“Clinical outcomes of a laparoscopic total vs 270-degree posterior fundoplication in chronic GERD” is a recent double blind randomized clinical trial published in JAMA (journal of American medical association). A total of 310 out of 407 available patients were followed for an average time of 16 years. 159 patients had a partial or Toupet fundoplication. The remaining patients had a Nissen fundoplication. Both groups were found to have equal control of reflux symptoms and similar improvements in quality-of-life scores. Of note, around 25% of patients in each group have resumed PPI intake. In addition, both groups had low dysphagia scores for both liquids and solids with no statistically significant difference. Interestingly, at two-year follow up, Nissen fundoplication group had a slightly higher dysphagia score to solids compared to partial fundoplication group (results published in a separate previous study). After 16 years, dysphagia score in the Toupet fundoplication group slightly increased to match that of the Nissen fundoplication group. Authors offer no explanation for this observation.
The authors are to be congratulated for a prospective long-term follow up analysis of two surgical techniques for treatment of acid reflux disease. However, dysphagia and GERD symptom scores are hard to interpret in the absence of objective data. The study would have been much more valuable if esophageal manometry and ambulatory pH testing were performed 16 years after surgery. 25% of patients in each group are back on PPIs 16 years after surgery. Does this mean than 25% of patients have a failed fundoplication? I doubt it. The only way to prove recurrent acid reflux after Nissen or Toupet fundoplication is to perform a comprehensive and thorough evaluation. Upper endoscopy is crucial to evaluate anatomy, rule out recurrent hiatal hernia, failed wrap… pH bravo study evaluate esophageal acid reflux over a period of 4 days. We have access to valuable testing modalities that can clearly demonstrate recurrent acid reflux and failed fundoplication surgery. I only wish the authors of this study can objectively re-evaluate those patients with recurrent symptoms in both groups and publish their data. Only then we can determine if Toupet fundoplication is as durable as a Nissen fundoplication.
Post-Nissen fundoplication dysphagia or difficulty swallowing is rare when surgery is performed by expert acid reflux specialists. Indeed, at Houston Heartburn and Reflux Center, our post-operative Nissen fundoplication dysphagia rate is zero. We only offer partial or Toupet fundoplication in cases of absent esophageal peristalsis on manometry. Rarely, gastric fundus is too small to perform a floppy Nissen fundoplication and a Toupet fundoplication is constructed instead.
Nissen fundoplication mechanism of action remains to be elucidated. Therefore, the optimal extent of wrapping to achieve the best acid reflux control remains unknown. However, there is clear evidence that shows both partial and Nissen fundoplications are equivalent in terms of acid reflux control. At Houston Heartburn and Reflux Center, Nissen fundoplication is our most performed procedure. Nissen fundoplication or wrap is constructed by suturing stomach to stomach. Full thickness bites are taken on both sides of the stomach to create a durable wrap. Toupet fundoplication, on the other hand, is constructed by suturing stomach to esophagus. This connection may be weaker than a stomach-to-stomach connection especially when distal esophagus wall is inflamed secondary to severe acid reflux. The result is a potentially weaker wrap that may fail over time.