Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects?

Characterization of gastric dysfunction after fundoplication using body surface gastric mapping

BACKGROUND

Adverse gastric symptoms persist in up to 20% of fundoplication operations completed for gastroesophageal reflux disease, causing significant morbidity and driving the need for revisional procedures. Noninvasive techniques to assess the mechanisms of persistent postoperative symptoms are lacking. This study aimed to investigate gastric myoelectrical abnormalities and symptoms in patients after fundoplication using a novel noninvasive body surface gastric mapping (BSGM) device.

METHODS

Patients with a previous fundoplication operation and ongoing significant gastroduodenal symptoms and matched controls were included. BSGM using Gastric Alimetry (Alimetry Ltd) was employed, consisting of a high-resolution 64-channel array, validated symptom-logging application, and wearable reader.

RESULTS

A total of 16 patients with significant chronic symptoms after fundoplication were recruited, with 16 matched controls. Overall, 6 of 16 patients (37.5%) showed significant spectral abnormalities defined by unstable gastric myoelectrical activity (n = 2), abnormally high gastric frequencies (n = 3), or high gastric amplitudes (n = 1). Patients with spectral abnormalities had higher Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index scores than those of patients without spectral abnormalities (3.2 [range, 2.8-3.6] vs 2.3 [range, 2.2-2.8], respectively; P = .024). Moreover, 7 of 16 patients (43.8%) had BSGM test results suggestive of gut-brain axis contributions and without myoelectrical dysfunction. Increasing Principal Gastric Frequency Deviation and decreasing Rhythm Index scores were associated with symptom severity (r > .40; P < .05).

CONCLUSION

A significant number of patients with persistent postfundoplication symptoms displayed abnormal gastric function on BSGM testing, which correlated with symptom severity. Our findings advance the pathophysiologic understanding of postfundoplication disorders, which may inform diagnosis and patient selection for medical therapy and revisional procedures.

Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years

INTRODUCTION

Having performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication.

OBJECTIVES

We report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation.

RESULTS

The operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery.

CONCLUSION

Both the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

Nissen Versus Toupet Fundoplication For Gastro-oesophageal Reflux Disease, Short And Long-term Outcomes. A Systematic Review And Meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) remains one of the most commonly encountered gastrointestinal disorders. Proton pump inhibitors still show an inadequate effect on about 10% to 40% of the patients. Laparoscopic antireflux surgery is the surgical alternative for managing GERD in patients who are not responding to proton pump inhibitors.

AIM OF THE STUDY

This study objected at comparing laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication (LTF) concerning the short-term and long-term outcomes.

PATIENTS AND METHODS

This is a systematic review and meta-analysis that evaluated the studies comparing between Nissen fundoplication and LTF for the treatment of GERD. Studies were obtained by searching on the EMBASE, the Cochrane Central Register of Controlled Trials, and PubMed central database.

RESULTS

The LTF group showed significantly longer operation time, less postoperative dysphagia and gas bloating, less pressure on the lower esophageal sphincter, and higher Demeester scores. No statistically significant differences were found between the 2 groups in the perioperative complications, the recurrence of GERD, the reoperation rate, the quality of life, or the reoperation rate.

CONCLUSION

LTF is favored for the surgical treatment of GERD being of lower postoperative dysphagia and gas bloating rates. These benefits were not at the expense of significantly additional perioperative complications or surgery failure.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

METHODS

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m²) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

RESULTS

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

CONCLUSION

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Surgical treatment of GERD: systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

METHODS

PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

RESULTS

From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I² = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I² = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I² = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I² = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I² = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

CONCLUSIONS

The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.

Laparoscopic fundoplication and new aspects of neural anatomy at the oesophagogastric junction

Background

In fundoplication, mobilization of the distal oesophagus and proximal stomach is essential to obtain a sufficient tension‐free intra‐abdominal oesophageal length for creation of an efficient antireflux barrier. Most surgical literature and anatomical illustrations do not describe nerve branches running from the diaphragm to the stomach. After observing small nerve branches at laparoscopic fundoplication, penetrating the left crus of the diaphragm lateral to the hiatus and apparently running into the stomach, an anatomical cadaver study was undertaken to identify the origin and target organ of these nerves.

Methods

Fifty‐three human cadavers (23 men, 30 women; age range 35–103 years) were dissected with special attention to the nerves that penetrate the left crus of the diaphragm. The entire course of these nerves was documented with standardized drawings and photos.

Results

Small nerve branches penetrating the diaphragm lateral to the left crus of the hiatus were found in 17 (32 per cent) of the 53 cadavers. In 14 of these 17 cadavers, one or two splanchnic nerve branches were identified, and in ten of the 17 the nerve branches were found to be phrenic nerves. In seven of these 17 cadavers, two different nerve branches were found and assigned to both splanchnic and phrenic nerves.

Conclusion

Nerves penetrating the left crus with splanchnic origin or phrenic origin have been identified. Their function remains unclear and their relationship to postfundoplication symptoms remains to be determined.

Severely impaired gastric accommodation is a hallmark of post-Nissen functional dyspepsia symptoms

BACKGROUND

Laparoscopic Nissen fundoplication is a commonly performed antireflux surgery, after which reflux symptoms are well controlled, however, complications such as inability to belch or dyspeptic symptoms (mimicking those of functional dyspepsia [FD]) might occur. The aim of the study was to prospectively evaluate symptom pattern and underlying pathophysiological mechanisms in patients with post-Nissen dyspepsia.

METHODS

Twenty-four patients (12 f, mean age 44.5±2.8 years) with post-Nissen dyspepsia symptoms, five patients (3 f, mean age 38.8±3.2 years) with post-Nissen dysphagia symptoms and 14 pre-fundoplication patients (3 f, mean age 42.1±2.5 years) were evaluated. Patients filled out a Rome II-based dyspepsia symptom severity score, performed a gastric emptying test, and a gastric barostat study was used to evaluate the function of the proximal stomach.

KEY RESULTS

Upper abdominal bloating scores were higher in post-Nissen dyspepsia patients (P=.016) and symptoms of postprandial distress syndrome (PDS) were more present in post-Nissen dyspepsia patients compared to the other two groups (P=.07). Weight loss was significantly higher in the post-Nissen groups compared to the pre-fundoplication (P=.02). Gastric emptying rates were similar in the three groups. Gastric accommodation (GA) was significantly impaired in the post-Nissen dyspepsia group (dyspepsia -30[-86-83] vs dysphagia 163[148-203] vs pre-fundoplication 147[75-174] mL, P=.004) and the prevalence of patients with impaired GA was higher in the post-Nissen group (P=.007). Postprandial fullness was more prevalent in patients with impaired GA compared to those with normal GA (P=.01).

CONCLUSIONS AND INTERFERENCES

Patients with post-Nissen dyspepsia show a symptom pattern similar to that in FD patients with PDS, and the main underlying mechanism seems to be impaired gastric accommodation to a meal.

A Meta-Analysis of Randomized Controlled Trials to Compare Long-Term Outcomes of Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease

Aim

In recent years, several studies with large sample sizes and recent follow-up data have been published comparing outcomes between laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication. It is now timely to be re-evaluated and synthesized long-term efficacy and adverse events of both total and partial posterior fundoplication.

Materials and Methods

Electronic searches for RCTs comparing the outcome after laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication were performed in the databases of MEDLINE, EMBASE, and the Cochrane Center Register of Controlled Trials. The data of evaluation in positive and adverse results of laparoscopic Nissen fundoplication and laparoscopic Nissen fundoplication were extracted and compared using meta-analysis.

Results

13 RCTs were ultimately identified involving 814 (52.05%) and 750 (47.95%) patients who underwent laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication, respectively. The operative time, perioperative complications, postoperative satisfaction, recurrence, and the rates of medication adoption or re-operation due to recurrence were not significantly different between two groups. The two types of fundoplication both reinforced the anti-reflux barrier and elevated the lower esophageal sphincter pressure. However, rates of adverse results involving dysphasia, gas-bloat syndrome, inability to belch and re-operation due to severe dysphasia were significantly higher after LNF. In the subgroup analysis of wrap length≤2cm, laparoscopic Nissen fundoplication was associated with a significantly higher incidence of postoperative dysphagia. However, in the subgroup wrap length>2cm, the difference was not statistically significant.

Conclusion

Laparoscopic Toupet fundoplication might be the better surgery approach for gastroesophageal reflux disease with a lower rate of postoperative adverse results and equal effectiveness as Laparoscopic Nissen fundoplication.

Pain after laparoscopic antireflux surgery

INTRODUCTION

The benefits of antireflux surgery are well established. Laparoscopic techniques have been shown to be generally safe and effective. The aim of this paper was to review the subject of pain following laparoscopic antireflux surgery.

METHODS

A systematic review of the literature was conducted using the PubMed database to identify all studies reporting pain after laparoscopic antireflux surgery. Publications were included for the main analysis if they contained at least 30 patients. Operations in children, Collis gastroplasty procedures, endoluminal fundoplication and surgery for paraoesophageal hernias were excluded. The frequency of postoperative pain was calculated and the causes/management were reviewed. An algorithm for the investigation of patients with pain following laparoscopic fundoplication was constructed.

RESULTS

A total of 17 studies were included in the main analysis. Abdominal pain and chest pain following laparoscopic fundoplication were reported in 24.0% and 19.5% of patients respectively. Pain was mild or moderate in the majority and severe in 4%. Frequency of pain was not associated with operation type. The authors include their experience in managing patients with persistent, severe epigastric pain following laparoscopic anterior fundoplication.

CONCLUSIONS

Pain following laparoscopic antireflux surgery occurs in over 20% of patients. Some have an obvious complication or a diagnosis made through routine investigation. Most have mild to moderate pain with minimal effect on quality of life. In a smaller proportion of patients, pain is severe, persistent and can be disabling. In this group, diagnosis is more difficult but systematic investigation can be rewarding, and can enable appropriate and successful treatment.

The evolution of laparoscopic antireflux surgery and its influence on postoperative stay

Laparoscopic fundoplication is an established treatment for refractory gastro-oesophageal reflux disease. This study aims to compare the outcome of two laparoscopic antireflux techniques in a regional specialist unit. A sequential audit was carried out on patients undergoing laparoscopic Nissen (LN: performed May 1994 to November 2000) or laparoscopic anterior (LA: performed March 2001 to December 2004) fundoplication. Patient satisfaction was assessed by postal questionnaire. The cohorts undergoing each operation were also divided into two chronological groups of 51 patients, to study the effect of possible learning curve progression on the number of nights spent in the hospital postoperatively. In all, 142/204 (70%) questionnaires were returned from patients with follow-up ranging from 5 to 40 months postoperation. Overall, 102/142 (72%) reported a good or excellent outcome. Patients who underwent LA had a higher rate of antacid medication use (LN 17.4% versus LA 34.2%, P = 0.036) but there was a higher score for inability to belch following LN (LN 2.03 versus LA 1.53, P = 0.034). When comparing the chronologically divided cohorts, LN was associated with a significantly longer hospital stay than LA (P < 0.001, Mann-Whitney U test). There was a significant decrease in hospital stay from the first to second group of 51 LNs (P < 0.001, Mann-Whitney U test) and a further significant reduction in hospital stay from the first 51 to second 51 LAs (P < 0.001, Mann-Whitney U test). In conclusion, both procedures provide good symptom control. Increased requirement for acid suppression following LA and inability to belch following LN, may suggest more long-term durability of the LN wrap. The decrease in the number of nights spent in hospital may be related to the procedure performed but seems more likely to be an effect of increasing volume of surgical experience.

Surgical technique for gastroesophageal reflux disease

AIMS

Laparoscopic fundoplication is the standard surgical therapy for managing gastroesophageal reflux disease. According to the pre-existing esophageal motility of the patient, tailoring antireflux surgery has been proposed in order to avoid postoperative dysphagia. Thus, the aim of this study is to evaluate the long-term results following this tailored concept.

METHODS

One-hundred sixty patients were included in this prospective study. A 360° Nissen fundoplication (NF) was performed on n = 127 patients with a normal esophageal peristalsis, whereas a 270° Toupet fundoplication (TF) was conducted on n = 33 patients having an esophageal motility disorder. Before surgery, all the patients were subjected to pH-metry, manometry, gastroscopy, and they had to respond to a standardized questionnaire. Postoperatively, pH-metry, and manometry were performed. In addition to the questionnaire, side effects and complications were evaluated.

RESULTS

The NF cohort and the TF cohort were each followed up for an average of 39 ± 13 months and 43 ± 12 months, respectively. Dysphagia was significantly reduced after NF (p = .033). The TF, however, decreased the intensity but not the incidence of dysphagia (p = .884). Heartburn was significantly diminished in both cohorts. The DeMeester score was significantly reduced after NF, whereas it was not significantly reduced following TF with a still evident, pathological acid reflux occurring postoperatively.

CONCLUSION

Our data indicate that tailoring antireflux surgery to the esophageal motility of the patient seems unnecessary. In summary, technical surgical aspects appear to be more important for clinical outcome.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Globus jugularis and dysphagia in patients with hiatus hernia

The aim of the article was to study if there is any relationship between globus sensation in the jugular fossa (GJ), intermittent esophageal dysphagia (IED), and the presence of a hiatus hernia, and if GJ can be relieved after hiatus hernia repair. 167 patients with a hiatus hernia (Group A) and 61 other patients with hiatus hernia and gastroesophageal reflux disease who were surgically treated with Nissen fundoplication (Group B), filled in a symptom questionnaire on GJ and IED. GJ was found in 66% and IED in 68% of patients in group A. In group B, 49% had GJ and 64% IED before surgery. At surgical follow-up 16% (P < 0.005) and 43% (P < 0.05) had GJ and IED, respectively. The combination of GJ and IED was found in 28% of IED patients before operation and in 31% at surgical follow-up. The high frequency of GJ in patients with hiatus hernia and the significant relief of GJ after hiatus hernia repair imply that GJ most likely is a referred sensation from the esophagus. IED and GJ are two parallel phenomena in patients with hiatus hernia, but do not seem to have any causal relationship.

Division of the short gastric vessels during laparoscopic Nissen fundoplication: clinical and functional outcome during long-term follow-up in a prospectively randomized trial

BACKGROUND

Although the first laparoscopic Nissen fundoplication was performed almost two decades ago, division of the short gastric vessels is still controversially discussed. The aim of this prospectively randomized trial was to evaluate the clinical and functional outcome following laparoscopic Nissen fundoplication with division versus saving of the short gastric vessels during short- and long-term follow-up.

METHODS

Forty-one consecutive patients (30 men, 11 women) with gastroesophageal reflux disease were allocated to undergo Nissen fundoplication without division (group 1, n = 19) or with division (group 2, n = 22) of short gastric vessels. All patients were evaluated prior to and at 6 months as well as 5 years following fundoplication. Tests included endoscopy, barium swallow, 24-h pH monitoring, and esophageal manometry. Gastroesophageal reflux disease (GERD) symptoms were evaluated and a gastrointestinal quality-of-life index was calculated.

RESULTS

Preoperative symptoms such as heartburn (84/86%), regurgitation (79/86%), pulmonary symptoms (47/45%), dysphagia (11/32%), chest pain (16/9%), and globus sensation (21/27%) were seen in groups 1 and 2, respectively. In group 1 regurgitation and mild dysphagia were seen in 7 and 26% of patients, respectively, at 5 years. In group 2 the rate of dysphagia decreased from 32 to 17% during short-term follow-up, but increased thereafter to 18%. Reflux esophagitis (preoperative rates: group 1, 74%; group 2, 59%) disappeared in all patients after fundoplication. Mean operative time (group 1, 109 min versus group 2, 125 min; p < 0.05) and mean blood loss (group 1, not measurable; group 2, 25 ml; p < 0.05) showed statistically significant differences. DeMeester score improved in group 1 from 26.6 to 2.2 and in group 2 from 24.7 to 2.5 at 5-year follow-up (p = 0.02). Lower esophageal sphincter (LES) resting pressure returned to normal values (group 1, 23.9 mmHg; group 2, 24.6 mmHg; p < 0.007) with regular relaxation. Quality-of-life index was high in both cohorts, without statistically significant differences between the two groups.

CONCLUSION

Routine division of the short gastric vessels during Nissen fundoplication in the followed patient group yields neither functional nor clinical advantages in short- or long-term follow-up.

Chylous cyst formation following laparoscopic fundoplication

Formation of an abdominal chylous cyst is a rare event, predominantly occurring after spinal, vascular or urologic retroperitoneal surgery. As far as we know, the presented case is the first report in the literature of chylous cyst formation after laparoscopic fundoplication. A 57-year-old man with a history of a conservatively treated spinal compression fracture (T11/12) underwent laparoscopic fundoplication in 1996 for recurrent heartburn with insufficient response to treatment with PPI. His reflux symptoms disappeared but over the following years he developed intermittent abdominal pain in the right upper quadrant. Gastroscopy in 2002 revealed a slight compression of the distal esophagus. CT scan revealed a cystic formation next to the distal esophagus which was initially interpreted to be part of the fundoplicate itself. Aggravation of symptoms and weight loss was noted in 2006. A further CT scan revealed a 7 cm cyst along the fundoplicate and the lesser curvature of the stomach. The cyst was subsequently drained laparoscopically. Cholesterol (351 mg/d), LDL-cholesterol (263 mg/dl), triglycerides (334 mg/dl) and chylomicrons led to the diagnosis chylous cyst and the patient was put on a medium-chain triglyceride diet. After 12 weeks the discharge stopped and the drain was removed. The patient remained symptom-free for seven months but then presented again with the same complaints. This time an even larger cyst was diagnosed, extending from the lesser curvature of the stomach through the esophageal hiatus up to the right atrium. A Roux-en-Y chylous cystojejunostomy was then performed and has solved the problem up to the present. A chylous cyst may develop after laparoscopic fundoplication. If simple drainage fails, a cystojejunostomy can solve this problem.

An anterior or posterior approach to partial fundoplication? Long-term results of a randomized trial

BACKGROUND

Partial fundoplications have been popularized by their lower risk of mechanical side effects. The question then emerges whether a similar partial wrap should be done posterior or anterior to the distal esophagus? We therefore conducted a study to compare the long-term outcome of laparoscopic partial fundoplications constructed either as anterior (AF) or posterior (PF) repairs.

PATIENTS AND METHODS

Ninety-five patients were enrolled in a randomized clinical trial. After a mean follow up of 65 months, 43 AF and 45 PF patients remained in the study. The levels of reflux control and postfundoplication complaints were assessed by use of validated instruments.

RESULTS

A posterior fundoplication was found to provide significantly better control of reflux related symptoms (heartburn p < 0.0001, acid regurgitation p < 0.0001). This was also reflected in a significantly lower number of reoperations and need for antisecretory drug therapy. The earlier postoperative difference in postfundoplication symptoms had disappeared.

CONCLUSIONS

A laparoscopic posterior partial fundoplication offers a high and durable level of disease control with few side effects. The current anterior type of repair cannot be recommended due to insufficient reflux control.