Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials.
Broeders, Joris A
Roks, David J
Ahmed Ali, Usama
Baigrie, Robert J
Maddern, Guy J
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Objective: To compare short and longer-term outcome after laparoscopic anterior 180˚ fundoplication (180˚ LAF) versus laparoscopic Nissen fundoplication (LNF). Summary of background data: LNF is currently the most frequently performed surgical therapy for GORD. Alternatively, 180˚ LAF has been alleged to reduce troublesome dysphagia and gas-related symptoms, with similar reflux control. Methods: MEDLINE, EMBASE, Cochrane Library and ISI web of Knowledge CPCI-S were searched for randomized clinical trials (RCTs) comparing primary 180˚ LAF versus LNF. The methodological quality was evaluated to assess bias risk. Primary outcomes were esophageal acid exposure, esophagitis, heartburn score, dilatation for dysphagia, modified Dakkak dysphagia score [0-45] and reoperation rate. Meta-analysis was conducted at one and five years. Results: Five distinct RCTs comparing 180˚ LAF (n=227) versus LNF (n=231) were identified. At one year, the Dakkak dysphagia score (2.8 vs 4.8; weighted mean difference (WMD) -2.25; 95% CI [-2.66, -1.83]; P<0.001), gas bloating (11% vs 18%; relative risk (RR) 0.59; 95% CI [0.36,0.97]; P=0.04), flatulence (14% vs 25%; RR 0.57; 95% CI [0.35,0.91]; P=0.02), inability to belch (19% vs 31%; RR0.63 ;95% CI [0.40,0.99]; P=0.05) and inability to relieve bloating (34% vs 44%; RR 0.74; 95% CI [0.55,0.99]; P=0.04) were lower after 180˚ LAF. Esophageal acid exposure (standardized mean difference (SMD) 0.19; 95% CI [-0.07,0.46]; P=0.15), esophagitis (19% vs 13%; RR 1.42; 95% CI [0.69, 2.91]; P=0.34), heartburn score (SMD 1.27; 95% CI [-0.36,2.90]; P=0.13), dilatation rate (1.4% vs 2.8%; RR 0.60; 95% CI [0.19,1.91]; P=0.39), reoperation rate (5.7% vs 2.8%; RR 2.08; 95% CI [0.80,5.41]; P=0.13), perioperative outcome, regurgitation, PPI use, LES pressure and patient satisfaction were similar after 180˚ LAF and LNF. At 5 years, the Dakkak dysphagia score, flatulence, inability to belch and inability to relieve bloating remained lower after 180˚ LAF. The five-year heartburn score, dilatation rate, reoperation rate, PPI use and patient satisfaction were similar. Conclusions: At one and five years, dysphagia and gas-related symptoms are lower after 180˚ LAF compared with LNF, and esophageal acid exposure and esophagitis are similar, with no differences in heartburn scores, patient satisfaction, dilatations and reoperation rate. These results lend level 1a support for the use of 180˚ LAF for the surgical treatment of GERD.
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