Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta‐Analysis

Abstract

Background and Aims Partial fundoplication is commonly performed in conjunction with Heller Myotomy. It is, however, controversial whether anterior Dor or posterior Toupet partial fundoplication is the antireflux procedure of choice. The aim was to perform a systematic review and meta-analysis of studies comparing these two procedures. Material and Methods A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, Google scholar and current contents for English language articles comparing Dor and Toupet fundoplication following HM between 1991 and 2018 was performed. The outcome variables analyzed included operating time, length of hospital stay (LOHS), overall complication rate, quality of life (QOL), postoperative reflux, residual postoperative dysphagia, treatment failure and reoperations. The meta-analysis was prepared in accordance with the PRISMA-P statement. Results Seven studies totaling 486 patients (Dor = 245, Toupet = 241) were analyzed. LOHS was significantly shorter for Toupet repair compared to Dor procedure (WMD 0.73, 95% CI 0.47 to 0.99; P \ 0.0001). Furthermore, patients after Toupet experienced significantly better QOL than those after Dor (WMD 1.68, 95% CI 0.68 to 2.73, P \ 0.001). All other variables showed comparable effects for these two procedures. Conclusion Our systematic review and meta-analysis revealed that Toupet fundoplication is superior to Dor in terms of LOHS and QOL following HM. For other variables such as postoperative reflux, postoperative dysphagia, complication rates and treatment failure, both Dor and Toupet fundoplication produced effective and equivalent results.

Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia

“…For this reason, LHM coupled with an antireflux fundoplication is standardly performed. 6 Regarding choice of partial fundoplication technique, neither anterior 180-degree Dor nor posterior 270-degree Toupet fundoplication have demonstrated superiority. A recent randomized controlled trial comparing LHM with either Dor or Toupet fundoplication demonstrated no difference in function outcomes 12 months postoperatively.…”

Long-term results of laparoscopic Heller myotomy with Dor-fundoplication in surgical treatment of achalasia: A single-center experience

“…They noted no difference between Dor and Toupet regarding acid reflux symptoms. These data were confirmed by two additional randomized controlled studies and two meta-analyses [7,8,21,22]. Considering these data, which fundoplication method to be used was left to the surgeon's preference.…”

The comparisons of different therapeutic modalities for idiopathic achalasia

“…In contrary, the Toupet approach is less standardized and time-consuming when looking to achieve circumferential esophageal mobilization, which may prevent scarring and adhesion of the separated muscle edge, while also reducing recurrent dysphagia. [ 42 , 43 ] Recently, two meta-analyses [ 44 , 45 ] have revealed equivalent results, while Siddaiah-Subramanya et al additionally reported that Toupet fundoplication is better than Dor in terms of length of hospitalization and quality of life. In our study, LHM + Toupet ranked higher than LHM + Dor in both short-term and mid-term efficacy, although not significantly, while only LHM without fundoplication showed worse gastroesophageal acid reflux than PD.…”