[Efficacy comparison of laparoscopic Nissen, Toupet and Dor fundoplication in the treatment of hiatal hernia complicated with gastroesophageal reflux disease].

OBJECTIVE: To compare the efficacy and safety among laparoscopic Nissen, Toupet and Dor fundoplication in the treatment of hiatal hernia complicated with gastroesophageal reflux disease (GERD).

METHODS: Clinical data of 276 patients of hiatal hernia complicated with GERD undergoing operation in our hospital from December 2012 to January 2015 were retrospectively analyzed, including 149 patients of laparoscopic Nissen fundoplication (Nissen group), 41 of laparoscopic Toupet fundoplication (Toupet group), and 86 patients of laparoscopic Dor fundoplication (Dor group). Esophageal reflux status, esophageal manometry, GERD Q rating scale, and postoperative recovery were compare among the three groups.

RESULTS: Reflux status was improved significantly in the three groups after operation(all P<0.05),except that the efficacy in reducing reflux episodes and reflux longest time was not obvious in Toupet group(P>0.05). There were no significant differences in postoperative reflux time, acid reflux time ratio, reflux longest time ratio, DeMeester score among the three groups (all P>0.05). Pairwise comparison showed that Dor group was significantly better than Toupet group in reducing the number of reflux episode(14.36±10.58 vs. 29.83±19.71) and long-reflux (0.64±0.21 vs. 6.20±3.48)(both P<0.05), but Nissen group was better than these two groups in reducing the number of long-reflux (0.38±0.16, P<0.05). As compared to pre-operation, the postoperative esophageal sphincter pressure and residual pressure increased significantly, and the relaxation rate reduced significantly (all P<0.05), while the episode of ineffective swallowing increased significantly in Toupet group (11.25±2.04 vs. 6.36±3.26, P<0.05). The contrast in esophageal manometry between Toupet and Dor group showed that Dor group was better than Toupet group in the recovery of lower esophageal sphincter pressure (mean resting breathing) [(20.69±13.95) mmHg vs.(12.91±6.89) mmHg] and the decrease of ineffective swallowing [9.15±6.44 vs. 11.25±2.04](both P<0.05), while such results of Dor group were similar to Nissen group[(19.87±10.40) mmHg, 6.15±2.95, all P>0.05]. The GERD Q scores were significantly decreased after operation in 3 groups(Nissen group:10.94±2.20 vs.7.41±1.43, t=11.667, P=0.001; Toupet group: 10.91±2.02 vs.7.18±1.33, t=5.109, P=0.005; Dor group: 10.69±1.69 vs. 7.10±1.30, t=7.610, P=0.002). There was no significant difference in GERD Q scores among three groups (F=1.465, P=0.207). The operative time, blood loss, hospital stay and complications were not significantly different among 3 groups (all P>0.05). Follow-up period was 12-51 months (median 19 months), and no significant difference in recurrence was found [Nissen group: 2 cases (1.3%), Toupet group: 1 case (2.4%), Dor group: 1 case (1.2%), χ2 =0.363, P=0.834].

CONCLUSIONS: It is safe and feasible for these three laparoscopic fundoplications to the treatment of hiatal hernia complicated with GERD. But laparoscopic Nissen and Dor fundoplication are better than Toupet fundoplication in reducing the number of reflux episodes, suppressing long reflux, increasing lower esophageal sphincter pressure (mean resting respiration) and decreasing the incidence of postoperative dysphagia.