A Long-Term Randomized Prospective Trial of the Nissen Procedure Versus a Modified Toupet Technique

Abstract

Thirty-one patients about to undergo surgery for gastroesophageal reflux were randomized into either a Nissen fundoplication group (12) or a modified Toupet semifundoplication group (19). All patients were followed on a long-term basis for 5 years with a standard questionnaire, endoscopy, and manometry. Ninety-five percent of the patients in the modified Toupet group had good or excellent results versus 67% for the Nissen group. However both procedures are effective in curtailing esophagitis with an improvement of the endoscopic grading in the Nissen group by 91% and 89% in the group undergoing the modified Toupet procedure. A significant improvement in symptoms (acid regurgitation, heartburn, retrosternal pain) was noted in both groups, except for dysphagia in the Nissen group. Three patients with a Nissen fundoplication had a slipped Nissen requiring reoperation and two had gas-bloat syndrome. These specific complications of the Nissen procedure were not found in the modified Toupet group.

Evidence-Based Appraisal of Antireflux Fundoplication

“…98,99 In this analysis (Table 6), partial fundoplication appeared to be a better procedure than total fundoplication, showing similar operative time, morbidity and recurrence rates, but a significantly reduced rate of reoperations for failure (1.6% versus 9.6%), mainly due to postoperative dysphagia (10.1% versus 16.8%). All but 3 RCTs 45,46,54 showed an equal distribution of patients with esophageal motility disorders in this analysis (Table 5). In the most recent trial, 58 a subgroup analysis in patients with esophageal motility disorders failed to detect any difference in the occurrence of postoperative new-onset dysphagia and/or endoscopic evidence of recurrent disease.…”

“…Six dealt with open fundoplication: 1 from Honolulu, USA; 44 1 multicenter from France; 45 1 from Stockolm, 46 and another from Goteborg, [47][48][49][50][51][52] Sweden; 1 from Liverpool, UK; 53 and 1 from Santiago, Chile. 54 The remaining 3 trials dealt with laparoscopic fundoplication: from Birmingham, USA; 55 from Adelaide, Australia; 56 and from Hamburg, Germany.…”

Long-Term Comparison of Antireflux Surgery Versus Conservative Therapy for Reflux Esophagitis

“…At follow-up of these 37 patients, (31) 84% had no or only occasional mild heartburn, (33) 89% were free from erosive esophagitis, and (2) 5% were taking H2 antagonists or omeprazole. The corresponding figures in the 68 patients with only conservative treatment were (36) 53%, (31) 45%, and (14) 21 %. The mean change in symptom score between referral time and follow-up was 5.7 in the surgically treated group and 1.7 in the nonsurgically treated group.…”

“…Two patients with fundoplication occasionally used H2 antagonists for reflux symptoms, and endoscopy showed the fundic wrap to be defective in both cases. Of the 68 conservatively treated patients, 14 (21%) used omeprazole or H2 antagonists regularly and 22 (33%) occasionally because of reflux symptoms. Of the six patients who declined to attend, three were using H2 antagonists daily.…”

Surgical treatment of gastroesophageal reflux disease: total or partial fundoplication? Systematic review and meta-analysis

“…Three studies were excluded by exclusion criteria: one study in children (10) , one comparing Hill fundoplication (7) and another that not include the principal outcomes studied (6) . Four studies were excluded by low methodological quality (14,18,33,36) . At the end, 10 RCTs were selected ( Figure 4).…”