Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility

• Published in: Surgical endoscopy Vol. 22; no. 1; pp. 21 - 30
• Main Authors: Strate, U., Emmermann, A., Fibbe, C., Layer, P., Zornig, C.
• Format: Journal Article
• Language: English
• Published: New York Springer-Verlag 01-01-2008; Springer; Springer Nature B.V
• Subjects: Abdominal Surgery; Adult; Aged; Aged, 80 and over; Biological and medical sciences; Digestive system. Abdomen; Endoscopy; Esophageal Motility Disorders - diagnosis; Esophageal Motility Disorders - surgery; Esophagoscopy - methods; Female; Follow-Up Studies; Fundoplication - adverse effects; Fundoplication - methods; Gastric Acidity Determination; Gastroenterology; Gastroesophageal Reflux - diagnosis; Gastroesophageal Reflux - surgery; Gynecology; Hepatology; Humans; Hydrogen-Ion Concentration; Investigative techniques, diagnostic techniques (general aspects); Laparoscopy - adverse effects; Laparoscopy - methods; Male; Manometry - methods; Medical sciences; Medicine; Medicine & Public Health; Middle Aged; Postoperative Care; Probability; Proctology; Prospective Studies; Recurrence; Reference Values; Reoperation; Risk Assessment; Severity of Illness Index; Statistics, Nonparametric; Surgery; Treatment Outcome; Abdominal; GERD; GORD; Human; Motility; Prognosis; Laparoscopy; Abdomen; Esophagus; Nissen operation; Endoscopy; Preoperative; Comparative study
• ISSN: 0930-2794; 1432-2218
• DOI: 10.1007/s00464-007-9546-8

Objective
To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures.
Summary background data
Nissen fundoplication (360°) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270°) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia).
Methods
200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry.
Results
After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication compared to Toupet (19 vs. 8,
p
< 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the Nissen procedure.
Conclusion
Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good as the Nissen fundoplication in controlling reflux.