Abstract
Background
The goal of antireflux surgery is to create a competent antireflux valve at the esophagogastric junction (EGJ). The two most common types of fundoplications constructed are the 360° Nissen and the 270° Toupet. We sought to determine whether there was a significant difference in distensibility at the EGJ based on fundoplication geometry (full vs. partial).
Methods
This is a retrospective review of prospective data. All subjects underwent laparoscopic fundoplication over a 47-month period for primary GERD or failed fundoplication. An endoluminal functional luminal-imaging probe (EndoFLIP®) was used to assess EGJ distensibility intraoperatively. Minimum esophageal diameter (D min), cross-sectional area (CSA), and distensibility index (DI) were measured at 30- and 40-mL balloon distension volumes prior to abdominal insufflation, after hiatal dissection, and following fundoplication. DI is defined as the narrowest CSA divided by the corresponding pressure expressed in mm2/mmHg. Analysis was conducted to compare distensibility metrics based on the type of fundoplication constructed (Nissen or Toupet). As a secondary outcome, we sought to determine whether there was a difference in distensibility of the EGJ prior to surgery in patients with primary GERD as opposed to those with recurrent GERD after a failed fundoplication.
Results
A total of 75 patients underwent fundoplications during the study interval. There were 44 primary and 31 reoperative fundoplications. Nissen fundoplication was constructed in 45 and Toupet in 30. Based on the distensibility index, the EGJ distensibility significantly decreased from prior to surgery to following fundoplication in all patients. Patients undergoing reoperative antireflux surgery had an initial DI at the EGJ similar to that of patients with primary GERD. Following Toupet, the EGJ was significantly more distensible than that after Nissen fundoplication.
Conclusions
Laparoscopic fundoplication results in decreased EGJ distensibility in patients with GERD. The EGJ following partial fundoplication is significantly more distensible than that after a full fundoplication.
Similar content being viewed by others
References
Fass R (2012) Therapeutic options for refractory gastroesophageal reflux disease. J Gastroenterol Hepatol 27(Supple 3):3–7
Hershcovici T, Fass R (2013) Step by step management of refractory gastroesophageal reflux disease. Dis Esophagus 26:27–36
Kahrilas PJ (2008) Gastroesophageal reflux disease. N Engl J Med 359:1700–1707
Lundell L, Miettinen P, Myrvold H, Hatlebakk J, Wallin L, Malm A, Sutherland I, Walan A (2007) Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis. Br J Surg 94:198–203
Broeders JA, Mauritz FA, Ahmed Ali U, Draaisma WA, Ruurda JP, Gooszen HG, Smout AJ, Broeders IA, Hazebroek EJ (2010) Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease. Br J Surg 97:1318–1330
Kwiatek M, Pandolfino J, Hirano I, Kahrilas P (2010) Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc 72:272–278
Pandolfino J, Shi G, Trueworthy B, Kahrilas P (2003) Esophagogastric junction opening during relaxation distinguishes nonhernia reflux patients, hernia patients, and normal subjects. Gastroenterology 125:1018–1024
Pandolfino J, Shi G, Curry J, Joehl R, Brasseur J, Kahrilas P (2002) Esophagogastric junction distensibility: a factor contributing to sphincter incompetence. Am J Physiol Gastrointest Liver Physiol 282:G1052–G1058
Kwiatek MA, Kahrilas PJ, Soper NJ, Bulsiewicz WJ, Mcmahon BP, Gregersen H, Pandolfino JE (2009) Esophagogastric junction distensibility after fundoplication assessed with a novel functional luminal imaging probe. J Gastrointest Surg 14:268–276
Pandolfino J, Curry J, Shi G, Joehl R, Brasseur J, Kahrilas P (2005) Restoration of normal distensive characteristics of the esophagogastric junction after fundoplication. Ann Surg 242:43–48
Blom D, Bajaj S, Liu J, Hofmann C, Rittmann T, Derksen T, Shaker R (2005) Laparoscopic Nissen fundoplication decreases gastroesophageal junction distensibility in patients with gastroesophageal reflux disease. J Gastrointest Surg 9:1318–1325
Ilczyszyn A, Botha A (2013) Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication. Dis Esophagus 27:637–644
DeMeester SR, DeMeester TR (2000) Columnar mucosa and intestinal metaplasia of the esophagus: fifty years of controversy. Ann Surg 231:303–321
Worrell SG, Greene CL, DeMeester TR (2014) The state of surgical treatment of gastroesophageal reflux disease after five decades. J Am Coll Surg 219:819–830
Chrysos E, Tsiaoussis J, Zoras OJ, Athanasakis E, Mantides A, Katsamouris A, Xynos E (2003) Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial fundoplication? J Am Coll Surg 197:8–15
Koch O, Kaindlstorfer A, Antoniou SA, Asche KU, Granderath FA, Pointner R (2012) Laparoscopic Nissen versus Toupet fundoplication: objective and subjective results of a prospective randomized trial. Surg Endosc 26:413–422
Ruiz-Tovar J, Diez-Tabernilla M, Chames A, Morales V, Sanjuanbenito A, Martinez-Molina E (2010) Clinical outcome at ten years after laparoscopic fundoplication: Nissen versus Toupet. Am Surg 76(12):1408–1411
Jobe BA, Wallace J, Hansen PD, Swanstrom LL (1997) Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux. Surg Endosc 11(11):1080–1083
Patti MG, Robinson T, Galvani C, Gorodner MV, Fisichella PM, Way LW (2004) Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 198(6):863–869
Tian ZC, Wang B, Shan CX, Zhang W, Jiang DZ, Qiu M (2015) A Meta-analysis of randomized controlled trials to compare long-term outcomes of Nissen and Toupet fundoplication for gastroesophageal reflux disease. PLoS ONE 10(6):e0127627
Broeders JA, Bredenoord AJ, Hazebroek EJ, Broeders IA, Gooszen HG, Smout AJ (2011) Effects of anti-reflux surgery on weakly acidic reflux and belching. Gut 60:435–441
Wykypiel H, Hugl B, Gadenstaetter M, Bonatti H, Bodner J, Wetscher GJ (2008) Laparoscopic partial posterior (Toupet) fundoplication improves esophageal bolus propagation on scintigraphy. Surg Endosc 22:1845–1851
Nissen R (1961) Gastropexy and ‘fundoplication’ in surgical treatment of hiatus hernia. Am J Dig Dis 6:954–961
Ip S, Tatsioni A, Conant A, Karagozian R, Fu L, Chew P, Raman G, Lau J, Bonis P (2009) Predictors of clinical outcomes following fundoplication for gastroesophageal reflux disease remain insufficiently defined: a systematic review. Am J Gastroenterol 104:752–758
Vakil N, Shaw M, Kirby R (2003) Clinical effectiveness of laparoscopic fundoplication in a US community. Am J Med 114:1–5
Teitelbaum EN, Boris L, Arafat FO, Nicodème F, Lin Z, Kahrilas PJ, Hungness ES (2013) Comparison of esophagogastric junction distensibility changes during POEM and Heller myotomy using intraoperative FLIP. Surg Endosc 27:4547–4555
Tucker E, Sweis R, Anggiansah A, Wong T, Telakis E, Knowles K, Wright J, Fox M (2013) Measurement of esophago-gastric junction cross-sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease. Neurogastroenterol Motil 25:904–910
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Reece K. DeHaan, Daniel Davila, and Matthew J. Frelich declare no conflicts of interest. Jon C. Gould is a consultant for Torax Medical.
Rights and permissions
About this article
Cite this article
DeHaan, R.K., Davila, D., Frelich, M.J. et al. Esophagogastric junction distensibility is greater following Toupet compared to Nissen fundoplication. Surg Endosc 31, 193–198 (2017). https://doi.org/10.1007/s00464-016-4956-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-016-4956-0