Laparoscopic Toupet versus Nissen fundoplication for the treatment of gastroesophageal reflux disease

The Nissen fundoplication is the most popular laparoscopic operation performed for the surgical treatment of gastroesophageal reflux disease (GERD). However, for patients in whom esophageal peristalsis is documented to be weak preoperatively, use of a partial wrap, or Toupet procedure, has often been used as an alternative to lessen the potential for postoperative dysphagia. Recent reports have criticized the Toupet procedure as having a higher long-term failure rate than the Nissen approach, especially for patients with severe forms of GERD. We reviewed our experience performing laparoscopic antireflux surgery over a 7-year period and compared the results of patients undergoing laparoscopic Nissen versus Toupet procedures. All procedures were performed at our institution by a single surgeon. Data recorded included preoperative demographic data, preoperative disease parameters, perioperative data, postoperative course, and symptom scores. Follow-up was based on a combination of medical records and phone interviews. There were 142 patients with complete records allowing review for this study. Of these, 118 underwent 122 Nissen fundoplications and 26 underwent 27 Toupet fundoplications. Selection of the procedure was based on preoperative manometric studies. There were seven reoperations. Seven of the patients (28%) who underwent Toupet procedures had severe GERD, a percentage comparable to the Nissen group (31.6%). Preoperative parameters were comparable for both groups, although the Toupet patients had lower average preoperative LES pressures (9.79 mmHg) than did the Nissen patients (16.1 mmHg, P < 0.05). The operative duration, operative blood loss, morbidity, length of hospitalization, need for reoperation, and efficacy in terms of relieving symptoms (average follow-up = 27.5 months) were comparable for both groups. Based on this experience, the Toupet procedure seems safe and effective in treating the symptoms of GERD, including patients with severe forms of the disease. We recommend its selective use in patients with preoperative esophageal hypomotility who are undergoing laparoscopic antireflux surgery.