ABSTRACT
OBJECTIVE: The aim of the study was to compare the efficacy and mechanical consequences of 2 partial fundoplications performed laparoscopically under the framework of a randomized, controlled clinical trial. SUMMARY BACKGROUND DATA: Although laparoscopic total fundoplication procedures have proven their effectiveness in the control of gastroesophageal reflux, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone. Partial fundoplications have been found to be associated with fewer mechanical side effects. PATIENTS AND METHODS: During a 2-year period, 95 patients with gastroesophageal reflux disease were enrolled into a randomized, controlled single-institution clinical trial comparing a partial posterior (Toupét, n = 48) fundoplication and an anterior partial wrap (Watson, n = 47). All patients were assessed postoperatively at predefined time points, and the 12-month follow-up data are presented in terms of clinical results and 24-hour pH monitoring variables. RESULTS: Both patient groups were strictly comparable at the time of randomization. All operations were completed laparoscopically, and no serious complications were encountered. During the first postoperative year, a difference regarding the control of reflux symptoms was observed in favor of the posterior fundoplication. Esophageal acid exposure (% time pH <4) was substantially reduced by both operations but to a significantly lower level after a Toupét compared with the Watson partial fundoplication (1.0 +/- 0.3 vs. 5.6 +/- 1.1 mean +/- SEM; p < 0.001). Postfundoplication symptoms were infrequently recorded with no difference between the groups. CONCLUSIONS: When performing a laparoscopic partial fundoplication, the posterior modification (Toupét) offers advantages in terms of better reflux control compared with an anterior type (Watson).
Subject(s)
Fundoplication/methods , Gastroesophageal Reflux/surgery , Laparoscopy , Adult , Computer Graphics , Female , Follow-Up Studies , Humans , Male , Middle Aged , Statistics, NonparametricABSTRACT
The efficacy of fundoplication operations in the long-term management of gastroesophageal reflux disease (GERD) has been documented. However, only a few prospective controlled series support the long-term (>10 years) efficacy of these procedures, and further data are required to also determine whether the type of fundoplication affects the frequency of postfundoplication complaints. The aim of this study was to conduct a randomized, controlled clinical trial to assess the long-term symptomatic outcome of a partial posterior fundoplication as compared to a total fundic wrap. During the years 1983 to 1991, a total of 137 patients with chronic gastroesophageal reflux disease were enrolled in the study; 72 were randomized to semifundoplication (Toupet) and 65 to total fundoplication (Nissen-Rossetti). A standardized symptom questionnaire was used for follow-up of these patients. A total of 110 patients completed a median follow-up of 11.5 years; 54 had a total wrap and 56 underwent a partial posterior fundoplication. During this period, seven patients required reoperation (Nissen-Rossetti in 5 and Toupet in 2), 11 patients died, and nine patients were lost to follow-up or did not comply with the follow-up program. Control of heartburn (no symptoms or mild, intermittent symptoms) was achieved in 88% and 92% in the total and partial fundoplication groups, respectively, and the corresponding figures for control of acid regurgitation were 90% and 94%. We observed no difference in dysphagia scoring between the two groups, although odynophagia was somewhat more frequently reported in those undergoing a total fundoplication. On the other hand, a significant difference was observed in the prevalence of rectal flatus and postprandial fullness, which were recorded significantly more often in those undergoing a total fundoplication (P < 0.001 and P < 0.03, respectively). Posterior partial fundoplication seems to maintain the same high level of reflux control as total fundoplication. Earlier observations demonstrating the advantages of a partial fundoplication, which included fewer complaints associated with gas-bloat, continue to be valid after more than 10 years of follow-up.
