Systematic review and meta-analysis of laparoscopic Nissen (posterior total)versusToupet (posterior partial) fundoplication for gastro-oesophageal reflux disease

Abstract

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. 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. 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. 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.