Gastroesophageal Reflux Disease: Toupet or Nissen Fundoplication?
It has long been controversially discussed whether the partial posterior fundoplication according to Toupet is superior to the total fundoplication according to Nissen in the treatment of GERD. Various studies, including those with prospective randomized design (RCTs), have attempted to resolve the "Toupet vs. Nissen" controversy. Through meta-analysis of the available data from these RCTs (2 – 8), Broeders et al. from the University Hospital Utrecht/Netherlands in 2010 established a new level of evidence (1).
The included RCTs were published between 1997 and 2010 and involved 404 patients who had undergone laparoscopic Nissen and 388 patients who had undergone laparoscopic Toupet. The laparoscopic Nissen was associated with a significantly higher incidence of postoperative dysphagia compared to the laparoscopic Toupet. Accordingly, the rate of postoperative dilation treatments due to dysphagia was also significantly higher after laparoscopic Nissen compared to laparoscopic Toupet.
Operative reinterventions were also more frequently required after laparoscopic Nissen than after the Toupet technique. Similarly, the laparoscopic Nissen was more frequently associated with belching and the so-called "gas bloating."
Regarding the recurrence of pathological acid exposure and reflux esophagitis, there were no differences between the two techniques. The operation time and duration of hospital stay were also the same in both patient groups.
Broeders et al. conclude that their meta-analysis of randomized controlled trials on the question "Toupet vs. Nissen" now provides level-1a evidence suggesting the laparoscopic Toupet as the procedure of choice for the treatment of gastroesophageal reflux disease.
A possible criticism of the Dutch meta-analysis is the relatively short follow-up period: 4 studies (2, 3, 4, 6) refer to 12 months, 2 studies (5, 8) to 24 and 27 months respectively, and only one study to a 60-month follow-up. It should also be considered that the institutions involved in the RCTs were predominantly expert centers (10).
A strength of the meta-analysis by Broeders et al. is that, unlike previous meta-analyses, the work focused exclusively on the comparison of posterior laparoscopic Nissen vs. laparoscopic Toupet fundoplications and did not consider the anterior fundoplication, which is now considered inferior.