Gastro-esophageal reflux disease: Toupet or Nissen fundoplication?
There has been a long-standing controversy regarding whether partial posterior fundoplication (Toupet) is superior to total fundoplication (Nissen) in the treatment of GERD. Various studies, including those with prospective randomized design (RCTs) have tried to clarify the controversy “Toupet versus Nissen”. With their meta-analysis in 2010 of the data available for these RCTs (2–8), Broeders et al from the Utrecht University Medical Center in The Netherlands have produced a new level of evidence (1).
The RCTs included in the analysis had been published between 1997 and 2010, comprising 404 patients with the laparoscopic Nissen procedure and 388 patients with the laparoscopic Toupet fundoplication. Compared with the laparoscopic Toupet procedure, the laparoscopic Nissen fundoplication yielded a significantly higher rate of postoperative dysphagia. Consequently, the rate of postoperative dilation procedures due to dysphagia was significantly higher in laparoscopic Nissen fundoplication versus laparoscopic Toupet surgery.
Laparoscopic Nissen fundoplication also required more frequent revision surgery than the laparoscopic Toupet procedure. And laparoscopic Nissen fundoplication was also associated more often with belching and gas bloating.
The two techniques did not differ in recurrent pathologic acid exposition and reflux esophagitis. Also, both groups of patients did not differ in the duration of surgery and length of stay in hospital.
Broeders et al conclude that their meta-analysis of these randomized controlled trials on “Toupet versus Nissen” has resulted in data of evidence level 1a, which suggest the laparoscopic Toupet procedure as the procedure of choice for the treatment of gastro-esophageal reflux disease.
One possible criticism concerns the rather short follow-up period in this Dutch meta-analysis: 4 studies (2, 3, 4, 6) had a follow-up of 12 months, 2 studies (5, 8) a follow-up of 24 and 27 months respectively, and only one study had a follow-up of 60 months. It should also be noted that both institutions participating in the RCTs are more or less expert centers (10).
One strength of the meta-analysis by Broeders et al is the fact that, contrary to previous meta-analyses, their paper solely compared the laparoscopic posterior Nissen fundoplication with the laparoscopic Toupet cuff and did not consider the anterior fundoplication, a procedure now regarded as inferior.