Laparoscopic Toupet fundoplication is an inadequate procedure for patientswith severe reflux disease

Recently we have shown that laparoscopic Toupet fundoplication is associate d with a high degree of late failure when employed as a primary treatment f or gastroesophageal reflux disease (GERD). This study defines preoperative risk factors that predispose patients to failure. Data from 48 patients wit h objective follow-up performed as part of a prospective long-term outcomes project (24-hour pH monitoring, manometry, and esophagogastroduodenoscopy [EGD] at 6 months, 3 years, and 6 years) was analyzed. Preoperative studies of patients with documented postoperative failure (n = 22), defined as an abnormal 24-hour pH study (DeMeester score > 14.9), were compared to preope rative studies of patients with normal 24-hour pH studies (n = 26). Outcome s were assessed at a mean of 22 months (range 18 to 37 months) postoperativ ely. Of the 22 patients in the failure group, 16 (77%) were symptomatic and the majority (64%) had resumed proton pump inhibitor therapy. Preoperative indices of severe reflux were significantly more prevalent in the failure group including a very low or absent lower esophageal sphincter (LES) press ure on manometry, biopsy-proved Barrett's metaplasia, presence of a strictu re, grade III or greater esophagitis, and a DeMeester score greater than 50 with ambulatory 24-hour pH testing. Comparison of pre- and postoperative m anometric analysis of the LES revealed adequate augmentation of the LES in both soups and there were no wrap disruptions documented by postoperative E GD or manometry, indicating that reflux was most likely occurring through a n intact wrap in the failure group. Esophageal dysmotility was present befo re surgery in four of the nonrefluxing patients and in three of the failure s. Intact wraps were noted to have herniated in eight patients, all of whom had postoperative reflux. Laparoscopic Toupet fundoplication is associated with a high rate of failure both clinically and by objective testing. Surg ery is more likely to fail in patients with severe GERD than in patients wi th uncomplicated or mild disease. A preoperative DeMeester score greater th an 50 was 86% sensitive for predicting failure in our patient population. L aparoscopic Toupet fundoplication should not be used as a standard antirefl ux procedure particularly in patients with severe or complicated reflux dis ease.