Randomized controlled trial of laparoscopic anterior versus posterior fundoplication for gastro-oesophageal reflux disease

Background: The aim of the study was to compare the effect of laparoscopic anterior and posterior fundoplication on gastro-oesophageal reflux disease by means of a prospective randomized controlled trial. Methods: One hundred and three patients were randomised to undergo either anterior (53) or posterior (50) fundoplication. Initial enrolment and subsequent clinical appointments were undertaken 1, 3, 6 and 12 months after the procedure using a standardized questionnaire. Ambulatory pH monitoring and manometry were undertaken both preoperatively and at approximately 3 months post-procedure. Results: The mean operating time was similar in both groups (48 versus 52 min). Two operations in each group were converted to open surgery. Post-operative dysphagia in the first month was higher in the posterior fundoplication group compared with the anterior group (at 1 month, P = 0.002; and at 3 months, P = 0.014). The number of individuals suffering from post-operative heartburn was greater in the anterior fundoplication group (at 1 month, P = 0.008; at 3 months, P < 0.001; and at 6 months, P = 0.002). Eight individuals required reoperation in the anterior group and two individuals in the posterior group (P = 0.057). Conclusion: Anterior and posterior fundoplication each have their advantages and disadvantages. There is an increased risk of early post-operative dysphagia after posterior fundoplication. Anterior fundoplication carries a greater risk of persistent or recurrent reflux. Overall, a posterior fundoplication produces a better management option for controlling gastro-oesophageal reflux disease when compared with an anterior fundoplication technique which utilizes unilateral fixation of the gastric fundus.