Nissen vs Toupet laparoscopic fundoplication - A prospective randomized study of 200 patients with and without preoperative esophageal motility disorders

Background: Nissen fundoplication (360degrees) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270degrees) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures. Methods: From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry. Results: Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p < 0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure. Conclusion: Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.