title: Is Toupet fundoplication the procedure of choice for treating gastroesophageal reflux disease? Results of a prospective randomized experimental trial comparing three major antireflux operations in a porcine model.
abstract: BACKGROUND
  Gastroesophageal reflux disease (GERD) is among the most common dysfunctions of the upper gastrointestinal tract. It interferes with quality of life and is a risk factor for the development of adenocarcinoma in the lower esophagus. Laparoscopic fundoplication is an effective treatment of GERD, but the physiologic mechanisms of the different available procedures had not been investigated to date.
  
  
  METHODS
  In this study, 28 German Landrace pigs underwent baseline manometry and 24-h pH monitoring followed by myotomy to induce reflux esophagitis. After new-onset reflux was proved, the pigs were randomized to groups based on four treatments: total fundoplication, anterior hemifundoplication, posterior hemifundoplication, and control. On days 10 and 60 after the intervention, the effectiveness of the different fundoplication modifications was compared with that of the control subjects by 24-h pH monitoring manometry. Finally, the pigs were killed, after which the minimum volume and pressure required to breach the gastroesophageal junction were recorded.
  
  
  RESULTS
  After myotomy, a significant increase in the reflux could be confirmed. The findings after fundoplication showed a significant decrease in the fraction of time that the pH fell below four and an increase in the vector volume compared with the measurement after myotomy. Total fundoplication and posterior hemifundoplication were highly effective, whereas measurements after anterior fundoplication still showed increased fraction times. Pharmacologic stimulation with pentagastrin showed an increase in the vector volume of the esophageal sphincter.
  
  
  CONCLUSIONS
  Total fundoplication and posterior hemifundoplication are potent operations for the treatment of GERD. Anterior hemifundoplication reduces the reflux as well, but the effects are significantly less than with total and posterior fundoplication. Pharmacologic stimulation showed excellent results after posterior hemifundoplication, and a tendency to overcorrection was shown after total fundoplication.
authors.affiliation: Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Bachmann
authors.forename: R
authors.initials: R
authors.lastname: Wachowiak
authors.forename: C
authors.initials: C
authors.lastname: Rempf
authors.forename: Y
authors.initials: Y
authors.lastname: Vashist
authors.forename: O
authors.initials: O
authors.lastname: Mann
authors.forename: E F
authors.initials: EF
authors.lastname: Yekebas
authors.forename: J R
authors.initials: JR
authors.lastname: Izbicki
authors.forename: K A
authors.initials: KA
authors.lastname: Gawad
mesh_terms: D000704:Analysis of Variance; D000818:Animals; D004195:Disease Models, Animal; D050782:Esophageal pH Monitoring; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D008365:Manometry; D011446:Prospective Studies; D011897:Random Allocation; D013552:Swine