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Laparoscopic Anterior 180-Degree Versus Nissen Fundoplication for Gastroesophageal Reflux Disease: Systematic Review and Meta-Analysis of Randomized Clinical Trials

Broeders, Joris A. MD, PhD*; Roks, David J. MD*; Ahmed Ali, Usama MD; Watson, David I. MBBS, MD, FRACS; Baigrie, Robert J. MBBS, MD, FRCS§; Cao, ZhanGuo MD; Hartmann, Jens MD; Maddern, Guy J. FRACS, PhD*

doi: 10.1097/SLA.0b013e31828604dd

Objective: To compare short- and long-term outcome after 180-degree laparoscopic anterior fundoplication (180-degree LAF) with laparoscopic Nissen fundoplication (LNF).

Summary of Background Data: LNF is currently the most frequently performed surgical therapy for gastroesophageal reflux disease. Alternatively, 180-degree LAF has been alleged to reduce troublesome dysphagia and gas-related symptoms, with similar reflux control.

Methods: MEDLINE, EMBASE, Cochrane Library, and web of Knowledge CPCI-S were searched for randomized clinical trials comparing primary 180-degree LAF with 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 1 and 5 years.

Results: Five distinct randomized clinical trials comparing 180-degree LAF (n = 227) with LNF (n = 231) were identified. At 1 year, the Dakkak dysphagia score [2.8 vs 4.8; weighted mean difference: −2.25; 95% confidence interval (CI): −2.66 to −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%; RR: 0.63; 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-degree LAF. Esophageal acid exposure (standardized mean difference: 0.19; 95% CI: −0.07 to 0.46; P = 0.15), esophagitis (19% vs 13%; RR: 1.42; 95% CI: 0.69–2.91; P = 0.34), heartburn score (standardized mean difference: 1.27; 95% CI:−0.36 to 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, proton pump inhibitor (PPI) use, lower esophageal sphincter pressure, and patient satisfaction were similar after 180-degree LAF and LNF. At 5 years, the Dakkak dysphagia score, flatulence, inability to belch, and inability to relieve bloating remained lower after 180-degree LAF. The 5-year heartburn score, dilatation rate, reoperation rate, PPI use, and patient satisfaction were similar.

Conclusions: At 1 and 5 years, dysphagia and gas-related symptoms are lower after 180-degree LAF than after 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-degree LAF for the surgical treatment of gastroesophageal reflux disease.

Systematic review and meta-analysis demonstrating that 180-degree laparoscopic anterior fundoplication (180-degree LAF) reduces short- and long-term dysphagia and gas-related symptoms compared with laparoscopic Nissen fundoplication, with similar reflux control, dilatations, and reoperation rates. These results lend level 1a support for the use of 180-degree LAF for the surgical treatment of gastroesophageal reflux disease.

*Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville South, South Australia

Department of Surgery, Cleveland Clinic, Cleveland, OH

Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia

§Gastrointestinal Surgical Unit, University of Cape Town, Kingsbury Hospital, Cape Town, South Africa

TianJin Mini-invasive Surgery Center, TianJin Medical University, TianJin NanKai Hospital, TianJin, China

Department of General, Visceral, Vascular and Thoracic Surgery, University Medicine Berlin, Berlin, Germany.

Reprints: Joris A.J.L. Broeders, MD, PhD, The Queen Elizabeth Hospital, DX465314, Woodville South, South Australia 5011, Australia. E-mail:

Disclosure: Support for the randomized clinical trial from Adelaide has been provided by Research Project grants from the National Health and Medical Research Council (NHMRC) of Australia (grant nos. 157986 and 375111).

© 2013 by Lippincott Williams & Wilkins.