OBJECTIVE Failure of conventional surgical therapy for treatment of patients with gastroesophageal reflux disease (GERD) taxes the ingenuity of the esophageal surgeon. This study defines the role of vagotomy, antrectomy, and Roux-en-Y diversion coupled, when necessary, with resection of the esophagogastric junction as an alternative to other surgical procedures currently employed for these complicated cases. BACKGROUND Currently, the operation in question rarely is performed in the United States. Other procedures, such as interposition of short or long segments of intestine and total esophagectomy with gastric pull-up, are preferred. However, surgeons from Scandinavia, Great Britain, and Europe have published widely on the subject, some even preferring its use as a primary procedure in GERD. METHODS This report reviews the indications and results of the operation in 36 patients who underwent operation between January 1970 and January 1994. Follow-up evaluation was available for review in 33 patients observed from 1 to 20 years postoperatively (average, 6 2/3 years). Of these patients, 32 had undergone 66 previous operative procedures on the distal esophagus and stomach ranging from 1 to 6 per patient. There were no hospital deaths, but complications developed in nine patients (25%); only half of these complications were major. Of patients available for follow-up, 85% were improved by the operation, 24 of the 33 having excellent or good results. CONCLUSIONS The operation of vagotomy, antrectomy, and Roux-en-Y diversion, embodying the principles of acid suppression and alkaline diversion, has proved to be a successful alternative to other operative procedures currently favored in the United States for the treatment of the complex reoperative patient with GERD.