Concept of High Resistance and Low Resistance Fundoplication: The Nissen Fundoplication has a clear mechanical effect on the LES. By lowering the position of the Gastro-esophageal junction and increasing the intra-abdominal length of the lower esophagus, it increases the LES resting pressure accordingly. Consequently, with a normal Nissen of 2.0 to 2.5 cm in length, adequate resting LES pressure will be restored in most patients. In patients with decreased primary esophageal motility (decreased propulsion across the LES), the LES resting pressure should be lower thus a "low resistance" Nissen Fundoplication (1 cm in length) or a Toupet Fundoplication  will be constructed. Such procedure can also be performed on patients with endstage gastro-esophageal reflux (stricture, Barrett's) who usually have associated decreased motility.