Five-Year Outcome After Laparoscopic Anterior Partial Versus Nissen Fundoplication Four Randomized Trials

Objective: To compare longer term (5-year) outcomes for reflux control and postsurgery side effects after laparoscopic anterior (90 degrees and 180 degrees) partial versus Nissen fundoplication for gastroesophageal reflux. Background: Laparoscopic Nissen fundoplication is the most frequently performed surgical procedure for gastroesophageal reflux. It achieves excellent control of reflux, but in some patients it is followed by troublesome side effects. To reduce the risk of side effects laparoscopic anterior partial fundoplication variants have been advocated, although some studies suggest poorer reflux control. Methods: From 1995 to 2003, 461 patients with gastroesophageal reflux were enrolled in 4 randomized controlled trials comparing anterior partial versus Nissen fundoplication. Two trials evaluated anterior 180 degrees and 2 anterior 90 degrees partial fundoplication. The original trial data were combined, and a reanalysis from original data was undertaken to determine outcomes at 5 years follow-up. Reflux symptom control and side effects were evaluated in a blinded fashion using standardized questionnaires, including 0 to 10 analog scores (0 = no symptoms, 10 = severe symptoms). Results: At 5 years, patients who underwent an anterior 90 degrees or 180 degrees partial fundoplication had less side effects than those who underwent Nissen fundoplication and were equally satisfied with the overall outcome. Reflux control, measured by heartburn scores and antisecretory medication use, was similar for anterior 180 degrees partial versus Nissen fundoplication, but inferior after anterior 90 degrees partial versus Nissen fundoplication. Conclusions: Anterior 180 degrees partial fundoplication achieves durable control of reflux symptoms and fewer side effects compared with Nissen fundoplication. Reflux control after anterior 90 degrees partial fundoplication appears less effective than after Nissen fundoplication. This data supports the use of anterior 180 degrees partial fundoplication for the surgical treatment of gastroesophageal reflux.