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Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis

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Abstract

Purpose

We aim to review and quantitatively compare laparoscopic Toupet fundoplication (LTF), Nissen fundoplication (LNF), anterior partial fundoplication (APF), magnetic augmentation sphincter (MSA), radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), proton pump inhibitor (PPI), and placebo for the treatment of GERD. A number of meta-analyses compared the efficacy of surgical and endoscopic procedures for recalcitrant GERD, but considerable debate on the effectiveness of operative strategies remains.

Methods

A systematic review of MEDLINE databases, EMBASE, and Web of Science for randomized controlled trials (RCTs) comparing the aforementioned surgical and endoscopic GERD treatments was performed. Risk ratio and weighted mean difference were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference.

Results

Thirty-three RCTs were included. Surgical and endoscopic treatments have similar RR for heartburn, regurgitation, bloating. LTF has a lower RR of post-operative dysphagia when compared to APF (RR 3.3; Crl 1.4–7.1) and LNF (RR 2.5; Crl 1.3–4.4). The pooled network meta-analysis did not observe any significant improvement regarding LES pressure and pH < from baseline. LTF, APF, LNF, MSA, RFA, and TIF had have a similar post-operative PPI discontinuation rate.

Conclusion

LTF has a lower rate of post-operative dysphagia when compared to APF and LNF. The pre-post effects, such as GERD-HQRL, LES pressure, and pH <4, should be avoided in meta-analyses because results may be biased. Last, a consensus about the evaluation of GERD treatments’ efficacy and their outcomes is needed.

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Authors and Affiliations

  1. Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy

    E. Rausa & Marco Vitellaro

  2. General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy

    D. Ferrari

  3. Department of Surgery, St. James Hospital, School of Medicine—Trinity College Dublin, Dublin, Ireland

    M. E. Kelly

  4. General Surgery, Istituto Clinico Sant’Ambrogio, Milano, Italy

    A. Aiolfi, G. Bonitta & D. Bona

  5. Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy

    M. Rottoli

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Contributions

ER, MR, and AA did the literature search. ER, MK, and MV formed the study design. Data collection done by AA, DF. ER, GB, DB analyzed the data. ER, MV, and GB interpreted the data. ER, MV, and MR wrote the manuscript. All authors critically reviewed the manuscript.

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Supplementary information

Supplementary Figure 1.

Forest plots of network meta-analysis estimates the RR for E improvement in pH<4, F improvement in LES pressure and, D PPI discontinuation (PNG 90 kb)

High Resolution Image (TIF 127 kb)

Supplementary Figure 2.

The Ranking plot created using the rankogram function from R package applied to the three surgical approaches illustrating the empirical probability that each treatment is ranked 1st through 7th (left to right) for (E) improvement in pH<4 and (G) PPI discontinuation; and ranked 1st through 5th for (F) improvement in LES pressure. The abscissa axis shows the different treatments. The ordinate axis shows the probability (%) of ranking better (higher rankings associated with smaller outcomes values). (PNG 49 kb)

High Resolution Image (TIF 266 kb)

Supplementary Table 1.

Definition for treatment failure for each enrolled study (DOCX 16 kb)

Supplementary Table 2.

Description of the assessment tools for subjective symptoms in each enrolled study (DOCX 26 kb)

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Rausa, E., Ferrari, D., Kelly, M.E. et al. Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis. Langenbecks Arch Surg 408, 52 (2023). https://doi.org/10.1007/s00423-023-02774-y

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