Laparoscopic Nissen versus Toupet fundoplication in patients with gastroesophageal reflux disease and impaired distal esophageal motility

Introduction. A Nissen fundoplication for gastrooesophageal reflux disease may more often lead to persistent dysphagia than a Toupet fundoplication. The aim of this study was to assess the results of laparoscopic Nissen versus Toupet fundoplication in patients with reflux disease and impaired distal esophageal motility. Patients and Methods. In 15 patients a laparoscopic Nissen and in 17 a laparoscopic Toupet funcloplication was carried out. Criteria for an impaired motility of the distal esophagus were a mean amplitude of <30 mm Hg of swallow-induced contractions, or >33% non-propulsive or non-transmitted contraction waves. Before surgery, heartburn, dysphagia, regurgitation and other symptoms were scored and endoscopic, manometric and 24 hour pH-metric investigations performed. Patients were reinvestigated 3 to 30 (median 15) months after Nissen and 3 to 42 (median 7) months after Toupet funcloplication. Results. After Nissen as well as after Toupet funcloplication heartburn was significantly less frequent, whereas dysphagia and all other symptom-scores remained unchanged. In the 26 patients reinvestigated manometrically, the resting pressure of the lower esophageal sphincter was significantly higher following both operations and the residual sphincter pressure upon swallowing higher only after Nissen fundoplication. The amplitude of swallow-induced contractions and the percentages of non-propulsive and non-transmitted contraction waves were not significantly changed after either operation. In the 23 patients restudied pH-metrically, reflux activity was significantly reduced after both Nissen and Toupet funcloplication. Conclusion. In patients with reflux disease and impaired distal esophageal motility, laparoscopic Nissen and Toupet funcloplication both yielded satisfactory results and neither operation led to increased dysphagia.