Toupet fundoplication for gastroesophageal reflux in childhood

Hypothesis: Gastroesophageal reflux (GER) is a common condition in childhoo d that frequently requires operative treatment. The 360 degrees Nissen fund oplication (NF) has been the standard operation for GER, but is associated with substantial rates of recurrence, "gas bloat," gagging, and dysphagia. I believe that the Toupet fundoplication (TF),a 270 degrees posterior wrap originally described in conjunction with myotomy for achalasia, has fewer c omplications, and its longterm outcome in children compared with NF is favo rable. Design: Nonrandomized controlled trial. Setting: Tertiary care children's hospital. Patients: Two hundred fifty-six children (aged 3 months to 16 years) with G ER disease unresponsive to nonoperative therapy who underwent either NF (n = 102) or TF (n = 154). Intervention: Operative repair of GER disease by either NF or TF. Main Outcome Measures: Time to first feeding, time to discharge from the ho spital, postoperative dysphagia complications, recurrence, and rehospitaliz ation and reoperation rates for each fundoplication technique. Results: The 2 fundoplication techniques had equivalent recurrence rates, b ut TF had significantly lower rates of postoperative dysphagia (P = .008) a nd rehospitalization/reoperation rates (P = .005) and significantly shorter times to discharge from the hospital (P = .01) and to the first feeding (P = .02). Conclusions: These data show that both NF and TF are effective procedures f or GER in children, with acceptable recovery times and low recurrence rates . However, TF results in earlier feeding and discharge from the hospital an d has a significantly lower incidence of dysphagia, gagging, and gas bloat, resulting in fewer rehospitalizations. In this population, TF seems to be superior to NF.