Esophagogastric junction distensibility is greater following Toupet compared to Nissen fundoplication

Background: The goal of antireflux surgery is to create a competent antireflux valve at the esophagogastric junction (EGJ). The two most common types of fundoplications constructed are the 360° Nissen and the 270° Toupet. We sought to determine whether there was a significant difference in distensibility at the EGJ based on fundoplication geometry (full vs. partial).

Methods: This is a retrospective review of prospective data. All subjects underwent laparoscopic fundoplication over a 47-month period for primary GERD or failed fundoplication. An endoluminal functional luminal-imaging probe (EndoFLIP^®) was used to assess EGJ distensibility intraoperatively. Minimum esophageal diameter (D _min), cross-sectional area (CSA), and distensibility index (DI) were measured at 30- and 40-mL balloon distension volumes prior to abdominal insufflation, after hiatal dissection, and following fundoplication. DI is defined as the narrowest CSA divided by the corresponding pressure expressed in mm²/mmHg. Analysis was conducted to compare distensibility metrics based on the type of fundoplication constructed (Nissen or Toupet). As a secondary outcome, we sought to determine whether there was a difference in distensibility of the EGJ prior to surgery in patients with primary GERD as opposed to those with recurrent GERD after a failed fundoplication.

Results: A total of 75 patients underwent fundoplications during the study interval. There were 44 primary and 31 reoperative fundoplications. Nissen fundoplication was constructed in 45 and Toupet in 30. Based on the distensibility index, the EGJ distensibility significantly decreased from prior to surgery to following fundoplication in all patients. Patients undergoing reoperative antireflux surgery had an initial DI at the EGJ similar to that of patients with primary GERD. Following Toupet, the EGJ was significantly more distensible than that after Nissen fundoplication.

Conclusions: Laparoscopic fundoplication results in decreased EGJ distensibility in patients with GERD. The EGJ following partial fundoplication is significantly more distensible than that after a full fundoplication.