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Original Investigation
March 6, 2019

Comparison of Laparoscopic 270° Posterior Partial Fundoplication vs Total Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
  • 2Department of Surgery, Ersta Hospital, Stockholm, Sweden
  • 3Department of Clinical Sciences, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
  • 4Department of Surgery, Odense University Hospital, Odense, Denmark
JAMA Surg. 2019;154(6):479-486. doi:10.1001/jamasurg.2019.0047
Key Points

Question  Is partial or total fundoplication superior in laparoscopic antireflux surgery?

Finding  In this randomized clinical trial including 456 patients, partial and total fundoplication were equally effective in reducing esophageal acid exposure after 3 years, while mechanical adverse effects were more common after total fundoplication.

Meaning  Although partial and total fundoplication could be recommended for treatment of gastroesophageal reflux, partial fundoplication might be superior by inducing less dysphagia.

Abstract

Importance  Restoration of the esophagogastric junction competence is critical for effective long-term treatment of gastroesophageal reflux disease. Surgical repair results in such restoration, but mechanical adverse effects seem unavoidable. Minimizing these adverse effects without jeopardizing reflux control is warranted.

Objective  To determine whether partial fundoplication (PF) or total fundoplication (TF) is superior in laparoscopic antireflux surgery.

Design, Setting, and Participants  In this double-blind, randomized clinical trial of 1171 patients scheduled for laparoscopic antireflux surgery at a single university-affiliated center between November 19, 2001, and January 24, 2006, 456 patients were randomized and followed up for 5 years. Data were collected from November 2001 to April 2012, and data were analyzed from April 2012 to September 2018.

Interventions  A 270° posterior PF or a 360° Nissen TF.

Main Outcomes and Measures  Esophageal acid exposure at 3 years after surgery.

Result  Of the 456 randomized patients, 268 (58.8%) were male, and the mean (SD) age was 49.0 (11.7) years. A total of 229 patients were randomized to PF, and 227 patients were randomized to TF. At 3 years postoperatively, the median (interquartile range) esophageal acid exposure was reduced from 14.6% (9.8-21.9) to 1.8% (0.7-4.4) after PF and from 16.0% (10.4-22.7) to 2.5% (0.8-6.8) after TF (P = .31). Likewise, reflux symptoms were equally and effectively controlled. Early postoperative dysphagia (6 weeks) was common in both groups but then decreased toward normality. A small but statistically significant difference in favor of PF was noted in the mean (SD) scoring of dysphagia for liquids at 6 weeks (PF, 1.6 [0.9]; TF, 1.9 [1.3]; P = .01) and for solid food at 12 months (PF, 1.3 [1.0]; TF, 1.9 [1.4]; P < .001) and 24 months (PF, 1.3 [0.9]; TF, 1.7 [1.2]; P = .001). Quality of life was reduced before surgery but increased to normal values after surgery and remained so over 5-year follow-up, with no difference between the groups.

Conclusions and Relevance  The results from this randomized clinical trial suggest that although PF and TF could be recommended for treatment of gastroesophageal reflux disease, PF might be superior by inducing less dysphagia.

Trial Registration  ClinicalTrials.gov identifier: NCT03659487

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