Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis

Background Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease. Methods Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease. Results Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270 degrees, 360 degrees, anterior 180 degrees and anterior 90 degrees; and star network between 360 degrees and other treatments; and between anterior 180 degrees and other treatments. Laparoscopic 270 degrees (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180 degrees, and anterior 90 degrees were equally effective as 360 degrees for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270 degrees (OR 0.38, 95%, CI 0.24-0.60), anterior 90 degrees (moderate quality evidence), and anterior 180 degrees (low-quality evidence) compared to 360 degrees. The odds for gas-bloat were lower after 270 degrees (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90 degrees compared to 360 degrees (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence. Conclusion Laparoscopic 270 degrees fundoplication achieves a better outcome than 360 degrees total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective. Registration no. CRD42017074783.