Multicenter, prospective, double-blind, randomized trial of laparoscopic Nissen vs anterior 90° partial fundoplication

Hypothesis: Laparoscopic anterior 90degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. Design: A multicenter, prospective, double-blind, randomized controlled trial. Setting: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. Participants: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous anti-reflux surgery were excluded from this study. Interventions: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90degrees partial fundoplication. Main Outcome Measures: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. Results: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. Conclusions: At the 6-month follow-up, laparoscopic anterior 90degrees partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.