Laparoscopic Toupet Research Articles

Robot-assisted laparoscopic hiatal hernia and antireflux surgery.

Gastroesophageal reflux disease is a common disorder of the GE-junction that allows gastric acid to enter the esophagus. Surgery is indicated when the presence of the disease is objectively documented. The laparoscopic Toupet fundoplication is the preferred treatment of GERD. There is no clear advantage in robotic assistance for primary antireflux surgery. In our center we find the robot to be of added value for redo surgery or large and giant hiatal repair.

Efficacy of laparoscopic Toupet fundoplication for non-erosive reflux disease assessed by combined multichannel intraluminal impedance–pH monitoring

Background Non-erosive gastroesophageal reflux disease (NERD) is the most common form of gastroesophageal reflux disease (GERD). The aim of this study is to evaluate efficacy of laparoscopic Toupet fundoplication for NERD by combined multichannel intraluminal impedance–pH (MII–pH) monitoring.

Management of Gastroesophageal Reflux Disease: A Review of Medical and Surgical Management

Background. Gastroesophageal reflux disease currently accounts for the majority of esophageal pathologies. This study is an attempt to help us tackle the diagnostic and therapeutic challenges of this disease. This study specifically focuses on patients in the urban Indian setup. Materials and Methods. This study was a prospective interventional study carried out at a teaching public hospital in Mumbai from May 2010 to September 2012. Fifty patients diagnosed with gastroesophageal reflux disease (confirmed by endoscopy and esophageal manometry) were chosen for the study. Results. Fifty patients were included in the study. Twenty patients showed symptomatic improvement after three months and were thus managed conservatively, while 30 patients did not show any improvement in symptoms and were eventually operated. Conclusion. We suggest that all patients diagnosed to have gastroesophageal reflux disease should be subjected to 3 months of conservative management. In case of no relief of symptoms, patients need to be subjected to surgery. Laparoscopic Toupet's fundoplication is an effective and feasible surgical treatment option for such patients, associated with minimal side effects. However, the long-term effects of this form of treatment still need to be evaluated further with a larger sample size and a longer followup.

Reply to: “Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications”

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Symptom analysis improves GERD diagnosis and may be helpful to define a successful surgical approach

We read with interest the article by Koch et al. [1] that randomly allocated 125 patients with documented chronic gastroesophageal reflux disease (GERD) to either laparoscopic floppy Nissen fundoplication (n = 62) or laparoscopic Toupet fundoplication (n = 63). Both procedures proved to be equally effective in improving quality of life and both typical and atypical reflux-related symptoms. The authors also indicated that laparoscopic Toupet fundoplication was characterized to have a high ability to belch and a reduced rate of postoperative dysphagia. The authors opted to use the current gold standard for GERD diagnosis (i.e., impedance-pH testing), and thus, they carefully and objectively defined the inclusion criteria for undergoing surgical fundoplication [2]. Indeed, they considered patients for surgery who had a total number of refluxes higher than 73 per 24 h, a DeMeester score higher that 14.7, or a positive association between symptoms and reflux events by means of the symptom index (SI). One-year postsurgery impedance-pH studies clearly showed a marked decrease of reflux episodes (total, acid, proximal, upright, and recumbent refluxes) and a DeMeester score that paralleled the large improvement of GERD symptoms and quality of life, thus supporting the usefulness of impedance-pH testing in selecting GERD patients for surgery [3]. However, even though this study provides relevant novel data on the potential application of impedance-pH technology for the surgical management of GERD patients, we believe that the interpretation of their findings would be improved if the results of symptom association analysis after surgery were also reported. Few data are reported about SI (i.e., only preoperative information, and without describing whether the association was positive for acid and/or nonacid reflux episodes), and no data are provided for symptom association probability (SAP), which is considered by several authors to be the best index demonstrating an association between symptoms and reflux events. Indeed, SAP is based on statistical parameters, is not generated by chance, and clearly explores the relationship between symptoms and refluxes [4]. Although SI has the advantage of being easy to calculate, it does not take into account the total number of reflux episodes with the likelihood risk that a symptom is found to be associated with reflux by chance [5]. Therefore, because impedancepH permits the measurement of all types of reflux and correlates them to symptoms, it increases the diagnostic yield by using a symptom association analysis mode such as SI or SAP [6–10]. In fact, previous studies have shown that GERD patients, particularly those found to have no mucosal injuries at upper endoscopy, frequently have a normal distal acid exposure time and therefore a low acidrelated DeMeester score [3, 11]. Using these parameters, it has been observed that GERD patients have symptoms associated not only with acid reflux but also with weakly acidic reflux; this may explain the increased proton pump inhibitor failure observed in endoscopy-negative patients [3, 12], thus supporting the use of alternative surgical or endoscopic therapies in this patient population [13, 14]. So far, data concerning the SI and SAP for acidic and weakly acidic reflux should be reported in order to know whether N. de Bortoli (&) I. Martinucci S. Marchi Gastroenterology Unit, Department of Translational Medicine and New Technology, University of Pisa, Pisa, Italy e-mail: nick.debortoli@gmail.com

A Clinical Comparison of Laparoscopic Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease

To compare the advantages and disadvantages of laparoscopic Nissen and Toupet fundoplication in the treatment of gastroesophageal reflux disease (GERD) and their indications. From June 2001 to December 2011, 383 patients with GERD were randomized into two groups according to the last number in their hospitalization number. Overall, 215 patients underwent laparoscopic Nissen fundoplication, and 168 underwent laparoscopic Toupet fundoplication. No conversions to laparotomy or deaths were observed, and the symptoms disappeared completely postoperatively in both groups. Average follow-up was 5.6 years. No recurrence of symptoms was observed in the Nissen group. Eighteen patients experienced recurrence of symptoms in the Toupet group and were administered acid-suppressing drugs. Esophageal manometry and acid reflux testing were performed 4 months postoperatively, with normal results in both groups. The cure rate of esophageal inflammation was 88.4% in the Nissen group and 67.7% in the Toupet group. Four days postoperatively, the incidences of dysphagia and abdominal distension were significantly higher in the Nissen group compared with the Toupet group (28.4% and 16.7%, respectively); the difference between the two groups significantly decreased 1 year postoperatively (1.5% and 0.8%, respectively). In the short term, the incidence of dysphagia was significantly lower after Toupet fundoplication, but the difference decreased significantly with extension of the postoperative recovery period. For patients with moderate to severe GERD, the laparoscopic Nissen fundoplication may be optimal; for elderly patients or for patients with significantly reduced esophageal peristalsis detected in preoperative examinations, the laparoscopic Toupet fundoplication should be considered.

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce. This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294). Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF. Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Laparoscopic anti-reflux surgery to treat proton pump inhibitor-resistant non-erosive reflux disease

We performed surgery for proton pump inhibitor-resistant non-erosive reflux disease patients whose symptom index, confirmed by combined multichannel intraluminal impedance–pH monitoring, was positive. Laparoscopic Nissen fundoplication was performed in five patients and laparoscopic Toupet fundoplication in 3 patients. In 6 of 8 patients, non-acid or minor acid reflux caused the symptoms. Satisfaction percentages assessed 1 year postoperatively were 12.5 % (excellent) and 87.5 % (good).The number of total reflux events decreased to 28.5 ± 14.4 % postoperatively. The symptom index decreased from 63.8 to 20.8 %. It is controversial whether the surgery reduces weakly acidic reflux to the same degree as acid reflux. Previous reports discuss the effect of laparoscopic Nissen fundoplication on acid and weakly acidic reflux; however, the results of these studies are contradictory. In our cases, laparoscopic Toupet fundoplication as well as Nissen fundoplication improved symptoms, and reduced acid and non-acid reflux similarly. These findings strongly support the importance of surgical intervention in proton pump inhibitor-resistant non-erosive reflux disease patients.

Barrett’s esophagus following treatment of achalasia with botulinum toxin

Achalasia is an uncommon primary motor disorder of the esophagus with an annual incidence of 0.8/100,000. Very few cases of coexistent Barrett’s esophagus (BE) and achalasia in patients without prior surgical myotomy or pneumatic dilation have been reported. We report the case of a 65 year old female who was diagnosed with achalasia in June 2002. Endoscopy at that time revealed biopsy-confirmed normal esophageal mucosa. The patient subsequently underwent two trials of botox injection with progressively worsening dysphagia. A repeat endoscopy two years later showed a short segment of salmon-colored mucosa in the distal esophagus which was biopsy-confirmed Barrett’s epithelium with no dysplasia. The patient eventually underwent laparoscopic Heller myotomy and Toupet fundoplication. Postoperatively, she recovered well and with significant alleviation of her dysphagia. This study reviews reported cases of coexistent achalasia and BE, and discusses possible etiologies of concurrent BE and achalasia, and implications for treatment.

A prospective nonrandomized comparison of laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication in Indian population using detailed objective and subjective criteria

BACKGROUND:Laparoscopic Nissen fundoplication (LNF) is a commonly performed procedure for the treatment of gastro esophageal reflux disease (GERD) worldwide. However, unfavourable postoperative sequel, including gas bloat and dysphagia, has encouraged surgeons to perform alternative procedures such as laparoscopic Toupet fundoplication (LTF). This prospective nonrandomized study was designed to compare LNF with LTF in patients with GERD.MATERIALS AND METHODS:Hundred and ten patients symptomatic for GERD were included in the study after having received intensive acid suppression therapy for a minimum of 8 weeks. A 24-hour pH metry was done on all patients. Fifty patients having reflux on 24-hour pH metry were taken up for the surgery. Patients were further divided into group-A (LNF) and group-B (LTF).RESULTS:The median percentage time with esophageal pH < 4 decreased from 10.18% and 12.31% preoperatively to 0.85% and 1.94% postoperatively in LNF and LTF-groups, respectively. There was a significant and comparable increase in length of lower esophageal sphincter (LES), length of intraabdominal part of LES and LES pressure at respiratory inversion point in both the groups. In LNF-group, five patients had early dysphagia that improved afterwards. There were no significant postoperative complications.CONCLUSION:LNF and LTF are highly effective in the management of GERD with significant improvement in symptoms and objective parameters. LNF may be associated with significantly higher incidence of short onset transient dysphagia that improves with time. Patients in both the groups showed excellent symptom and objective control on 24-hour pH metry on short term follow-up.

Clinical Outcome at Ten Years after Laparoscopic Fundoplication: Nissen versus Toupet

Laparoscopic surgery has become the elective approach for the surgical treatment of gastroesophageal reflux disease in the last decade. Outcome data beyond 10 years are available for open fundoplication, with good-to-excellent results, but few studies report long-term follow-up after laparoscopic fundoplication. We performed a retrospective study of all the patients that underwent laparoscopic Nissen and Toupet fundoplications as antireflux surgery between 1995 and 1998 in our institution. To evaluate the long-term results, a face-to-face interview was performed in 2009. One hundred and six patients were included in the study. Surgical techniques performed were Nissen fundoplication (NF) in 56 patients and Toupet (TF) in 50. Complication rate was 4 per cent in both groups (nonsignificant [NS]). Two patients (4%) of NF required reoperation because of dysphagia. After 10 years, 10 per cent of the patients remain symptomatic in both groups. Fifteen per cent of NF take daily inhibitors of the proton pump versus 14 per cent of TF (NS). Twenty per cent of NF refer dysphagia, all of them without evidence of stenosis at endoscopy or contrasted studies. The satisfaction rate of the patients was 96 per cent in NF and 98 per cent in TF. Laparoscopic Toupet fundoplication seems to be as safe and long-term effective as Nissen, but with a lower incidence of postoperative dysphagia. In our experience Toupet fundoplication should be the elective approach for the surgical treatment of gastroesophageal reflux disease.

Meta‐analysis of laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastro‐oesophageal reflux disease based on randomized clinical trials

Laparoscopic Nissen fundoplication (LNF) is the standard procedure for surgical management of gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) is reported to be as effective as LNF but to be associated with a lower incidence of post-operative dysphagia. This meta-analysis was performed to compare the two techniques with respect to reflux control and associated complications, particularly dysphagia. Pubmed, Medline, Embase and The Cochrane Library were searched. Only randomized controlled trials (RCTs) comparing LNF and LTF were included. Outcomes evaluated were occurrences of heartburn and associated complications (e.g. dysphagia) and degree of patient's satisfaction at early (three to six months) and later (one to three years) post-operative periods. Of 939 patients in seven RCTs, 478 received LNF and 461 received LTF. For both groups, control of reflux was good and occurrence of heartburn were similar. A lower incidence of post-operative dysphagia for both early and later post-operative periods was observed for the LTF group. Patient's satisfaction following either procedure was similar. LNF and LTF are both safe and effective. LTF is truly associated with a lower occurrence of dysphagia. However, LTF is more likely than LNF to be associated with early surgical complications. On the whole, post-surgical satisfaction ratios for the two groups were comparable.

Systematic review and meta-analysis of laparoscopic Nissen (posterior total)versusToupet (posterior partial) fundoplication for gastro-oesophageal reflux disease

Laparoscopic Nissen fundoplication (LNF) is currently considered the surgical approach of choice for gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) has been said to reduce troublesome dysphagia and gas-related symptoms. A systematic review and meta-analysis of randomized clinical trials (RCTs) was performed to compare LNF and LTF. Four electronic databases (MEDLINE, Embase, Cochrane Library and ISI Web of Knowledge CPCI-S) were searched and the methodological quality of included trials was evaluated. Outcomes included recurrent pathological acid exposure, oesophagitis, dysphagia, dilatation for dysphagia and reoperation rate. Results were pooled in meta-analyses as risk ratios (RRs) and weighted mean differences. Seven eligible RCTs comparing LNF (n = 404) with LTF (n = 388) were identified. LNF was associated with a significantly higher prevalence of postoperative dysphagia (RR 1.61 (95 per cent confidence interval 1.06 to 2.44); P = 0.02) and dilatation for dysphagia (RR 2.45 (1.06 to 5.68); P = 0.04). There were more surgical reinterventions after LNF (RR 2.19 (1.09 to 4.40); P = 0.03), but no differences regarding recurrent pathological acid exposure (RR 1.26 (0.82 to 1.95); P = 0.29), oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40), subjective reflux recurrence, patient satisfaction, operating time or in-hospital complications. Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009) and gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001) were more prevalent after LNF. LTF reduces postoperative dysphagia and dilatation for dysphagia compared with LNF. Reoperation rate and prevalence of gas-related symptoms were lower after LTF, with similar reflux control. These results provide level 1a support for the use of LTF as the posterior fundoplication of choice for GORD.

A 5-year prospective review of posterior partial fundoplication in the management of gastroesophageal reflux disease

Introduction Laparoscopic Nissen fundoplication is the most common surgical procedure performed for gastroesophageal reflux disease (GORD). It is however associated with a number of mechanical complications with as many as one in three patients experiencing troublesome dysphagia or gas bloat. Partial fundoplication, either posterior or anterior, has been advocated in an attempt to reduce these problems. Our aim was to prospectively evaluate laparoscopic posterior partial (Toupet) fundoplication as the primary surgical treatment for GORD. Method Outcomes following Toupet fundoplication performed between October 2002 and October 2007 were recorded prospectively. All patients underwent a 270° posterior partial fundoplication with routine crural repair. All procedures were performed by a single surgeon. Pre-operative investigations included endoscopy, pH studies/manometry and contrast studies. DeMeester acidity scores, percentage reflux time and oesophageal motility were recorded. Pre- and post-operative DeMeester symptom scores (0–9, DSS) and Visick grading were used to assess the outcomes of surgery. Results 101 Patients were studied. Ages ranged from 17 to 69 years. The median pre-operative DSS of 5 fell to a median of 0 post-operatively. Scores decreased following surgery in all cases. 91 (91%) patients were discharged on the 2nd post-operative day or sooner. 5 (4.9%) patients had prolonged dysphagia (>3 months), and 8 (7.9%) had mild prolonged gas bloat. A single patient had a recurrence of reflux at 2 years and required re-do laparoscopic surgery. There were no conversions to open surgery. Conclusions Laparoscopic Toupet fundoplication provides excellent relief of GORD symptoms with a low incidence of post-operative mechanical complications. We would recommend it as the operation of choice for GORD.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

To demonstrate the optimal surgical procedure for gastroesophageal reflux disease. The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis. We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients' satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF. Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Long-term outcome of laparoscopic Nissen and laparoscopic Toupet fundoplication for gastroesophageal reflux disease: a prospective, randomized trial

A prospective, randomized trial was performed to evaluate the long-term outcome and patient satisfaction of laparoscopic complete 360 degrees fundoplication compared with partial posterior 270 degrees fundoplication. Partial fundoplication is purported to have fewer side effects with a higher failure rate in controlling gastroesophageal reflux disease (GERD), while complete fundoplication is thought to result in more dysphagia and gas-related symptoms. Patients were randomized to either laparoscopic Nissen (LN) or laparoscopic Toupet (LT) fundoplication. Esophageal manometry, 24-h pH studies, a detailed questionnaire, and a visual analog symptom (VAS) score were completed before and after surgery. A final global outcome questionnaire was performed. Failure was defined as recurrent GERD requiring revision surgery, maintenance proton pump inhibitor (PPI) therapy, or surgery for postoperative dysphagia. One hundred patients were randomized to LN (50) or LT (50). There were no differences between LN and LT with respect to postoperative symptoms and physiological variables except a higher wrap pressure in the LN group (15.2 vs. 12.0 mmHg). Dysmotility improved in 8/14 (57%) and 6/11 (54%) patients in the LN group and the LT group, respectively, after surgery. There was no correlation between dysmotility and dysphagia both pre- and post surgery in the two groups. Recurrent symptoms of GERD occurred in 8/47 (17.0%) and 8/48 (16.6%) in the LN group and the LT group, respectively. Outcome of patients with dysmotility was similar to those with normal motility in both groups. At final follow-up (59.76 + or - 24.23 months), in the LN group, 33/37 (89.1%) would recommend surgery to others, 32/37 (86.4%) would have repeat surgery, and 34/37 (91.8%) felt they were better off than before surgery. The corresponding numbers for the LT group (follow-up = 55.18 + or - 25.97 months) were 35/36 (97.2%), 30/36 (83.3%), and 33/36 (91.6%). LN and LT are equally effective in restoring the lower esophageal sphincter function and provide similar long-term control of GERD with no difference in dysphagia. Esophageal dysmotility had no influence on the outcome of either operation.

Asymptomatic free intraperitoneal gas with duodenal stenosis.

A 30-year-old man was referred to our hospital in October 2006 for asymptomatic free air in the peritoneal cavity found on a plain chest X-ray on a routine health examination. Esophagogastroduodenoscopy (EGD) revealed an ulcer scar and deformity of the duodenal bulb, a healing-phase ulcer in the anterior wall of the upper gastric corpus, gradeB esophagitis (Los Angeles grading system), and a sliding hiatal hernia. A test for Helicobacter pylori was negative. Upon obtaining an informed consent (asymptomatic perforation), laparoscopic selective proximal vagotomy, Toupet fundoplication, and small skin incision Finney pyloroplasty were performed. Intraoperatively, extensive adhesions of the greater omentum to the duodenal bulb were found, which were suspected to engulf the cryptic perforation. The patient's postoperative course has been uneventful and, at present, recurrence of the ulcer has not been observed. The presented case is rare considering the absence of surgical history, lack of symptoms, and incidental finding of the intraperitoneal free air during a health examination.

Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplications

Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) (n = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) (n = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia (P = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication.

Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled study

We read with great interest the recent Surgical Endoscopy publication entitled ‘‘Robot assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled study’’. The authors come to the conclusion that—besides shortened operation time—the application of the operation robot does not reveal a further benefit in laparoscopic fundoplication. In 2002 we were able to perform a pilot study on robot-assisted laparoscopic Toupet fundoplication with the DaVinci surgical system (Intuitive Surgical, Mountain View, Calif., USA) with a 6month follow-up and came to the same conclusion except for an even longer set-up and operating time in our series [1]. Despite demanding experience of the surgeon in order to obtain a good functional outcome the performance of a laparoscopic fundoplication does not require the four main advantages of robot assisted laparoscopic surgery: it is not an operation that cannot be performed laparoscopically without the robot [2]; it does not require microscopic view and movements of the arms; anatomically it is not an operation in a remote or narrow operating field [3, 4]; and in a normal laparoscopic fundoplication no complex manoeuvres such as creation of an intracorporeal anastomosis or complex suturing [5] are needed. Improved ergonomics for the surgeon and a shorter set-up and operation time as a matter of training (as demonstrated in the above mentioned paper) do not outweigh higher operative costs as long as no further clear advantage is proven. Laparoscopic redo fundoplications [6] often consist of an even more demanding intraoperative situation where the operation robot could allow for a more precise dissection, avoiding inadvertent lacerations (e.g., lacerations of the vagus nerve), and therefore lead to a better outcome. For training purposes in order to be prepared for such more demanding applications the performance of robot-assisted laparoscopic fundoplications seems justified.

Long-term comparative outcome between laparoscopic total Nissen and Toupet fundoplication: Symptomatic relief, patient satisfaction and quality of life

Laparoscopic antireflux surgery has become an established method of treatment of gastroesophageal reflux disease. This study compares the long-term outcome of total (Nissen) and partial (Toupet) fundoplication, performed in a single institution, by evaluating symptoms and quality of life. 266 patients who underwent laparoscopic Nissen or Toupet fundoplication completed a preoperative reflux symptom questionnaire. Postsurgery symptom evaluation, patient satisfaction and quality of life in reflux and dyspepsia (QOLRAD) questionnaires were sent to these patients in December 2004. The two groups were compared for each item nonparametrically. Completed questionnaires were received from 161 patients (61%) of whom 99 had a laparoscopic Nissen fundoplication and 62 laparoscopic Toupet fundoplication. Both procedures were equivalent in improving reflux symptom scores in the long term, 79/99 (80%) and 56/62 (90%) were either symptom free or had obtained significant symptomatic relief. Both groups had equivalent QoL scores on the QOLRAD questionnaire. An equivalent number of patients (86% and 83.9% after Nissen and Toupet, respectively) were sufficiently satisfied to recommend antireflux surgery to a friend or relative complaining of reflux symptoms. In conclusion, in patients who have returned the questionnaire, long-term satisfaction, general symptom scores, and quality of life are equivalent after laparoscopic Nissen (complete) or Toupet (partial) fundoplication. There is however, a significant increased prevalence of persistent heartburn after laparoscopic Toupet fundoplication.