Toupet or Nissen Fundoplication for GERD Treatment?

Nissen fundoplication is currently the gold standard treatment for GERD. A floppy and short 360 degree wrap around the distal esophagus is the most durable and reliable solution to stop reflux of gastric content into the esophagus. The Toupet fundoplication or 270-degree wrap is equally effective in controlling GERD but tends to fall apart with time due to lack of strong serosal adhesions between the two edges of the wrapped gastric fundus. Traditionally, a Toupet fundoplication was advocated in cases of severe esophageal dysmotility in order to prevent post-operative dysphagia. While this recommendation falls under common sense observation, there is no evidence to support its veracity. Indeed, the short and floppy Nissen fundoplication should offer zero resistance to esophageal motility. Contrary to popular belief, acid reflux is not treated by creating an iatrogenic esophageal obstruction or constriction. Nissen fundoplication surgery mechanism of action is not well understood. Many factors are at play, and lower esophageal sphincter mechanical constriction or pressure augmentation is less likely to be a contributing factor to acid reflux control following Nissen fundoplication surgery. A proper fundoplication should neither prevent complete lower esophageal sphincter relaxation with swallowing nor increase resting sphincter pressure. Consequently, there is no role for a Toupet fundoplication in the setting of esophageal dysmotility. At Houston Heartburn and Reflux Center, a Toupet fundoplication is only performed in the rare case of a small gastric fundus. Less than 1% of anti-reflux cases performed at Houston Heartburn and Reflux Center require a partial fundoplication due to a tight or small gastric fundus despite full mobilization. I have no anatomic or physiologic explanation for factors that determine gastric fundus size. I have noticed that some patients have a very large fundus that can easily wrap around the distal esophagus and others have a very small fundus that can only allow for a partial wrap. Luckily, the majority of cases qualify for a floppy 360-degree wrap. In cases of Toupet fundoplication, I take full thickness bites on either side of the esophagus using permanent sutures to strongly anchor the gastric fundus around to esophagus. Suturing the gastric fundus to the esophageal mucosa (the strongest layer in the esophagus) is crucial to increase the longevity of a Toupet wrap. Gentle full thickness sutures placed and tied laparoscopically do not increase the risk of esophageal wall injury and leak.