Toupet versus Nissen fundoplication for gastroesophageal reflux disease: are the outcomes different?

Abstract

© Digestive Medicine Research. All rights reserved. Dig Med Res 2022 | https://dx.doi.org/10.21037/dmr-22-65 Until the first half of the twentieth-century, gastroesophageal reflux disease (GERD) was not a common clinical problem. At that time, Allison (1) reported the outcomes of trans-thoracic crural diaphragmatic repair for hiatal hernia showing a modest 50% success rate. The concept of antireflux surgery (ARS) emerged following the key observation of Nissen (2) that plicating the gastric fundus for 360 degrees around the esophago-gastric anastomosis was highly effective not only to avoid leakage but also to prevent peptic esophagitis. This proof-of-concept experiment led to a change in focus from trans-thoracic crural repair to trans-abdominal fundoplication. A few years later Toupet described a partial posterior fundoplication (3), but the Nissen procedure is still quoted as the “gold standard” surgical therapy for GERD. With the inception of the laparoscopic era, restoration of the esophagogastric antireflux barrier, including remodeling of the hiatal orifice and lower esophageal sphincter augmentation using either the Nissen or the Toupet fundoplication, have become standard procedures (4). Despite the very low morbidity and mortality rates, ARS remains underused due to the perceived risk of persistent side-effects and limited durability. As a consequence, the majority of patients referred for surgical intervention are those with refractory symptoms, recurrent esophagitis, and large hiatal hernia. Today, many gastroenterologists and patients continue to consider proton-pump inhibitors (PPIs) as the therapy of choice, and bad publicity of the “gold standard” Nissen fundoplication has largely contributed to the current decline of ARS utilization. In an attempt to reduce the potential side-effects of the Nissen operation, partial fundoplication has emerged as the procedure of choice or as a “tailored” option for patients with poor esophageal motility. Systematic reviews and meta-analyses have shown that the Toupet fundoplication can decrease the incidence of dysphagia and gas-bloating compared to Nissen fundoplication (5,6). In some studies, the favorable outcomes of Toupet fundoplication have been offset by a higher incidence of recurrent reflux over time, and this may reflect heterogeneity due to selection bias, inclusion of patients with preoperative motility disorders, surgical approach, or variations in the circumference of the wrap (3). The late results of a randomized clinical trial comparing Nissen and Toupet fundoplication recently shed some light on this controversial issue and fill a gap in the interpretation of long-term ARS outcomes (7). This study follows a previous report (8) showing that the Toupet procedure was beneficial because of a reduced dysphagia rate up at 2 years and equivalent control of esophageal acid exposure at 3 years. It appears now that Toupet and Nissen fundoplication are equally effective in controlling symptoms of GERD and quality of life after 15 years. These findings corroborate evidence from non-randomized studies that the Toupet fundoplication is effective and durable, and has an excellent safety profile. Limitations of this trial are the lack of pHmetry data to confirm objective long-term reflux control, and the fact that the results cannot be generalized to nonspecialist surgical units where patient selection and surgical technique may be suboptimal due to lack of standardization. There are five main topics that deserve attention when Editorial Commentary