Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease.
BACKGROUND
Laparoscopic Nissen fundoplication (LNF) is currently considered the surgical approach of choice for gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) has been said to reduce troublesome dysphagia and gas-related symptoms. A systematic review and meta-analysis of randomized clinical trials (RCTs) was performed to compare LNF and LTF.


METHODS
Four electronic databases (MEDLINE, Embase, Cochrane Library and ISI Web of Knowledge CPCI-S) were searched and the methodological quality of included trials was evaluated. Outcomes included recurrent pathological acid exposure, oesophagitis, dysphagia, dilatation for dysphagia and reoperation rate. Results were pooled in meta-analyses as risk ratios (RRs) and weighted mean differences.


RESULTS
Seven eligible RCTs comparing LNF (n = 404) with LTF (n = 388) were identified. LNF was associated with a significantly higher prevalence of postoperative dysphagia (RR 1.61 (95 per cent confidence interval 1.06 to 2.44); P = 0.02) and dilatation for dysphagia (RR 2.45 (1.06 to 5.68); P = 0.04). There were more surgical reinterventions after LNF (RR 2.19 (1.09 to 4.40); P = 0.03), but no differences regarding recurrent pathological acid exposure (RR 1.26 (0.82 to 1.95); P = 0.29), oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40), subjective reflux recurrence, patient satisfaction, operating time or in-hospital complications. Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009) and gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001) were more prevalent after LNF.


CONCLUSIONS
LTF reduces postoperative dysphagia and dilatation for dysphagia compared with LNF. Reoperation rate and prevalence of gas-related symptoms were lower after LTF, with similar reflux control. These results provide level 1a support for the use of LTF as the posterior fundoplication of choice for GORD.
Broeders
J A J L
JA
Department of Surgery, Gastrointestinal Research Unit of the University Medical Center Utrecht, Utrecht, The Netherlands.
Mauritz
F A
FA
Ahmed Ali
U
U
Draaisma
W A
WA
Ruurda
J P
JP
Gooszen
H G
HG
Smout
A J P M
AJ
Broeders
I A M J
IA
Hazebroek
E J
EJ
D003680:Deglutition Disorders / Q000209:etiology; D004884:Eructation / Q000209:etiology; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012086:Reoperation / Q000706:statistics & numerical data; D016896:Treatment Outcome