title: Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial fundoplication?
abstract: BACKGROUND
  It has been proposed that partial fundoplication is associated with less incidence of postoperative dysphagia and consequently is more suitable for patients with gastroesophageal reflux disease (GERD) and impaired esophageal body motility. The aim of this study was to assess whether outcomes of Toupet fundoplication (TF) are better than those of Nissen-Rossetti fundoplication (NF) in patients with GERD and low-amplitude esophageal peristalsis.
  
  
  METHODS
  Thirty-three consecutive patients with proved GERD and amplitude of peristalsis at 5 cm proximal to lower esophageal sphincter (LES) less than 30 mmHg were randomly allocated to undergo either TF (19 patients: 11 men, 8 women; mean age: 61.7 +/- 8.7 SD years) or NF (14 patients: 7 men, 7 women; mean age: 59.2 +/- 11.5 years), both by the laparoscopic approach. Pre- and postoperative assessment included clinical questionnaires, esophageal radiology, esophageal transit time study, endoscopy, stationary manometry, and 24-hour ambulatory esophageal pH testing.
  
  
  RESULTS
  Duration of operation was significantly prolonged in the TF arm (TF: 90 +/- 12 minutes versus NF: 67 +/- 15 minutes; p < 0.001). At 3 months postoperatively, the incidences of dysphagia (grades I, II, III) and gas-bloat syndrome were higher after NF than after TF (NF: 57% versus TF: 16%; p < 0.01 and NF: 50% versus TF: 21%; p = 0.02, respectively), but decreased to the same level in both groups at the 1-year followup (NF: 14% versus TF: 16% and NF: 21% versus TF: 16%, respectively). At 3 months postoperatively, patients with NF presented with significantly increased LES pressure than those with TF (p = 0.02), although LES pressure significantly increased after surgery in both groups, as compared with preoperative values. Amplitude of esophageal peristalsis at 5 cm proximal to LES increased postoperatively to the same extent in both groups (TF, preoperatively: 21 +/- 6 mmHg versus postoperatively: 39 +/- 12 mmHg; p < 0.001, and NF, preoperatively: 20 +/- 8 mmHg versus postoperatively: 38 +/- 12 mmHg; p < 0.001). Reflux was abolished in all patients of both groups.
  
  
  CONCLUSIONS
  Both TF and NF efficiently control reflux in patients with GERD and low amplitude of esophageal peristalsis. Early in the postoperative period, TF is associated with fewer functional symptoms, although at 1 year after surgery those symptoms are reported at similar frequencies after either procedure.
authors.affiliation: Unit of Gastrointestinal Surgery and the Laboratory of Gastrointestinal Motility, University Hospital of Heraklion, Medical School, University of Crete, Greece.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Chrysos
authors.forename: John
authors.initials: J
authors.lastname: Tsiaoussis
authors.forename: Odysseus John
authors.initials: OJ
authors.lastname: Zoras
authors.forename: Elias
authors.initials: E
authors.lastname: Athanasakis
authors.forename: Apostolos
authors.initials: A
authors.lastname: Mantides
authors.forename: Asterios
authors.initials: A
authors.lastname: Katsamouris
authors.forename: Evaghelos
authors.initials: E
authors.lastname: Xynos
mesh_terms: D016009:Chi-Square Distribution; D003680:Deglutition Disorders / Q000453:epidemiology; D004947:Esophagus / Q000503:physiopathology*; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000503:physiopathology* / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010528:Peristalsis; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D016896:Treatment Outcome