Posterior Partial Fundoplication Better for Gastroesophageal Reflux

Laurie Barclay, MD

August 08, 2003

Aug. 8, 2003 — Posterior partial fundoplication adequately controlled gastroesophageal reflux (GER), whereas the anterior approach gave unacceptable results in a randomized controlled trial reported in the August issue of the Annals of Surgery.

"Although laparoscopic total fundoplication procedures have proven their effectiveness in the control of GER, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone," write Cecilia Hagedorn, MD, from Sahlgrenska University Hospital in Gothenburg, Sweden, and colleagues. "Partial fundoplications have been found to be associated with fewer mechanical side effects."

Of 95 patients with GER, 48 were randomized to undergo a partial posterior (Toupét) fundoplication, and 47 were randomized to undergo an anterior partial wrap (Watson). Both types of procedure were completed laparoscopically with infrequent postfundoplication symptoms and without serious complications.

Control of reflux symptoms was better during the first postoperative year in the Toupét group compared with the Watson group. Esophageal acid exposure was markedly decreased after both procedures, but more so after the Toupét than after the Watson (% time pH <= 4, 1.0 ± 0.3 vs. 5.6 ± 1.1; P < .001).

"A posterior partial fundoplication (Toupét) performed laparoscopically was followed by adequate reflux control assessed both objectively and subjectively but an anterior partial fundoplication gave unacceptable results both in terms of reflux control and esophageal acid reflux variables," the authors write. "Why should an anterior partial fundoplication function differently from a posterior one? The extent of the esophageal circumference that is encircled by the actual wrap varied somewhat between our study groups. Therefore, it can be argued that the buttressing effect of respective wrap might differ."

Ann Surg. 2003;238:189-196

Reviewed by Gary D. Vogin, MD