Gastroesophageal reflux disease (GERD) affects a significant portion of the adult population, with prevalence rates ranging from 10% to 20% in Western countries and up to 12% in the Middle East. Characterized by symptoms like heartburn and regurgitation, GERD can also manifest in extra-esophageal ways and predispose individuals to conditions like Barrett's esophagus and esophageal adenocarcinoma. When proton pump inhibitors (PPIs) fail to provide adequate relief or are not well-tolerated, anti-reflux surgery becomes a viable option. Nissen fundoplication and Toupet fundoplication are two established surgical approaches to treat GERD. This article delves into a detailed comparison of these procedures, examining their techniques, benefits, complications, and long-term outcomes.
Understanding Fundoplication
Fundoplication surgeries aim to strengthen the barrier between the esophagus and the stomach, reducing gastroesophageal reflux. The procedure involves wrapping the upper part of the stomach (fundus) around the lower part of the esophagus, essentially creating a valve mechanism to prevent the backward flow of stomach acid.
Pre-Operative Evaluation and Preparation
Before undergoing fundoplication, patients undergo a thorough evaluation to assess the severity of their GERD and identify any underlying conditions. This typically includes:
- Esophageal manometry: To assess the function of the lower esophageal sphincter (LES) and esophageal body motility.
- Upper GI endoscopy: To evaluate the anatomy and rule out recurrent hiatal hernia or failed wrap.
- Barium swallow: To assess anatomical integrity.
Surgeons may also check for narrowing in the esophagus or hiatal hernias, which can worsen GERD symptoms. Hiatal hernias, where the stomach bulges into the esophagus, are often repaired during fundoplication. Patients are typically advised to avoid eating or drinking after midnight on the day of surgery.
Surgical Techniques: Nissen vs. Toupet
The choice of fundoplication technique depends on factors such as the severity of GERD, the presence of a hiatal hernia, and findings from diagnostic studies.
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Nissen Fundoplication
Laparoscopic Nissen fundoplication (LNF) involves a complete 360° wrap of the gastric fundus around the esophagus. This creates a tight seal, providing durable reflux control. The procedure can be performed via open surgery or laparoscopically.
- Open Surgery: A large incision is made in the abdomen, allowing the surgeon to directly access and wrap the stomach around the esophagus before closing the incision with staples.
- Laparoscopic Surgery: This minimally invasive approach involves making four to six small incisions in the abdomen. A laparoscope (a small tube with a camera) is inserted to guide the surgeon, who uses tiny surgical tools to wrap the stomach around the esophagus and closes the incisions with stitches.
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. A 50F esophageal bougie is routinely used to prevent excessive tightness of the wrap.
Toupet Fundoplication
Laparoscopic Toupet fundoplication (LTF) involves a 270° posterior partial wrap of the stomach around the esophagus. This approach aims to reduce adverse effects like postoperative dysphagia and gas-bloat syndrome while maintaining comparable efficacy to the Nissen procedure. 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.
Comparative Outcomes: Nissen vs. Toupet
Numerous studies have compared the outcomes of Nissen and Toupet fundoplication. A recent double-blind randomized clinical trial published in JAMA followed 310 patients for an average of 16 years, with 159 undergoing Toupet fundoplication and the remainder undergoing Nissen fundoplication. The study found that both groups had equal control of reflux symptoms and similar improvements in quality-of-life scores. However, around 25% of patients in each group resumed PPI intake.
Dysphagia
Dysphagia, or difficulty swallowing, is a common concern following fundoplication. While both procedures can lead to dysphagia, studies suggest that Toupet fundoplication may be associated with a lower incidence.
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- A network meta-analysis of 13 RCTs involving 2063 patients found that Toupet fundoplication had a lower incidence of dysphagia compared to Nissen fundoplication.
- The JAMA study noted that while the Nissen fundoplication group had slightly higher dysphagia scores for solids at the two-year follow-up, the dysphagia scores in the Toupet fundoplication group increased to match those of the Nissen group after 16 years.
Hiatal Hernia Resolution
Hiatal hernias are often addressed during fundoplication. One study found that hiatal hernias were present in 70% of Nissen patients pre-operatively, resolving completely in only 14%. In the Toupet group, hiatal hernias were present in 80% of patients and resolved in 50%. Although the trend favored Toupet, the difference was not statistically significant.
Quality of Life
Both Nissen and Toupet fundoplication can significantly improve patients' quality of life by reducing GERD symptoms. A study comparing the two procedures found that both groups demonstrated significant improvements in GERD-HRQL scores, with a significantly greater reduction achieved in the Toupet group compared to the Nissen group.
Long-Term Side Effects
Common long-term side effects of fundoplication include the inability to vomit and altered bowel habits. The procedure that keeps stomach acid out of the esophagus can also prevent vomiting.
Potential Benefits and Complications
Benefits
- Eases acid reflux symptoms when other treatments aren’t successful.
- Reduces the risk of developing Barrett’s esophagus.
Complications
- Infection (as with all surgeries).
- Recurrence of symptoms, potentially requiring another procedure.
- Postoperative dysphagia, particularly following Nissen fundoplication.
- Bloating.
- Stenosis.
- Recurrence of GERD symptoms.
- Esophageal injury or mesh-related issues (if mesh is used during hiatal hernia repair).
The Role of Surgical Mesh
For patients undergoing hiatal hernia repair, the use of surgical mesh-either absorbable or permanent-remains a topic of significant discussion. Surgical mesh, namely absorbable mesh, has shown promise in reducing short-term recurrence rates when compared to primary surgical suture repairs.
Post-Operative Care and Evaluation
Patients are typically followed for several weeks postoperatively to assess symptom resolution and monitor for complications. Postoperative evaluation may include:
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- High-resolution manometry (HRM): To evaluate changes in LES pressure and esophageal motility compared to preoperative values.
- GERD-HRQL questionnaires: To measure quality of life.
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