Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the p rocedure has a lower rate of the side effects of dysphagia and gas bloat th an a complete Nissen fundoplication. However, there is increasing recogniti on that reflux control is not always as good with the Toupet procedure as w ith the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toup et fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesopha geal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period, All patients had preoperative esophagogastro duodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Eso phageal manometry was requested of all patients 6 weeks postoperatively. Cl inical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Fail ure was defined as the development of recurrent reflux documented by endosc opy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagi a persisting >3 months and requiring surgical revision. Results: Ar a mean follow-up of 30 months (range, 3-51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux, Failure was ass ociated with preoperative findings of a defective lower esophageal sphincte r (LES) (14/21), complicated esophagitis (13/21), and failure to divide sho rt gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Pre sence of either complicated esophagitis or a defective LES was associated w ith a 3-year 50% success rate, whereas presence of mild esophagitis and a n ormal LES was reflected in a 96% 3-year success rate. Conclusion. Laparoscopic Toupet fundoplication should be reserved for milde r cases of GERD, as assessed by manometry and endoscopy.