Surgical GERD fixes: which fundoplication dominates?

  • Håkanson BS & al.
  • JAMA Surg
  • 6 Mar 2019

  • International Clinical Digest
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Takeaway

  • In surgical treatment for GERD, partial fundal duplication (PF) might be better than total fundal duplication (TF) for inducing less dysphagia.
  • Otherwise, either could be recommended based on the results of this randomized clinical trial with 5 years of follow-up.

Why this matters

  • Surgical repair can restore a competent esophagogastric junction, but some adverse effects are almost a given.
  • Editorial: this “important study” confirms the efficacy of posterior PF and establishes either approach as having “a place in the armamentarium.”

Key results

  • At 3 years postop, esophageal acid exposure dropped (interquartile ranges):
    • PF: from 14.6% (9.8%-21.9%) to 1.8% (0.7%-4.4%).
    • TF: from 16.0% (10.4%-22.7%) to 2.5% (0.8%-6.8%).
  • Dysphagia during first 6 weeks postop was common but normalized.
  • PF slightly favored for dysphagia scores at 6 weeks (P=.01).
  • Also for solid food at 12 (P<.001>) and 24 months (P=.001). 
  • 2 conversions to open surgery, both TF.
  • PF involved longer operating time, as expected.

Study design

  • Randomized trial, 229 patients having 270° posterior PF and 227 having 360° Nissen TF.
  • Outcome: esophageal acid exposure at 3 years.
  • Funding: Stockholm City Council; Erling-Persson Family Foundation.

Limitations

  • No intraoperative bougie used.

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