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Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials

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Abstract

Background

In the surgical management of GERD, the traditional procedure is laparoscopic total (Nissen) fundoplication. However, partial fundoplication has been advocated as providing similar reflux control while potentially minimizing dysphagia. The comparative outcomes of different approaches to fundoplication are a topic of ongoing debate and long-term outcomes remain uncertain. This study aims to compare long-term gastroesophageal reflux disease (GERD) related outcomes following different fundoplication procedures.

Methods

MEDLINE, EMBASE, PubMed, and CENTRAL databases were searched up to November 2022 to identify randomized controlled trials (RCTs) comparing different types of fundoplications reporting long-term (> 5 years) outcomes. The primary outcome was incidence of dysphagia. Secondary outcomes included incidence of heartburn/reflux, regurgitation, inability to belch, abdominal bloating, reoperation, and patient satisfaction. DataParty, which uses Python 3.8.10 was used to perform the network meta-analysis. We evaluated the overall certainty of evidence with the GRADE framework.

Results

13 RCTs were included, with 2063 patients across Nissen (360°), Dor (anterior 180°–200°), and Toupet (posterior 270°) fundoplications. Network estimates demonstrated that Toupet had lower incidence of dysphagia compared to Nissen (OR 0.285; 95% CrI 0.06–0.958). There were no differences in dysphagia between Toupet and Dor (OR 0.473, 95% CrI 0.072–2.835) or between Dor and Nissen (OR 1.689, 95% CrI 0.403–7.699). The three fundoplication types were comparable in all other outcomes.

Conclusions

All three approaches of fundoplication share similar long-term outcomes, with the Toupet fundoplication likely providing the best long-term durability with lowest odds of developing postoperative dysphagia.

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Author information

Authors and Affiliations

  1. Division of General Surgery, McMaster University, Hamilton, ON, Canada

    Yung Lee, Umair Tahir, Lea Tessier, Kevin Yang, Taaha Hassan & Dennis Hong

  2. Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA

    Yung Lee

  3. Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA

    Jerry Dang & Matthew Kroh

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Appendices

Appendix 1

Search strategy for Nissen versus Dor comparison

  1. 1.

    Nissen fundoplication.mp.

  2. 2.

    Total fundoplication.mp.

  3. 3.

    Nissen.mp.

  4. 4.

    360 degree fundoplication.mp.

  5. 5.

    360-degree fundoplication.mp.

  6. 6.

    1 or 2 or 3 or 4 or 5.

  7. 7.

    180 degree partial fundoplication.mp.

  8. 8.

    Anterior partial fundoplication.mp.

  9. 9.

    Anterior fundoplication.mp.

  10. 10.

    Dor fundoplication.mp.

  11. 11.

    Partial fundoplication.mp.

  12. 12.

    180-degree fundoplication.mp.

  13. 13.

    180-degree partial fundoplication.mp.

  14. 14.

    7 or 8 or 9 or 10 or 11 or 12 or 13.

  15. 15.

    Reflux.mp.

  16. 16.

    exp gastroesophageal reflux/.

  17. 17.

    (gastro-esophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux or gastrooesophageal reflux).mp.

  18. 18.

    GERD.mp.

  19. 19.

    (anti-reflux or antireflux).mp.

  20. 20.

    15 or 16 or 17 or 18 or 19.

  21. 21.

    6 and 14 and 20.

  22. 22.

    Remove duplicates from 21.

Appendix 2

Search strategy for Nissen versus Toupet comparison

  1. 1.

    (Nissen Fundoplication or Total Fundoplication or Nissen or 360 Degree Fundoplication or 360-Degree Fundoplication).mp.

  2. 2.

    Toupet fundoplication.mp.

  3. 3.

    Toupet.mp.

  4. 4.

    270 Degree fundoplication.mp.

  5. 5.

    270-Degree fundoplication.mp.

  6. 6.

    270 degree wrap.mp.

  7. 7.

    270-degree wrap.mp.

  8. 8.

    Posterior fundoplication.mp.

  9. 9.

    Posterior partial fundoplication.mp.

  10. 10.

    2 or 3 or 4 or 5 or 6 or 7 or 8 or 9.

  11. 11.

    exp gastroesophageal reflux/

  12. 12.

    (Reflux or gastro-esophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux or gastrooesophageal reflux or GERD or anti-reflux or antireflux).mp.

  13. 13.

    11 or 12.

  14. 14.

    1 and 10 and 13.

  15. 15.

    Remove duplicates from 14.

Appendix 3

Search strategy for Toupet versus Dor comparison

  1. 1.

    (Toupet fundoplication or Toupet or 270 degree fundoplication or 270-degree fundoplication or 270 degree wrap or 270-degree wrap or posterior fundoplication or posterior partial fundoplication).mp.

  2. 2.

    (180 degree partial fundoplication or anterior partial fundoplication or anterior fundoplication or Dor fundoplication or partial fundoplication or 180-degree fundoplication or 180-degree partial fundoplication).mp.

  3. 3.

    exp gastroesophageal reflux/.

  4. 4.

    (Reflux or gastro-esophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux or gastrooesophageal reflux or GERD or anti-reflux or antireflux).mp.

  5. 5.

    3 or 4.

  6. 6.

    1 and 2 and 5.

  7. 7.

    Remove duplicates from 6.

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Lee, Y., Tahir, U., Tessier, L. et al. Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials. Surg Endosc 37, 5052–5064 (2023). https://doi.org/10.1007/s00464-023-10151-5

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