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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All authors, Dr. Yung Lee, Mr. Umair Tahir, Dr. Lea Tessier, Mr. Kevin Yang, Mr. Taaha Hassan, Dr. Jerry Dang, Dr. Matthew Kroh, and Dr. Dennis Hong have no conflicts of interest to disclose.
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Appendices
Appendix 1
Search strategy for Nissen versus Dor comparison
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Nissen fundoplication.mp.
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exp gastroesophageal reflux/.
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(gastro-esophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux disease or gastrooesophageal reflux disease or gastroesophageal reflux or gastrooesophageal reflux).mp.
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Appendix 2
Search strategy for Nissen versus Toupet comparison
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(Nissen Fundoplication or Total Fundoplication or Nissen or 360 Degree Fundoplication or 360-Degree Fundoplication).mp.
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exp gastroesophageal reflux/
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Appendix 3
Search strategy for Toupet versus Dor comparison
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(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.
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exp gastroesophageal reflux/.
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(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.
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3 or 4.
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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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DOI: https://doi.org/10.1007/s00464-023-10151-5