Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication -: Results of a randomized, controlled clinical trial

Objective: The aim of the study was to compare the efficacy and mechanical consequences of 2 partial fundoplications performed laparoscopically under the framework of a randomized, controlled clinical trial. Summary Background Data: Although laparoscopic total fundoplication procedures have proven their effectiveness in the control of gastroesophageal reflux, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone. Partial fundoplications have been found to be associated with fewer mechanical side effects. Patients and Methods: During a 2-year period, 95 patients with gastroesophageal reflux disease were enrolled into a randomized, controlled single-institution clinical trial comparing a partial posterior (Toupet, n = 48) fundoplication and an anterior partial wrap (Watson, n = 47). All patients were assessed postoperatively at predefined time points, and the 12-month follow-up data are presented in terms of clinical results and 24-hour pH monitoring variables. Results: Both patient groups were strictly comparable at the time of randomization. All operations were completed laparoscopically, and no serious complications were encountered. During the first postoperative year, a difference regarding the control of reflux symptoms was observed in favor of the posterior fundoplication. Esophageal acid exposure (% time pH <4) was substantially reduced by both operations but to a significantly lower level after a Toupet compared with the Watson partial fundoplication (1.0 +/- 0.3 vs. 5.6 +/- 1.1 mean +/- SEM; p < 0.001). Postfundoplication symptoms were infrequently recorded with no difference between the groups. Conclusions: When performing a laparoscopic partial fundoplication, the posterior modification (Toupet) offers advantages in terms of better reflux control compared with an anterior type (Watson).