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From the medical perspective, "refractory" gastroesophageal reflux disease (GERD) is symptomatic pathologic acid reflux that is not responsive to medical management, usually in the form of proton pump inhibitors (PPI). The basis of this approach is not to eliminate volume reflux, but to make reflux imperceptible by eliminating the stomach's ability to produce acid. Refractory, in this view, means that elimination of gastric acid does not lead to elimination of symptoms. GERD is protean in its manifestations and severity, both from the standpoint of symptoms, but also pathological manifestations, such as esophagitis, Barrett's esophagus, and eventual esophageal adenocarcinoma. The constellation of GERD manifestations, both typical and atypical, can have varying effects on the patient's quality of life. 1 Most quality of life decline is generally driven by symptoms, however other aspects can also contribute, such as the need to take medication indefinitely, medications' possible untoward effects, and concerns about neoplasia development. The only way to truly "cure" both acid and volume reflux is surgical. Therefore, from the surgical perspective, refractory GERD is diagnosed in the patient for whom reflux has produced such a detriment in their quality of life that they wish something more than medication.The purpose of this article is to discuss who should be considered for anti-reflux surgery (ARS), selection of operation, and pitfalls in patient selection. Our opinion is informed by our multidisciplinary approach to esophageal and swallowing disorders at the Joy McCann Culverhouse Center for Swallowing Disorders at the