Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toilet) fundoplication for gastro-oesophageal reflex disease based on preoperative oesophageal manometry

Background: Laparoscopic fundoplication is an accepted treatment for symptomatic gastro-oesophageal reflux disease. The aim of this study was to clarify whether total (Nissen) or partial (Toupet) fundoplication is preferable, and whether preoperative oesophageal manometry should be used to determine the degree of fundoplication performed. Methods: Preoperative oesophageal manometry was used to stratify 127 patients with established gastro-oesophageal reflux disease into effective (75) and ineffective (52) oesophageal motility groups. Patients in each group were randomized to Nissen (64) or Toupet (63) fundoplication. Results: No significant differences between the operative groups were seen in heartburn, regurgitation or other reflex-related symptoms up to 1 year after surgery. Dysphagia of any degree (27 versus 9 per cent; P = 0018) and chest pain on eating (22 versus 5 per cent; P = 0.018) were more prevalent at 1 year in the Nissen group. There were no differences in postoperative symptoms between the effective and ineffective motility groups. Surgery failed in eight patients on postoperative pH criteria, three in the Nissen group and five in the Toupet group. Conclusion: Any differences in the symptomatic outcome of laparoscopic Nissen and Toupet fundoplication appear minimal. There is no reason to tailor the degree of fundoplication to preoperative oesophageal manometry.