NEW YORK (Reuters Health) – A modified procedure intended to improve on Nissen fundoplication for gastroesophageal reflux disease has been shown in an Australian study to actually have less satisfactory outcomes.

On 5-year follow-up, laparoscopic Nissen fundoplication and laparoscopic anterior 90-degree partial fundoplication had similar adverse effect profiles, but control of reflux symptoms was not as good with the newer technique.

Dr. David I. Watson of Flinders University in Bedford Park, South Australia, and colleagues had previous success with laparoscopic anterior 180-degree partial fundoplication, they note in their report in the Archives of Surgery for June. The modified procedure controlled reflux well while reducing dysphagia and preserving the ability to belch to relieve gas bloating.

This led to a further modification — a 90-degree partial fundoplication — aimed at even better improvement. “Key steps for the anterior 90-degree partial fundoplication included a posterior esophagopexy to the right hiatal pillar, fixation of a length of esophagus within the abdomen, recreation of the angle of His, and construction of a fundoplication that covered the left anterolateral intra-abdominal esophagus,” the group explains.

The technique was tested in a double-blind trial involving 112 patients undergoing primary antireflux surgery; 52 patients underwent laparoscopic Nissen fundoplication and 60 had laparoscopic 90-degee partial fundoplication.

Early results at 6 months’ follow-up were promising, but the data now being reported after 5 years show mean analog scores for heartburn of 0.9 for Nissen fundoplication compared to 2.2 for anterior fundoplication (p=0.003). Mean scores for dysphagia and patient satisfaction were similar in both groups.

In a commentary on the results, Dr. Robert John Baigrie at Groote Schuur Hospital and the University of Cape Town in South Africa says the 90-degree wrap should be seen as “a disappointing procedure that has failed to make better an already good (if imperfect) therapy.”

However, the Australian group is not so dismissive. “We think this trial shows that a limited anterior partial fundoplication can achieve an acceptable long-term result in the majority of patients, but there is a trade-off between recurrent reflux vs side effects,” Dr. Watson told Reuters Health by email.

“Our view is that there is a spectrum across which there is a trade-off between reflux vs side effects,” he continued. For example, similar results to those currently being reported were obtained in another trial of the 90-degree procedure, while the anterior 180-degree partial fundoplication gives good outcomes at 10 years, Dr. Watson explained.

“Eighty to ninety percent (of patients) will be happy with the outcome of all these procedures at late follow-up. The choice of procedure becomes a discussion between the surgeon and the patient – i.e., weighing up the pros and cons of each approach.”

In fact, preference is shifting away from Nissen fundoplication. “Outside clinical trials, we are now undertaking approx 15% anterior 90, 60% anterior 180 and 25% Nissen fundoplication — i.e., we have moved away from the Nissen procedure because we are happy with the longer term results of the anterior partial fundoplication variants,” Dr. Watson concluded.

Reference:

Arch Surg 2010;145:552-557.