flap (short-loose or wide-loose fundoplication)[ 25 ], and application of other auxiliary techniques (such as intraoperative bougie dilation of the esophagogastric junction)[ 26 , 27 ], the authors believe that thorough preoperative explanation and communication, as well as reasonable postoperative dietary guidance, also help alleviate patients' fear of dysphagia. On one hand, surgeons should strive to avoid severe postoperative dysphagia, and on the other hand, patients should understand the surgical process, the principles of anti-reflux surgery, and the physiological evolution of the surgical site (fundoplication area) postoperatively. This helps patients to understand the causes of dysphagia and accept mild dysphagia more easily, further improving their compliance and satisfaction with surgical treatment. Additionally, there are significant differences in the selection of surgical indications for GERD, surgical techniques, choice of surgical approaches, and overall patient management across different treatment centers, leading to large variations in treatment efficiency, recurrence rates, and patient satisfaction[ 24 ]. Therefore, comprehensive preoperative evaluation (including HRM, 24-h MII-pH monitoring, and other specific diagnostic tools), standardized diagnosis and treatment processes, and GERD centers with certain treatment experience are crucial for improving the level of individualized treatment for GERD patients[ 15 , 28 – 30 ]. The His angle, also known as cardiac incisure, or esophagogastric angle, is the angle between the lower esophagus and the gastric fundus. The left wall of the abdominal esophagus connects to the gastric fundus, forming the angle of His at this junction, which is one of the important anti-reflux structures and participates in the formation of the gastroesophageal valve flap. In patients with HH, the angle of His significantly increases or even disappears, causing the gastroesophageal valve flap to shrink or disappear, weakening or losing its anti-reflux function[ 31 , 32 ]. In view of this, this study reconstructed the angle of His during routine fundoplication to explore its anti-reflux effect. The results showed that the Dor fundoplication combined with RAH could further improved regurgitation and heartburn symptoms compared to pure fundoplication, which indicated fundoplication with RAH had better anti-reflux efficacy, while not increasing the incidence of surgical complications. Based on our surgical operational experience and insights, the reasons why the reconstruction of angle of His synergistically enhances anti-reflux effects, we analyze the possible reasons as follows: (1) After angle of His is reconstructed, the gastroesophageal valve flap structure is restored, strengthening its anti-reflux function. (2) During the process of the reconstruction of angle of His, the fundus used for plication is sutured and fixed to the diaphragm (as shown in the Fig. 1 ), which reduces tension on the fundoplication flap and fixes the flap, thus stabilizing the flap's shape and reducing the recurrence of HH. There are very few research reports on the application of RAH for the treatment of GERD. Previous reports have mentioned the use of RAH in the treatment of achalasia [ 33 ], partial gastrectomy [ 34 , 35 ], sleeve gastrectomy[ 36 ], etc., with results showing that RAH can alleviate or prevent the occurrence of GERD-related symptoms after surgery. In 2022, Zhang[ 37 ] reported that laparoscopic RAH had anti-reflux effects similar to fundoplication, and had advantages such as less operative time, less intraoperative blood loss, shorter postoperative hospital stay, and fewer surgical complications. It should be noted that this study evaluated pure RAH, not fundoplication with RAH. Additionally, the method of RAH in this study is to fix the gastric fundus to the left wall of the abdominal esophagus, which is different from our method (Fig. 1 ). This study explored the anti-reflux effect of laparoscopic Dor fundoplication with RAH. During clinical practice, the authors summarized several key points for the operation of the procedure: (1) Non-absorbable sutures were used for suture. The needle insertion point on the gastric fundus was selected at the highest point of the folded fundus. Before inserting the needle, the fundus was everted to avoid bulky and redundant tissues from filling between the fundus and the esophagus, so as to reduce the occurrence of postoperative discomfort symptoms such as dysphagia and abdominal distension; (2) The needle insertion point on the diaphragm was selected at the left anterior side of the esophagus, avoiding the subphrenic blood vessels, so that the reconstructed angle of His could form a smaller and deeper acute angle, making the anti-reflux effect of the gastroesophageal valve flap more obvious (Fig. 1 ). There were some limitations in our study. First, In the postoperative follow-up, there were not objective data evaluations, such as gastroscopy, 24-h MII-pH monitoring, and HRM, which may cause bias in the research results. Second, this study was a retrospective, single-center, medium-term follow-up result with a limited sample size, and the research results need to be verified by prospective, multi-center, large-sample, and long-term follow-up data. Conclusions In conclusion, this study preliminarily found that compared with pure laparoscopic Dor fundoplication, Dor fundoplication combined with RAH has a better anti-reflux effect and does not increase the occurrence of postoperative gastrointestinal functional complications. It is worthy of further exploration and verification of its therapeutic value for GERD. Abbreviations GERD Gastro-esophageal reflux disease RAH reconstruction of angle of His HH Hiatus hernia HRM High-resolution manometry 24-h MII-pH 24-hour multichannel intraluminal impedance pH AET Acid exposure time BET Bolus exposure time LES Lower esophageal sphincter SD standard deviation IQR interquartile rang. Declarations Acknowledgements Not applicable. Funding There is no funding for the study. Availability of data and materials The data generated and analyzed during this study are available from the corresponding author on reasonable request. Authors’ contributions All authors read and approved the final version of the manuscript, including the authorship. Study concept and design: XD, HYD, and DGL; acquisition of data: XD, HYD, HJD, YPR, and DGL; analysis and interpretation of data: XD, HYD, DGL; manuscript draft: XD, HYD, HJD; critical revision of the manuscript for important intellectual content: XD, HYD, DGL, and YPR. Competing interests All authors have declared that no competing interests exist. Consent to publish Not applicable. Ethics approval and consent to participate Approval for this study was obtained from the institutional review boards of Xuanwu Hospital, Capital Medical University (Beijing, China), and written informed consent was acquired from all participants. Authors' Information 1 Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing 100053, China. 2 Department of General Surgery, Xiong an Xuan Wu Hospital, Hebei 071800, China. References Phillips HR, Kamboj AK, Leggett CL. Diagnosis and Management of Gastroesophageal Reflux Disease: A Concise Review for Clinicians. MAYO CLIN PROC. 2025; 100(5):882-89. Fuchs K, Hann A, Meining A. Gastroesophageal Reflux Disease - A Review of Important Management Components. CHIRURGIA-BUCHAREST. 2025; 120(1):5. Blaine Sauer S, Bock J, Bor S, Allen J, Randall DR, Mittal S, Carroll TL. Extraesophageal reflux: Clinical manifestations and tools for diagnosis and treatment. ANN NY ACAD SCI. 2025; 1547(1):233-44. Fernandez AM, Chan WW. Update on extraesophageal manifestations of gastroesophageal reflux. CURR OPIN GASTROEN. 2024; 40(4):305-13. Gyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E, Sifrim D, Spechler S, Zerbib F, Fox MR et al. 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VISC MED. 2024:1-6. Liu Y, Huang J, Zhong S, Zheng Z, Xu Z, Zhou D, Xie S, Lin Z, Li S, Chen R. Efficacy and safety of antireflux surgery in gastroesophageal-related cough: a systematic review and meta-analysis. INT J SURG. 2024; 111(1):1348-56. Schlottmann F, Bertona S, Herbella FAM, Patti MG. Gastroesophageal reflux disease: indications for antireflux surgery, outcomes, and side effects. Expert Review of Gastroenterology & Hepatology. 2024; 18(11):693-703. Paranyak M, Patel R. A prospective randomized trial on laparoscopic total vs partial fundoplication in patients with atypical symptoms of gastroesophageal reflux disease. LANGENBECK ARCH SURG. 2023; 408(1):269. Analatos A, Lindblad M, Ansorge C, Lundell L, Thorell A, Hakanson BS. Total versus partial posterior fundoplication in the surgical repair of para-oesophageal hernias: randomized clinical trial. BJS OPEN. 2022; 6(3). Broeders JA, Roks DJ, Ahmed Ali U, Watson DI, Baigrie RJ, Cao Z, Hartmann J, Maddern GJ. Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. ANN SURG. 2013; 257(5):850-59. Broeders JA, Broeders EA, Watson DI, Devitt PG, Holloway RH, Jamieson GG. Objective outcomes 14 years after laparoscopic anterior 180-degree partial versus nissen fundoplication: results from a randomized trial. ANN SURG. 2013; 258(2):233-39. Du X, Wang F, Hu Z, Wu J, Wang Z, Yan C, Zhang C, Tang J. The diagnostic value of pepsin detection in saliva for gastro-esophageal reflux disease: a preliminary study from China. BMC GASTROENTEROL. 2017; 17(1):107. Kockerling F, Jacob D, Adolf D, Zherdyev V, Riediger H, Scheuerlein H. Laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastroesophageal reflux disease: a propensity score-matched comparison of the perioperative and 1-year follow-up outcome. HERNIA. 2024; 28(5):1629-39. Dallemagne B, Perretta S. Long-term Efficacy of Total and Partial Posterior Fundoplication to Treat Gastroesophageal Reflux Disease. JAMA SURG. 2022; 157(6):480. Broeders JA, Roks DJ, Jamieson GG, Devitt PG, Baigrie RJ, Watson DI. Five-year outcome after laparoscopic anterior partial versus Nissen fundoplication: four randomized trials. ANN SURG. 2012; 255(4):637-42. Trepanier M, Dumitra T, Sorial R, Siblini A, Vassiliou M, Fried GM, Feldman LS, Ferri LE, Lee L, Mueller CL. Comparison of Dor and Nissen fundoplication after laparoscopic paraesophageal hernia repair. SURGERY. 2019; 166(4):540-46. Lee Y, Tahir U, Tessier L, Yang K, Hassan T, Dang J, Kroh M, Hong D. Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials. SURG ENDOSC. 2023; 37(7):5052-64. Raiser F, Hinder RA, McBride PJ, Katada N, Filipi CJ. The technique of laparoscopic Nissen fundoplication. Chest Surg Clin N Am. 1995; 5(3):437-48. Amundson JR, Kuchta K, Zimmermann CJ, VanDruff VN, Joseph S, Che S, Ishii S, Hedberg HM, Ujiki MB. Target distensibility index on impedance planimetry during fundoplication by choice of wrap and choice of bougie. SURG ENDOSC. 2023; 37(11):8670-81. Seok D, Kaushik M, Jacobs M. Routine Intraoperative Use of Esophageal Bougie in Minimally Invasive Hiatal Hernia Repair is Not Necessary. JSLS-J SOC LAPAROEND. 2022; 26(4). Bonavina L. Individualizing the choice of surgical therapy for gastroesophageal reflux disease. CURR OPIN GASTROEN. 2025; 41(4):245-50. Walle KV, Funk LM, Xu Y, Davies KD, Greenberg J, Shada A, Lidor A. Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication. J SURG RES. 2019; 235:52-57. Zimmermann CJ, Kuchta K, Amundson JR, VanDruff VN, Joseph S, Che S, Hedberg HM, Ujiki M. Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes. SURG ENDOSC. 2024; 38(6):3273-8. Zhang S, Joseph AA, Gross L, Ghadimi M, Frahm J, Beham AW. Diagnosis of Gastroesophageal Reflux Disease Using Real-time Magnetic Resonance Imaging. SCI REP-UK. 2015; 5:12112. Michael S, Marom G, Brodie R, Salem SA, Fishman Y, Shein GS, Helou B, Pikarsky AJ, Mintz Y. The Angle of His as a Measurable Element of the Anti-reflux Mechanism. J GASTROINTEST SURG. 2023; 27(11):2279-86. Balakrishna P, Parshad R, Rohila J, Saraya A, Makharia G, Sharma R. Symptomatic outcome following laparoscopic Heller's cardiomyotomy with Dor fundoplication versus laparoscopic Heller's cardiomyotomy with angle of His accentuation: results of a randomized controlled trial. SURG ENDOSC. 2015; 29(8):2344-51. Tomita R. Surgical techniques to prevent reflux esophagitis in proximal gastrectomy reconstructed by esophagogastrostomy with preservation of the lower esophageal sphincter, pyloric and celiac branches of the vagal nerve, and reconstruction of the new His angle for early proximal gastric cancer. SURG TODAY. 2016; 46(7):827-34. Aizawa M, Ishida M, Kodera Y, Kanazawa T, Fukushima R, Akashi Y, Yoshimura F, Ota S, Oshio A, Nakada K. A comparison of the effects of anti-reflux procedures during esophagogastrostomy after proximal gastrectomy on the postoperative quality of life. SURG TODAY. 2023; 53(2):182-91. Cao K, Shi XY, Jin Y, Ye ZW, Zhai CX, Wu YL, Fan JM, Wang ZJ, Han JG. Short-term effects of laparoscopic sleeve gastrectomy combined with reconstruction of the acute His angle on postoperative gastroesophageal reflux disease. Zhonghua Wei Chang Wai Ke Za Zhi. 2024; 27(10):1050-5. Zhang R, Li Z, Li C, Ji F, Han X, Wang Z. Effect of laparoscopic angle of His reconstruction in the treatment of patients with gastroesophageal reflux disease and hiatal hernia. CHINESE MED J-PEKING. 2022; 135(14):1750-2. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Feb, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviews received at journal 24 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor invited by journal 23 Jun, 2025 Editor assigned by journal 19 Jun, 2025 Submission checks completed at journal 19 Jun, 2025 First submitted to journal 18 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6924682","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485399355,"identity":"7f0e8e31-e55f-4ec9-96b2-d89107d5119a","order_by":0,"name":"Xing Du","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xing","middleName":"","lastName":"Du","suffix":""},{"id":485399356,"identity":"df58f30a-21d8-49bb-8af6-144449a85dc4","order_by":1,"name":"Hongyi Dong","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hongyi","middleName":"","lastName":"Dong","suffix":""},{"id":485399357,"identity":"2944ad9c-1f15-4aad-bca1-d3fb43b0c8af","order_by":2,"name":"Haijun Du","email":"","orcid":"","institution":"Xiongan Xuanwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haijun","middleName":"","lastName":"Du","suffix":""},{"id":485399358,"identity":"ae02c31d-c1a5-4954-ab76-bbb9606d4812","order_by":3,"name":"Diangang Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYDCCA2AkIcfY3tj48AMJWiyMmXsONxtLEKsFCCoS22ektwnwEKOD70aO4eGCXxKJvTMftjFIMNjJ6TYQ0CJ5Iy3h8Mw+CeOZsxPbHhQwJBubHSCgxeBG8oHDvD0SshtnJ7YbSDAcSNxGWEtiA0gL4/6bB9skeIjTArSF54eEYuMMRiK1SJ55lnCYt0HCmLEnERjIBkT4he94jvFnnj91wKg8/vDhhwo7OYJawICxDe5OYpSDwR+iVY6CUTAKRsFIBAAbeEqsol7AigAAAABJRU5ErkJggg==","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Diangang","middleName":"","lastName":"Liu","suffix":""},{"id":485399359,"identity":"2a88594a-a6b6-49fb-9844-8e7df1381194","order_by":4,"name":"YinPeng Ren","email":"","orcid":"","institution":"Xuan Wu Hospital of the Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"YinPeng","middleName":"","lastName":"Ren","suffix":""}],"badges":[],"createdAt":"2025-06-18 15:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6924682/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6924682/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87043477,"identity":"b50ac307-e55e-452e-a78e-ec3bc803dda4","added_by":"auto","created_at":"2025-07-18 14:16:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":933313,"visible":true,"origin":"","legend":"\u003cp\u003eKey points of Dor fundoplication combined with reconstruction of angle of His procedure. \u003cstrong\u003eA\u003c/strong\u003e. Suturing two sides of the diaphragmatic crura to narrow the esophageal hiatus, \u003cstrong\u003eB\u003c/strong\u003e. Methods of reconstructon of angle of His, \u003cstrong\u003eC\u003c/strong\u003e. Effect diagram after reconstruction angle of His, \u003cstrong\u003eD\u003c/strong\u003e. Effect diagram after Dor fundoplication combined with reconstruction of angle of His procedure.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6924682/v1/0326caf6133fd9cb9c5e32d7.png"},{"id":87047195,"identity":"68a5ad1c-0d11-4a03-a71a-cb60811d83be","added_by":"auto","created_at":"2025-07-18 14:40:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2256144,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6924682/v1/3f5b2ba3-0d6b-42ac-8cd2-6710be795071.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medium-term efficacy of laparoscopic Dor fundoplication combined with the reconstruction of angle of His in the treatment of gastroesophageal reflux disease","fulltext":[{"header":"Background","content":"\u003cp\u003eGastro-esophageal reflux disease (GERD) refers to the reflux of gastric and duodenal contents into the esophagus, throat, mouth, respiratory tract and other sites, causing a series of uncomfortable symptoms, signs and complications[\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is currently one of the most common digestive tract diseases[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. As a global disease, GERD is characterized by high incidence rate and high misdiagnosis and mistreatment rate. The course of the disease can last for months to decades, seriously affecting patients' life and work, and has become a major public health problem [[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]].\u003c/p\u003e\u003cp\u003eIn recent decades, laparoscopic antireflux surgery has received increasing attentions. The first laparoscopic Nissen fundoplication was performed and reported by GEAGEa in 1991[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Since then, this surgical procedure has gradually become popular in European and American countries and has become the \"gold standard\" for the treatment of GERD[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. When the surgical indications are strictly controlled and appropriate cases are selected, laparoscopic Nissen fundoplication can achieve definite and good antireflux effects. However, the surgery itself may cause some complications related to digestive tract functions, such as dysphagia, abdominal distension, difficulty to belch, etc. On the premise of not reducing the surgical efficacy, in order to reduce the occurrence of postoperative complications, domestic and foreign scholars have continuously tried new antireflux surgical procedures[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]: (1) modifying the Nissen procedures, such as the Nissen-Rossetti procedure that preserves the short gastric vessels; (2) reducing the circumferential wrapping of the esophagus, that is, partial fundoplication[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], such as the posterior Toupet (270\u0026deg;), the anterior Dor (180\u0026deg;) and 90\u0026deg; fundoplication. Studies have shown that compared with the Nissen procedure, laparoscopic Dor fundoplication can achieve similar antireflux effects, while reducing postoperative complications such as dysphagia and abdominal distension[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAngle of His is the angle between the lower esophagus and the gastric fundus, which is involved in the formation of the gastroesophageal valve and is one of the important antireflux structures. When hiatal hernia (HH) occurs, the structure the angle of His will be damaged, leading to the reduction or disappearance of its antireflux function. Therefore, theoretically, reconstructing the angle of His, meaning restoring the function of the gastroesophageal valve, can play a role in anti-reflux and improving the symptoms and complications of GERD. At present, there is no report on laparoscopic Dor fundoplication combined with reconstruction of angle of His (RAH) in the treatment of GERD in the international literatures. Since January 2019, Department of General Surgery, Xuanwu Hospital, Capital Medical University has explored this surgical procedure, followed up the patients, analyzed the data, and now reports the medium-term follow-up results as follows.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSubjects\u003c/h2\u003e\u003cp\u003eA retrospective analysis was performed on GERD patients who were hospitalized in the General Surgery Department of Xuanwu Hospital of Capital Medical University from January 2019 to June 2022 and received laparoscopic anterior Dor fundoplication combined with RAH (Dor\u0026thinsp;+\u0026thinsp;RAH group, 116 cases) or pure Dor fundoplication (Dor group, 107 cases). All patients underwent pre-operative examinations, such as symptom scoring, upper gastrointestinal endoscopy, high-resolution esophageal manometry (HRM), 24-hour multichannel intraluminal impedance pH (24-h MII-pH) monitoring, and upper gastrointestinal barium meal radiography. This study was approved by the hospital ethics committee, and all patients were informed and signed informed consent forms.\u003c/p\u003e\u003cp\u003eInclusion criteria: ① Age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; ② GERD-related symptoms for \u0026ge;\u0026thinsp;6 months, such as regurgitation, heartburn (burning sensation behind the sternum), non-cardiac chest pain, subxiphoid distension and fullness, cough, wheezing, and pharyngeal foreign body sensation, etc.; ③ GERD was diagnosed by preoperative objective examinations; ④ Achalasia and nutcracker syndrome were excluded by HRM; ⑤ The informed consent form was provided by all patients. Exclusion criteria: ① History of surgery in the esophagus, stomach and other parts; ② patients with esophageal and gastrointestinal malignant tumors; ③ those complicated with severe central nervous system diseases, fibromyalgia, severe coagulation disorders and other diseases; ④ those who could not tolerate surgery due to severe cardiovascular and cerebrovascular diseases, etc.; ⑤ those who refused to participate in the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePreoperative Examinations\u003c/h3\u003e\n\u003cp\u003ePositive diagnostic criteria for esophageal 24-h MII-pH monitoring (Sandhill Scientific, Highlands Ranch, CO, USA) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]: DeMeester scores\u0026thinsp;\u0026ge;\u0026thinsp;14.72, or acid exposure time (AET)\u0026thinsp;\u0026ge;\u0026thinsp;4.2%, or percent bolus exposure time (BET)\u0026thinsp;\u0026ge;\u0026thinsp;1.4%, or total number of reflux episodes\u0026thinsp;\u0026ge;\u0026thinsp;73.\u003c/p\u003e\u003cp\u003eHRM examination: The resting pressure of the lower esophageal sphincter (LES)\u0026thinsp;\u0026lt;\u0026thinsp;13 mmHg was defined as reduced LES pressure (normal reference value: 13\u0026ndash;43 mmHg). HH was diagnosed when the LES pressure zone was separated from the diaphragmatic pressure zone.\u003c/p\u003e\u003cp\u003e Upper gastrointestinal endoscopy: Reflux esophagitis was classified into LA-A、LA-B、LA-C and LA-D according to the Los Angeles (LA) classification criteria. Endoscopic diagnostic criteria for HH: With the patient in the left lateral decubitus position during quiet breathing (avoiding nausea or vomiting), the gastroesophageal junction (Z-line or dentate line) was clearly observed. The distance from the Z-line to the incisors and the distance from the diaphragmatic indentation to the incisors were measured, and the difference between the two distances was calculated. A distance difference\u0026thinsp;\u0026ge;\u0026thinsp;2.0 cm was defined as HH.\u003c/p\u003e\u003cp\u003eThe diagnostic criteria for GERD: Positive diagnosis was made with 24-h MII-pH monitoring indicated GERD, or reflux esophagitis was found with gastroscopy.\u003c/p\u003e\u003cp\u003eThe diagnostic criteria for HH: The diagnosis of HH could be made if HH was found in either HRM or gastroscopy.\u003c/p\u003e\n\u003ch3\u003eSurgical procedure\u003c/h3\u003e\n\u003cp\u003eAll surgeries were performed by the same surgical team. The patient was placed in a supine position with a head-high and foot-low (Split-leg) position at an angle of 30\u0026deg; to 45\u0026deg;. The chief surgeon stood between the patient's legs, the first assistant was on the patient's left side, and the endoscope holder was on the patient's right side. After successful tracheal intubation anesthesia, a conventional five-port method was used to establish observation and operation ports. Once the light source entered the abdominal cavity, the size and type of HH could be roughly observed. The hepatogastric ligament and lesser omentum were transected with a ultrasonic scalpel, the hernia sac was dissected, the esophageal was fully mobilized, the hernia contents were reduced, and the length of the abdominal segment of the esophagus was ensured to be \u0026ge;3 cm without tension. Care was taken to protect the anterior and posterior branches of the vagus nerve. The right and left of diaphragmatic crura were sutured together with 2\u0026thinsp;\u0026minus;\u0026thinsp;0 non-absorbable sutures to narrow the hiatus to an appropriate degree without compressing the esophagus. If the anteroposterior diameter of the hiatus was \u0026ge;\u0026thinsp;5 cm or the diaphragmatic cruras were obviously weak, a patch (Covidien, 8 cm\u0026times;8 cm) was placed at the diaphragmatic crura and fixed with an absorbable stapler.\u003c/p\u003e\u003cp\u003eAnterior Dor Fundoplication with the reconstruction of angle of His: Gastric fundus was mobilized fully and the short gastric vessels could be transected if necessary. The fundus was pulled from the anterior side of the esophagus to the right side of the esophagus, and abdominal segment of the esophagus was wrapped with the fundus with the degree of 180\u0026ndash;200. The folded fundus was sutured and fixed to the esophagus and diaphragm with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 non-absorbable sutures for 3\u0026ndash;4 stitches, and the Dor fundoplication was created. On the left side of the esophagus, the folded fundus was sutured and fixed to the diaphragm with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 non-absorbable sutures, avoiding the inferior phrenic vessels, to complete the reconstruction of angle of His, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eObservation indicators\u003c/h3\u003e\n\u003cp\u003eSymptom scoring: Patients were surveyed using a self-developed questionnaire-based grading symptom scoring system before surgery and 2 years after surgery. Attack frequency score (0\u0026ndash;5 points): 0 points: asymptomatic; 1 point : attack frequency\u0026thinsp;\u0026lt;\u0026thinsp;1 day/week; 2 points : attacks 1\u0026ndash;2 days/week; 3 points : 3\u0026ndash;4 days/week; 4 points: 5\u0026ndash;6 days/week; 5 points: \u0026ge;6 days/week. Symptom severity score (0\u0026ndash;5 points): 0 points: asymptomatic; 1 point: mild symptoms; 2 points: mild discomfort, not affecting daily life or work; 3 points: moderate, affecting daily life and work; 4 points: severe discomfort, causing partial inability to care for oneself; 5 points: extremely severe, life-threatening, causing loss of self-care ability, with a history of one or more rescues. The score of each symptom was the sum of the symptom severity score and the frequency score. Esophageal symptoms included regurgitation, heartburn, non-cardiac chest pain, and a feeling of subxiphoid distension and fullness. Extraesophageal symptoms included cough, wheezing, and pharyngeal foreign body sensation. Postoperative functional complications: dysphagia, abdominal distension, difficulty to belch, increased flatus, chronic abdominal pain, as well as postoperative recurrence and reoperation. The severity of postoperative dysphagia was classified into none, mild, moderate and severe. None dysphagia: no choking sensation when eating solid foods, no need for water; mild dysphagia: obvious choking sensation when eating solid foods, requiring water to relieve symptoms; moderate dysphagia: only able to eat liquid or soft foods, unable to eat solid foods; severe dysphagia: unable to drink water and other liquid food. Satisfaction survey: At 2 years postoperatively, outpatient or telephone follow-up was conducted to assess patients\u0026rsquo; overall satisfaction with surgical efficacy, classified as satisfied, neutral, or dissatisfied.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe SPSS 26.0 statistical software package (IBM, Armonk, NY) was used for data processing. Continuous data were summarized as Mean \u0026plusmn; SD if normally distributed and as median (interquartile rang, IQR) otherwise, and categorical variables were summarized as counts and frequencies. For measurement data that follow a normal distribution, an independent two-sample t-test was used for comparisons between groups. For paired non-normally distributed measurement data, the Wilcoxon signed-rank test was used for comparisons. For two independent samples of non-normally distributed measurement data, the Mann-Whitney U test was used for comparisons. Chi-squared test was used for categorical parameter. All tests of significance were 2-sides, with \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05 considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003ePatient characteristic\u003c/h2\u003e\u003cp\u003eA total of 223 patients were included in the analysis, among whom 116 were in the Dor\u0026thinsp;+\u0026thinsp;RAH group (52 male and 64 female; mean age, 53.98\u0026plusmn;11.68 years) and 107 were in the Dor group (46 male and 61 female; mean age, 54.87\u0026plusmn;11.98 years). There were not significant differences in the ages, body mass index, sex distribution of subjects, distribution of reflux esophagitis, parameters of 24-h MII-pH monitoring and HRM, and implantation rate of patches among two groups (\u003cem\u003eP\u003c/em\u003e \u0026gt;0.05 for all) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of baseline data between two groups of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical Variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDor\u0026thinsp;+\u0026thinsp;RAH group (\u003cem\u003eN\u003c/em\u003e = 116)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDor group (\u003cem\u003eN\u003c/em\u003e = 107)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ/χ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender, (M/F), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52/64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46/61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.782\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (yr), mean\u0026plusmn;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.98\u0026plusmn;11.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.87\u0026plusmn;11.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.811\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e), mean\u0026plusmn;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.4\u0026plusmn;3.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.1\u0026plusmn;4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.521\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReflux esophagitis, n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83(71.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76(71.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.782\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24-h MII-pH monitoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemeester score, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.4 (14.6, 43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.4 (14.6, 41.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.153\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAET (%), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.3 (4.2, 12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.1 (4.1, 11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.098\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.423\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBET (%), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.3 (0.8, 41.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.2 (0.6, 3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-2.413\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.156\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of all reflux episodes, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70 (52, 79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (56, 86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.207\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHRM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResting LES pressure (mmHg), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.1 (3.6, 13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.8 (4.1, 12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.185\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResting UES pressure (mmHg), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.1 (32.1, 83.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.8 (39.8, 80.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-2.371\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.595\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApplication of Mesh (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81(69.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72(67.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eAbbreviations: M/F\u003c/em\u003e male/female, \u003cem\u003eBMI\u003c/em\u003e body mass index, \u003cem\u003eSD\u003c/em\u003e standard deviation, \u003cem\u003e24-h MII-pH\u003c/em\u003e 24-hour multichannel intraluminal impedance pH, \u003cem\u003eIQR\u003c/em\u003e interquartile rang, \u003cem\u003eAET\u003c/em\u003e acid exposure time, \u003cem\u003eBET\u003c/em\u003e bolus exposure time, \u003cem\u003eHRM\u003c/em\u003e high resolution manometry, \u003cem\u003eLES\u003c/em\u003e lower esophageal sphincter, \u003cem\u003eUES\u003c/em\u003e upper esophageal sphincter, \u003cem\u003eDor\u0026thinsp;+\u0026thinsp;RAH\u003c/em\u003e Dor fundoplication combined with reconstruction of angle of His.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eComparison of reflux symptom scores\u003c/h3\u003e\n\u003cp\u003eThere was no significant difference in the preoperative esophageal symptoms (regurgitation, heartburn, chest pain, and subxiphoid distension and fullness) and extraesophageal symptoms (cough, wheezing, and pharyngeal foreign body sensation) between the two groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. At 2 years postoperatively, the scores of esophageal symptoms and extraesophageal symptoms in both groups were significantly lower than those before surgery (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The scores of postoperative regurgitation and heartburn symptoms in the Dor\u0026thinsp;+\u0026thinsp;RAH group were lower than those in the Dor group, with significant differences (Z=-3.735, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Z=-2.736, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006). However, there was no significant difference in the scores of other symptoms (chest pain, subxiphoid distension and fullness, cough, wheezing, and pharyngeal foreign body sensation) between the two groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of preoperative GERD symptom scores between two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom scores, median (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDor\u0026thinsp;+\u0026thinsp;RAH (\u003cem\u003eN\u003c/em\u003e = 116)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDor group (\u003cem\u003eN\u003c/em\u003e = 107)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEsophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(6, 7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.255\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.209\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart burn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.753\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(0, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.567\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.571\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubxiphoid distension and fullness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.5(0, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.256\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.798\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtraesophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.997\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.319\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheezing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.776\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.076\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharyngeal foreign body sensation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.261\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eAbbreviations: GERD\u003c/em\u003e gastro-esophageal reflux disease, \u003cem\u003eIQR\u003c/em\u003e interquartile rang, \u003cem\u003eDor\u0026thinsp;+\u0026thinsp;RAH\u003c/em\u003e Dor fundoplication combined with reconstruction of angle of His.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSymptom scores of patients in both groups before and after antireflux surgery\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom scores, median (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBefore surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAfter surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDor\u0026thinsp;+\u0026thinsp;RAH group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEsophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-13.298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart burn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-13.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(0, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-5.276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubxiphoid distension and fullness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.5(0, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-5.851\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtraesophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 1.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.814\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheezing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.820\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharyngeal foreign body sensation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-5.970\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDor group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEsophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-11.794\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart burn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(6, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-5.811\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.734\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubxiphoid distension and fullness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtraesophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.604\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheezing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.974\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharyngeal foreign body sensation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eAbbreviations:IQR\u003c/em\u003e interquartile rang, \u003cem\u003eDor\u0026thinsp;+\u0026thinsp;RAH\u003c/em\u003e Dor fundoplication combined with reconstruction of angle of His.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of postoperative GERD symptom scores between two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom scores, median (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDor\u0026thinsp;+\u0026thinsp;RAH group (\u003cem\u003eN\u003c/em\u003e = 116)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDor group (\u003cem\u003eN\u003c/em\u003e = 107)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEsophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.5(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.735\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart burn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-2.736\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.379\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubxiphoid distension and fullness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.592\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.554\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtraesophageal symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 1.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.927\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.354\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheezing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharyngeal foreign body sensation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.984\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eAbbreviations: GERD\u003c/em\u003e gastro-esophageal reflux disease, \u003cem\u003eIQR\u003c/em\u003e interquartile rang, \u003cem\u003eDor\u0026thinsp;+\u0026thinsp;RAH\u003c/em\u003e Dor fundoplication combined with reconstruction of angle of His.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eComparison of the occurrence of functional complications\u003c/h2\u003e\u003cp\u003eWithin 2 weeks after surgery, 93.3% of patients experienced dysphagia. The incidence was 92.2% (107/116) in the Dor\u0026thinsp;+\u0026thinsp;RAH group and 94.3% (101/107) in the Dor group, with no significant difference between the two groups (χ\u0026sup2;=0.411, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.522). With dietary guidance, all patients showed significant improvement in dysphagia symptoms, and all patients were able to transition to a semi-liquid diet at 2 months postoperatively. At 2 years postoperatively, no moderate dysphagia was observed in either group, and all patients could eat soft food smoothly. None of the patients required endoscopic esophageal dilation or secondary surgery.\u003c/p\u003e\u003cp\u003eAt 1 month postoperatively, the incidence rates of abdominal distension, difficulty to belch, increased flatus, and chronic abdominal pain were 11.2%, 10.2%, 6.2%, and 2.1%, respectively. With dietary guidance, lifestyle modifications, and medication, all of the above symptoms were significantly alleviated in patients at 2 years postoperatively.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eComparison of of satisfaction\u003c/h2\u003e\u003cp\u003eAt 2 years postoperatively, 106 patients in the Dor\u0026thinsp;+\u0026thinsp;RAH group were satisfied with the overall surgical efficacy, 7 had neutral opinions, and 3 were dissatisfied. In the Dor group, 96 patients were satisfied, 7 had neutral opinions, and 4 were dissatisfied. The satisfaction rate with surgical treatment was 91.4% (106/116) in the Dor\u0026thinsp;+\u0026thinsp;RAH group and 89.7% (96/107) in the Dor group, with no significant difference between the two groups (χ\u0026sup2; =0.18, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.672).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eComparison of perioperative mortality, severe complications, and reoperation rates\u003c/h2\u003e\u003cp\u003eAll patients had no conversion to laparotomy, and no severe complications such as massive hemorrhage, gastrointestinal perforation, hepatic or splenic rupture, or death occurred. All patients successfully weaned from the ventilator, had their tracheal intubation removed, and were safely transferred back to the general ward after surgery. At 2 years postoperatively, all patients had no symptomatic or anatomical recurrence, and no reoperation was performed.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSince the clinical application of laparoscopic fundoplication in 1991, numerous studies have confirmed its effectiveness, safety, and long-term efficacy in treating GERD[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The ultimate goal of modifying and evolving anti-reflux surgical procedures is to reduce the occurrence of postoperative complications such as dysphagia while ensuring surgical efficacy. BROEDERS \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]reported that laparoscopic anterior Dor fundoplication achieved similar 5-year anti-reflux effects compared to the Nissen procedure, while reducing the incidence of postoperative complications. The results of our study showed that anti-reflux surgery could significantly improve both esophageal and extra-esophageal symptoms in GERD patients, significantly improve quality of life, and achieve an overall satisfaction rate of approximately 90% with surgical efficacy, consistent with other research findings[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It is important to note that this study adopted subxiphoid distension and fullness as an symptom parameter. This symptom is often a clinical manifestation of HH, caused by the compression of the gastric fundus or body by the bilateral diaphragmatic crura during HH formation. It has a high incidence in HH patients and causes significant distress, but has not been mentioned in previous studies.In this study, the incidence of dysphagia during the perioperative period (within 2 weeks postoperatively) was 93.3% (208/223), with similar rates in both groups (92.2% vs. 94.3%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.522). All patients showed significant improvement in dysphagia symptoms through dietary guidance. At 2 months postoperatively, all patients could transition to a semi-liquid diet, and at 2 years postoperatively, there was no moderate dysphagia, with all patients able to eat soft food smoothly. During the follow-up period, none of the patients underwent endoscopic esophageal dilation or reoperation due to dysphagia. Postoperative dysphagia is one of the most common postoperative complications. In addition to considering different surgical procedures (Nissen, Toupet, Dor), selection of width of fundoplication flap (short-loose or wide-loose fundoplication)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and application of other auxiliary techniques (such as intraoperative bougie dilation of the esophagogastric junction)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the authors believe that thorough preoperative explanation and communication, as well as reasonable postoperative dietary guidance, also help alleviate patients' fear of dysphagia. On one hand, surgeons should strive to avoid severe postoperative dysphagia, and on the other hand, patients should understand the surgical process, the principles of anti-reflux surgery, and the physiological evolution of the surgical site (fundoplication area) postoperatively. This helps patients to understand the causes of dysphagia and accept mild dysphagia more easily, further improving their compliance and satisfaction with surgical treatment. Additionally, there are significant differences in the selection of surgical indications for GERD, surgical techniques, choice of surgical approaches, and overall patient management across different treatment centers, leading to large variations in treatment efficiency, recurrence rates, and patient satisfaction[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, comprehensive preoperative evaluation (including HRM, 24-h MII-pH monitoring, and other specific diagnostic tools), standardized diagnosis and treatment processes, and GERD centers with certain treatment experience are crucial for improving the level of individualized treatment for GERD patients[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe His angle, also known as cardiac incisure, or esophagogastric angle, is the angle between the lower esophagus and the gastric fundus. The left wall of the abdominal esophagus connects to the gastric fundus, forming the angle of His at this junction, which is one of the important anti-reflux structures and participates in the formation of the gastroesophageal valve flap. In patients with HH, the angle of His significantly increases or even disappears, causing the gastroesophageal valve flap to shrink or disappear, weakening or losing its anti-reflux function[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In view of this, this study reconstructed the angle of His during routine fundoplication to explore its anti-reflux effect. The results showed that the Dor fundoplication combined with RAH could further improved regurgitation and heartburn symptoms compared to pure fundoplication, which indicated fundoplication with RAH had better anti-reflux efficacy, while not increasing the incidence of surgical complications. Based on our surgical operational experience and insights, the reasons why the reconstruction of angle of His synergistically enhances anti-reflux effects, we analyze the possible reasons as follows: (1) After angle of His is reconstructed, the gastroesophageal valve flap structure is restored, strengthening its anti-reflux function. (2) During the process of the reconstruction of angle of His, the fundus used for plication is sutured and fixed to the diaphragm (as shown in the Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), which reduces tension on the fundoplication flap and fixes the flap, thus stabilizing the flap's shape and reducing the recurrence of HH.\u003c/p\u003e\u003cp\u003eThere are very few research reports on the application of RAH for the treatment of GERD. Previous reports have mentioned the use of RAH in the treatment of achalasia [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], partial gastrectomy [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], sleeve gastrectomy[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], etc., with results showing that RAH can alleviate or prevent the occurrence of GERD-related symptoms after surgery. In 2022, Zhang[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] reported that laparoscopic RAH had anti-reflux effects similar to fundoplication, and had advantages such as less operative time, less intraoperative blood loss, shorter postoperative hospital stay, and fewer surgical complications. It should be noted that this study evaluated pure RAH, not fundoplication with RAH. Additionally, the method of RAH in this study is to fix the gastric fundus to the left wall of the abdominal esophagus, which is different from our method (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study explored the anti-reflux effect of laparoscopic Dor fundoplication with RAH. During clinical practice, the authors summarized several key points for the operation of the procedure: (1) Non-absorbable sutures were used for suture. The needle insertion point on the gastric fundus was selected at the highest point of the folded fundus. Before inserting the needle, the fundus was everted to avoid bulky and redundant tissues from filling between the fundus and the esophagus, so as to reduce the occurrence of postoperative discomfort symptoms such as dysphagia and abdominal distension; (2) The needle insertion point on the diaphragm was selected at the left anterior side of the esophagus, avoiding the subphrenic blood vessels, so that the reconstructed angle of His could form a smaller and deeper acute angle, making the anti-reflux effect of the gastroesophageal valve flap more obvious (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere were some limitations in our study. First, In the postoperative follow-up, there were not objective data evaluations, such as gastroscopy, 24-h MII-pH monitoring, and HRM, which may cause bias in the research results. Second, this study was a retrospective, single-center, medium-term follow-up result with a limited sample size, and the research results need to be verified by prospective, multi-center, large-sample, and long-term follow-up data.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study preliminarily found that compared with pure laparoscopic Dor fundoplication, Dor fundoplication combined with RAH has a better anti-reflux effect and does not increase the occurrence of postoperative gastrointestinal functional complications. It is worthy of further exploration and verification of its therapeutic value for GERD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGERD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGastro-esophageal reflux disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRAH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ereconstruction of angle of His\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHiatus hernia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHRM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHigh-resolution manometry\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e24-h MII-pH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e24-hour multichannel intraluminal impedance pH\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAET\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcid exposure time\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBET\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBolus exposure time\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLES\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLower esophageal sphincter\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003estandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003einterquartile rang.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no funding for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated and analyzed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final version of the manuscript, including the authorship. Study concept and design: XD, HYD, and DGL; acquisition of data: XD, HYD, HJD, YPR, and DGL; analysis and interpretation of data: XD, HYD, DGL; manuscript draft: XD, HYD, HJD; critical revision of the manuscript for important intellectual content: XD, HYD, DGL, and YPR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have declared that no competing interests exist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for this study was obtained from the institutional review boards of Xuanwu Hospital, Capital Medical University (Beijing, China), and written informed consent was acquired from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing 100053, China. \u003csup\u003e2\u003c/sup\u003eDepartment of General Surgery, Xiong an Xuan Wu Hospital, Hebei 071800, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePhillips HR, Kamboj AK, Leggett CL. 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LANGENBECK ARCH SURG. 2023; 408(1):269.\u003c/li\u003e\n \u003cli\u003eAnalatos A, Lindblad M, Ansorge C, Lundell L, Thorell A, Hakanson BS. Total versus partial posterior fundoplication in the surgical repair of para-oesophageal hernias: randomized clinical trial. BJS OPEN. 2022; 6(3).\u003c/li\u003e\n \u003cli\u003eBroeders JA, Roks DJ, Ahmed Ali U, Watson DI, Baigrie RJ, Cao Z, Hartmann J, Maddern GJ. Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. ANN SURG. 2013; 257(5):850-59.\u003c/li\u003e\n \u003cli\u003eBroeders JA, Broeders EA, Watson DI, Devitt PG, Holloway RH, Jamieson GG. Objective outcomes 14 years after laparoscopic anterior 180-degree partial versus nissen fundoplication: results from a randomized trial. ANN SURG. 2013; 258(2):233-39.\u003c/li\u003e\n \u003cli\u003eDu X, Wang F, Hu Z, Wu J, Wang Z, Yan C, Zhang C, Tang J. 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ANN SURG. 2012; 255(4):637-42.\u003c/li\u003e\n \u003cli\u003eTrepanier M, Dumitra T, Sorial R, Siblini A, Vassiliou M, Fried GM, Feldman LS, Ferri LE, Lee L, Mueller CL. Comparison of Dor and Nissen fundoplication after laparoscopic paraesophageal hernia repair. SURGERY. 2019; 166(4):540-46.\u003c/li\u003e\n \u003cli\u003eLee Y, Tahir U, Tessier L, Yang K, Hassan T, Dang J, Kroh M, Hong D. Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials. SURG ENDOSC. 2023; 37(7):5052-64.\u003c/li\u003e\n \u003cli\u003eRaiser F, Hinder RA, McBride PJ, Katada N, Filipi CJ. The technique of laparoscopic Nissen fundoplication. Chest Surg Clin N Am. 1995; 5(3):437-48.\u003c/li\u003e\n \u003cli\u003eAmundson JR, Kuchta K, Zimmermann CJ, VanDruff VN, Joseph S, Che S, Ishii S, Hedberg HM, Ujiki MB. Target distensibility index on impedance planimetry during fundoplication by choice of wrap and choice of bougie. SURG ENDOSC. 2023; 37(11):8670-81.\u003c/li\u003e\n \u003cli\u003eSeok D, Kaushik M, Jacobs M. Routine Intraoperative Use of Esophageal Bougie in Minimally Invasive Hiatal Hernia Repair is Not Necessary. JSLS-J SOC LAPAROEND. 2022; 26(4).\u003c/li\u003e\n \u003cli\u003eBonavina L. Individualizing the choice of surgical therapy for gastroesophageal reflux disease. CURR OPIN GASTROEN. 2025; 41(4):245-50.\u003c/li\u003e\n \u003cli\u003eWalle KV, Funk LM, Xu Y, Davies KD, Greenberg J, Shada A, Lidor A. Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication. J SURG RES. 2019; 235:52-57.\u003c/li\u003e\n \u003cli\u003eZimmermann CJ, Kuchta K, Amundson JR, VanDruff VN, Joseph S, Che S, Hedberg HM, Ujiki M. Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes. SURG ENDOSC. 2024; 38(6):3273-8.\u003c/li\u003e\n \u003cli\u003eZhang S, Joseph AA, Gross L, Ghadimi M, Frahm J, Beham AW. Diagnosis of Gastroesophageal Reflux Disease Using Real-time Magnetic Resonance Imaging. SCI REP-UK. 2015; 5:12112.\u003c/li\u003e\n \u003cli\u003eMichael S, Marom G, Brodie R, Salem SA, Fishman Y, Shein GS, Helou B, Pikarsky AJ, Mintz Y. The Angle of His as a Measurable Element of the Anti-reflux Mechanism. J GASTROINTEST SURG. 2023; 27(11):2279-86.\u003c/li\u003e\n \u003cli\u003eBalakrishna P, Parshad R, Rohila J, Saraya A, Makharia G, Sharma R. Symptomatic outcome following laparoscopic Heller\u0026apos;s cardiomyotomy with Dor fundoplication versus laparoscopic Heller\u0026apos;s cardiomyotomy with angle of His accentuation: results of a randomized controlled trial. SURG ENDOSC. 2015; 29(8):2344-51.\u003c/li\u003e\n \u003cli\u003eTomita R. 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CHINESE MED J-PEKING. 2022; 135(14):1750-2.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gastro-esophageal reflux disease, Fundoplication, Angle of His, Reconstruction, Efficacy","lastPublishedDoi":"10.21203/rs.3.rs-6924682/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6924682/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eGastroesophageal reflux disease (GERD)is currently one of the most common digestive tract diseases. There is no report on laparoscopic fundoplication combined with reconstruction of angle of His (RAH) in the treatment of GERD. Thus, this study aimed to investigate the medium-term efficacy of laparoscopic Dor fundoplication combined with RAH for GERD patients.\u003cbr\u003e\n \u003cstrong\u003eMethods\u003c/strong\u003e Clinical data of GERD patients who underwent Dor fundoplication combined with RAH (Dor+RAH group, 116 cases) or Dor fundoplication (Dor group, 107 cases) in Department of General Surgery, Xuanwu Hospital, Capital Medical University from January 2019 to June 2022 were retrospectively analyzed. Esophageal and extraesophageal symptom scores, functional complications, and patient satisfaction were compared between the two groups after two years postoperatively.\u003cbr\u003e\n \u003cstrong\u003eResults\u003c/strong\u003e There was no significant difference in esophageal and extraesophageal symptom scores between the two groups before surgery (all \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05). At 2 years postoperatively, esophageal and extraesophageal symptom scores of both two groups decreased significantly compared with those preoperatively (all \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01). In the 2-year postoperative symptom scores, the scores for regurgitation and heartburn in the Dor+RAH group were lower than those in the Dor group, with statistically significant differences (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01, \u003cem\u003eP\u003c/em\u003e=0.006), while there were no significant differences in other symptom scores between the two groups (all \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05). The incidences of postoperative functional complications (including dysphagia, abdominal distension, difficulty to belch, increased flatus, and chronic abdominal pain) were similar in both groups, and all were significantly relieved by conservative treatment. The patient satisfaction rate with surgical treatment was 92.2% (107/116) in the Dor+RAH group, showing no significant difference from 90.7% (97/107) in the Dor group (\u003cem\u003eP\u003c/em\u003e=0.671).\u003cbr\u003e\n \u003cstrong\u003eConclusions:\u003c/strong\u003e Both Dor fundoplication combined with RAH and pure Dor fundoplication demonstrate good anti-reflux effects in treating GERD, with few surgical complications and high patient satisfaction. Compared with Dor fundoplication, Dor fundoplication with RAH has a better effect in controlling regurgitation and heartburn symptoms, indicating it may have a better therapeutic effect for GERD patients.\u003c/p\u003e","manuscriptTitle":"Medium-term efficacy of laparoscopic Dor fundoplication combined with the reconstruction of angle of His in the treatment of gastroesophageal reflux disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 14:16:15","doi":"10.21203/rs.3.rs-6924682/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-08T15:57:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T11:29:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333737144750237793626097983412430737541","date":"2026-01-22T14:21:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43083470962159001356607822945018188035","date":"2026-01-22T08:28:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T15:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116042088573711246764425155446414600889","date":"2025-07-21T07:09:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98535820031227675911873124615692821096","date":"2025-07-14T17:32:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T17:21:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-23T14:21:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-20T00:16:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-20T00:15:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-06-18T15:51:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"792dd39f-a15c-41ea-b5d1-13841c034ff1","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T09:40:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-18 14:16:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6924682","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6924682","identity":"rs-6924682","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}