Comparison of Partial vs Total Fundoplication for the Treatment of Gastroesophageal Reflux Disease | Gastroenterology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Comparison of Laparoscopic 270° Posterior Partial Fundoplication vs Total Fundoplication for the Treatment of Gastroesophageal Reflux DiseaseA Randomized Clinical Trial

Educational Objective To identify whether a partial (PF) or total fundoplication (TF) is superior as a laparoscopic antireflux procedure.
1 Credit CME
Key Points

Question  Is partial or total fundoplication superior in laparoscopic antireflux surgery?

Finding  In this randomized clinical trial including 456 patients, partial and total fundoplication were equally effective in reducing esophageal acid exposure after 3 years, while mechanical adverse effects were more common after total fundoplication.

Meaning  Although partial and total fundoplication could be recommended for treatment of gastroesophageal reflux, partial fundoplication might be superior by inducing less dysphagia.

Abstract

Importance  Restoration of the esophagogastric junction competence is critical for effective long-term treatment of gastroesophageal reflux disease. Surgical repair results in such restoration, but mechanical adverse effects seem unavoidable. Minimizing these adverse effects without jeopardizing reflux control is warranted.

Objective  To determine whether partial fundoplication (PF) or total fundoplication (TF) is superior in laparoscopic antireflux surgery.

Design, Setting, and Participants  In this double-blind, randomized clinical trial of 1171 patients scheduled for laparoscopic antireflux surgery at a single university-affiliated center between November 19, 2001, and January 24, 2006, 456 patients were randomized and followed up for 5 years. Data were collected from November 2001 to April 2012, and data were analyzed from April 2012 to September 2018.

Interventions  A 270° posterior PF or a 360° Nissen TF.

Main Outcomes and Measures  Esophageal acid exposure at 3 years after surgery.

Result  Of the 456 randomized patients, 268 (58.8%) were male, and the mean (SD) age was 49.0 (11.7) years. A total of 229 patients were randomized to PF, and 227 patients were randomized to TF. At 3 years postoperatively, the median (interquartile range) esophageal acid exposure was reduced from 14.6% (9.8-21.9) to 1.8% (0.7-4.4) after PF and from 16.0% (10.4-22.7) to 2.5% (0.8-6.8) after TF (P = .31). Likewise, reflux symptoms were equally and effectively controlled. Early postoperative dysphagia (6 weeks) was common in both groups but then decreased toward normality. A small but statistically significant difference in favor of PF was noted in the mean (SD) scoring of dysphagia for liquids at 6 weeks (PF, 1.6 [0.9]; TF, 1.9 [1.3]; P = .01) and for solid food at 12 months (PF, 1.3 [1.0]; TF, 1.9 [1.4]; P < .001) and 24 months (PF, 1.3 [0.9]; TF, 1.7 [1.2]; P = .001). Quality of life was reduced before surgery but increased to normal values after surgery and remained so over 5-year follow-up, with no difference between the groups.

Conclusions and Relevance  The results from this randomized clinical trial suggest that although PF and TF could be recommended for treatment of gastroesophageal reflux disease, PF might be superior by inducing less dysphagia.

Trial Registration  ClinicalTrials.gov identifier: NCT03659487

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: December 6, 2018.

Corresponding Author: Bengt S. Håkanson, MD, PhD, Department of Surgery, Ersta Hospital, PO Box 4619, SE 116 91 Stockholm, Sweden (bengt.hakanson@erstadiakoni.se).

Published Online: March 6, 2019. doi:10.1001/jamasurg.2019.0047

Author Contributions: Dr Håkanson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Håkanson, Thorell.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Håkanson, Bylund.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Håkanson, Bylund, Thorell.

Obtained funding: Håkanson, Thorell.

Administrative, technical, or material support: Håkanson, Bylund, Thorell.

Study supervision: Håkanson, Lundell, Thorell.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was financially supported by grants 2003-7558 and 2004-7620 from the Stockholm City Council and grant 140604 from the Erling-Persson Family Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 4.

References
1.
Vakil  N.  Disease definition, clinical manifestations, epidemiology and natural history of GERD.  Best Pract Res Clin Gastroenterol. 2010;24(6):759-764. doi:10.1016/j.bpg.2010.09.009PubMedGoogle ScholarCrossref
2.
Dodds  WJ, Dent  J, Hogan  WJ,  et al.  Mechanisms of gastroesophageal reflux in patients with reflux esophagitis.  N Engl J Med. 1982;307(25):1547-1552. doi:10.1056/NEJM198212163072503PubMedGoogle ScholarCrossref
3.
Bredenoord  AJ, Smout  AJPM. Hiatus hernia and gastro-oesophageal reflux disease. In: Richter  JE, Castell  DO, eds.  The Esophagus. 5th ed. Oxford, England: Wiley-Blackwell; 2012:394-404.
4.
Lundell  L, Miettinen  P, Myrvold  HE,  et al; Nordic GERD Study Group.  Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis.  Clin Gastroenterol Hepatol. 2009;7(12):1292-1298. doi:10.1016/j.cgh.2009.05.021PubMedGoogle ScholarCrossref
5.
Galmiche  JP, Hatlebakk  J, Attwood  S,  et al; LOTUS Trial Collaborators.  Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial.  JAMA. 2011;305(19):1969-1977.PubMedGoogle ScholarCrossref
6.
Anvari  M, Allen  C, Borm  A.  Laparoscopic Nissen fundoplication is a satisfactory alternative to long-term omeprazole therapy.  Br J Surg. 1995;82(7):938-942. doi:10.1002/bjs.1800820728PubMedGoogle ScholarCrossref
7.
Mehta  S, Bennett  J, Mahon  D, Rhodes  M.  Prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: seven-year follow-up.  J Gastrointest Surg. 2006;10(9):1312-1316. doi:10.1016/j.gassur.2006.07.010PubMedGoogle ScholarCrossref
8.
Grant  AM, Wileman  SM, Ramsay  CR,  et al; REFLUX Trial Group.  Minimal access surgery compared with medical management for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial.  BMJ. 2008;337:a2664. doi:10.1136/bmj.a2664PubMedGoogle ScholarCrossref
9.
Brusselaers  N, Wahlin  K, Engstrand  L, Lagergren  J.  Maintenance therapy with proton pump inhibitors and risk of gastric cancer: a nationwide population-based cohort study in Sweden.  BMJ Open. 2017;7(10):e017739. doi:10.1136/bmjopen-2017-017739PubMedGoogle ScholarCrossref
10.
Cheung  KS, Chan  EW, Wong  AYS, Chen  L, Wong  ICK, Leung  WK.  Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study.  Gut. 2018;67(1):28-35.PubMedGoogle ScholarCrossref
11.
Scarpellini  E, Ang  D, Pauwels  A, De Santis  A, Vanuytsel  T, Tack  J.  Management of refractory typical GERD symptoms.  Nat Rev Gastroenterol Hepatol. 2016;13(5):281-294. doi:10.1038/nrgastro.2016.50PubMedGoogle ScholarCrossref
12.
Nissen  R.  A simple operation for control of reflux esophagitis  [in German].  Schweiz Med Wochenschr. 1956;86(suppl 20):590-592.PubMedGoogle Scholar
13.
Rossetti  M, Hell  K.  Fundoplication for the treatment of gastroesophageal reflux in hiatal hernia.  World J Surg. 1977;1(4):439-443. doi:10.1007/BF01565907PubMedGoogle ScholarCrossref
14.
Toupet  A.  Technic of esophago-gastroplasty with phrenogastropexy used in radical treatment of hiatal hernias as a supplement to Heller's operation in cardiospasms  [in French].  Mem Acad Chir (Paris). 1963;89:384-389.PubMedGoogle Scholar
15.
Roks  DJ, Broeders  JA, Baigrie  RJ.  Long-term symptom control of gastro-oesophageal reflux disease 12 years after laparoscopic Nissen or 180° anterior partial fundoplication in a randomized clinical trial.  Br J Surg. 2017;104(7):852-856. doi:10.1002/bjs.10473PubMedGoogle ScholarCrossref
16.
Broeders  JA, Mauritz  FA, Ahmed Ali  U,  et al.  Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease.  Br J Surg. 2010;97(9):1318-1330. doi:10.1002/bjs.7174PubMedGoogle ScholarCrossref
17.
Hunter  JG, Swanstrom  L, Waring  JP.  Dysphagia after laparoscopic antireflux surgery: the impact of operative technique.  Ann Surg. 1996;224(1):51-57. doi:10.1097/00000658-199607000-00008PubMedGoogle ScholarCrossref
18.
Hagedorn  C, Jönson  C, Lönroth  H, Ruth  M, Thune  A, Lundell  L.  Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication: results of a randomized, controlled clinical trial.  Ann Surg. 2003;238(2):189-196. doi:10.1097/01.sla.0000080821.08262.53PubMedGoogle Scholar
19.
Catarci  M, Gentileschi  P, Papi  C,  et al.  Evidence-based appraisal of antireflux fundoplication.  Ann Surg. 2004;239(3):325-337. doi:10.1097/01.sla.0000114225.46280.fePubMedGoogle ScholarCrossref
20.
Roks  DJ, Koetje  JH, Oor  JE, Broeders  JA, Nieuwenhuijs  VB, Hazebroek  EJ.  Randomized clinical trial of 270° posterior versus 180° anterior partial laparoscopic fundoplication for gastro-oesophageal reflux disease.  Br J Surg. 2017;104(7):843-851. doi:10.1002/bjs.10500PubMedGoogle ScholarCrossref
21.
Varin  O, Velstra  B, De Sutter  S, Ceelen  W.  Total vs partial fundoplication in the treatment of gastroesophageal reflux disease: a meta-analysis.  Arch Surg. 2009;144(3):273-278. doi:10.1001/archsurg.2009.10PubMedGoogle ScholarCrossref
22.
Lundell  LR, Dent  J, Bennett  JR,  et al.  Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.  Gut. 1999;45(2):172-180. doi:10.1136/gut.45.2.172PubMedGoogle ScholarCrossref
23.
Dent  J, Kahrilas  PJ, Vakil  N,  et al.  Clinical trial design in adult reflux disease: a methodological workshop.  Aliment Pharmacol Ther. 2008;28(1):107-126. doi:10.1111/j.1365-2036.2008.03700.xPubMedGoogle ScholarCrossref
24.
Thor  KB, Silander  T.  A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique.  Ann Surg. 1989;210(6):719-724. doi:10.1097/00000658-198912000-00005PubMedGoogle ScholarCrossref
25.
Hill  LD, Kozarek  RA, Kraemer  SJ,  et al.  The gastroesophageal flap valve: in vitro and in vivo observations.  Gastrointest Endosc. 1996;44(5):541-547. doi:10.1016/S0016-5107(96)70006-8PubMedGoogle ScholarCrossref
26.
Sharma  P, Dent  J, Armstrong  D,  et al.  The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria.  Gastroenterology. 2006;131(5):1392-1399. doi:10.1053/j.gastro.2006.08.032PubMedGoogle ScholarCrossref
27.
Patterson  EJ, Herron  DM, Hansen  PD, Ramzi  N, Standage  BA, Swanström  LL.  Effect of an esophageal bougie on the incidence of dysphagia following Nissen fundoplication: a prospective, blinded, randomized clinical trial.  Arch Surg. 2000;135(9):1055-1061. doi:10.1001/archsurg.135.9.1055PubMedGoogle ScholarCrossref
28.
Wills  VL, Hunt  DR.  Dysphagia after antireflux surgery.  Br J Surg. 2001;88(4):486-499. doi:10.1046/j.1365-2168.2001.01662.xPubMedGoogle ScholarCrossref
29.
Watson  DI, Jamieson  GG.  Antireflux surgery in the laparoscopic era.  Br J Surg. 1998;85(9):1173-1184. doi:10.1046/j.1365-2168.1998.00829.xPubMedGoogle ScholarCrossref
30.
Hinder  RA, Filipi  CJ, Wetscher  G, Neary  P, DeMeester  TR, Perdikis  G.  Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease.  Ann Surg. 1994;220(4):472-481. doi:10.1097/00000658-199410000-00006PubMedGoogle ScholarCrossref
31.
Salminen  P, Hurme  S, Ovaska  J.  Fifteen-year outcome of laparoscopic and open Nissen fundoplication: a randomized clinical trial.  Ann Thorac Surg. 2012;93(1):228-233. doi:10.1016/j.athoracsur.2011.08.066PubMedGoogle ScholarCrossref
32.
Broeders  JA, Draaisma  WA, Rijnhart-de Jong  HG,  et al.  Impact of surgeon experience on 5-year outcome of laparoscopic Nissen fundoplication.  Arch Surg. 2011;146(3):340-346. doi:10.1001/archsurg.2011.32PubMedGoogle ScholarCrossref
33.
Funch-Jensen  P, Jacobsen  B.  Dysphagia after laparoscopic Nissen fundoplication.  Scand J Gastroenterol. 2007;42(4):428-431. doi:10.1080/00365520600955120PubMedGoogle ScholarCrossref
34.
Broeders  JA, Roks  DJ, Ahmed Ali  U, Draaisma  WA, Smout  AJ, Hazebroek  EJ.  Laparoscopic anterior versus posterior fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials.  Ann Surg. 2011;254(1):39-47. doi:10.1097/SLA.0b013e31821d4ba0PubMedGoogle ScholarCrossref
35.
Ludemann  R, Watson  DI, Jamieson  GG, Game  PA, Devitt  PG.  Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication.  Br J Surg. 2005;92(2):240-243. doi:10.1002/bjs.4762PubMedGoogle ScholarCrossref
36.
Hatlebakk  JG, Zerbib  F, Bruley des Varannes  S,  et al; LOTUS Study Group.  Gastroesophageal acid reflux control 5 years after antireflux surgery, compared with long-term esomeprazole therapy.  Clin Gastroenterol Hepatol. 2016;14(5):678-685.e3.PubMedGoogle ScholarCrossref
37.
Sandbu  R, Khamis  H, Gustavsson  S, Haglund  U.  Long-term results of antireflux surgery indicate the need for a randomized clinical trial.  Br J Surg. 2002;89(2):225-230. doi:10.1046/j.1365-2168.2002.01990.xPubMedGoogle Scholar
38.
Sandbu  R, Sundbom  M.  Nationwide survey of long-term results of laparoscopic antireflux surgery in Sweden.  Scand J Gastroenterol. 2010;45(1):15-20. doi:10.3109/00365520903342158PubMedGoogle ScholarCrossref
39.
Maret-Ouda  J, Wahlin  K, El-Serag  HB, Lagergren  J.  Association between laparoscopic antireflux surgery and recurrence of gastroesophageal reflux.  JAMA. 2017;318(10):939-946. doi:10.1001/jama.2017.10981PubMedGoogle ScholarCrossref
40.
Mardani  J, Lundell  L, Engström  C.  Total or posterior partial fundoplication in the treatment of GERD: results of a randomized trial after 2 decades of follow-up.  Ann Surg. 2011;253(5):875-878. doi:10.1097/SLA.0b013e3182171c48PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close