On: Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility [Surg Endosc 22(1):21–30

Abstract

Dear sirs, We read with great interest the recent publication entitled ‘‘Laparoscopic fundoplication: Nissen versus Toupet twoyear outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility’’ [1]. We already published in 2005 an analysis of our patients operated within the so-called tailored approach on 209 patients with a median follow-up of 52 months [2]. We compared those patients without recurrence regarding their long-term symptoms and their functional results and came to the same conclusion as the authors of the above mentioned publication. The laparoscopic partial posterior (Toupet) fundoplication seems to be the better operative procedure for the treatment of gastroesophageal reflux disease (GERD). It has a lower rate of side effects, nota bene less dysphagia and, given the appropriate technique, it restores the antireflux barrier to the same extent as the Nissen fundoplication [2]. Moreover, in our studies [2, 3] we were even able to demonstrate an improvement of former impaired esophageal motility in the Toupet group, while this was not found in the Nissen group. In our study, there was a strong correlation between postoperative dysphagia and impaired postoperative lower esophageal sphincter (LES) relaxation (Spearman correlation; rs = -0.75 at a p value \0.05) and the same was true for bloating (rs = -0.71), inability to belch (rs = -0.82), inability to vomit (rs = -0.86), and epigastric pain (rs = -0.68). In other words, the Nissen fundoplication may lead to an impairment of the LES relaxation often to an extent like in achalasia, while this was not seen after a Toupet fundoplication; so we concluded that an impaired relaxation could be the main cause of this problem. Unlike mentioned in the discussion of Strate et al.’s paper, patients without symptoms but inflammation of the esophagus or those with pathologic acid exposure of the distal esophagus in 24-h pH monitoring should rather be counted as recurrencies, since we know that heartburn symptoms do not correlate with esophagitis in a large number of patients. Whenever neoplastic consequences of GERD are discussed, a recurrent exposition of the esophagus to refluxate will lead GERD potentially to progress into metaplasia and dysplasia [4]. However, the dissection of the distal esophagus during surgery might lead to an altered sensitivity within the esophagus, thus leading to esophagitis without heartburn when reflux recurs. In the discussion of this publication, it is also stated that there were some discrepancies of manometric results in comparison with findings on 24-h pH monitoring [5]. The statement ‘‘...normal LES pressure due to an intact fundic wrap but still suffer from reflux recurrence due to crural disruption...’’ might probably rather be explained by the technique applied in manometry: the mean LES pressure value may be normal, but often a shortened intra-abdominal length diminishes the overall competency of the antireflux valve. This could be expressed by measuring the intra-abdominal vector volume of the LES [6]. This is supported by the fact that the reported mean intra-abdominal length in this paper is rather at the lower end of the norm. Several small details in operative technique, which are not even mentioned [7], could result in a different method H. Wykypiel (&) Department of General and Transplant Surgery, Medical University Innsbruck, Innsbruck, Austria e-mail: heinz.wykypiel@uibk.ac.at