Influence of Wrap Length on the Effectiveness of Nissen and Toupet Fundoplication: a Prospective Randomized Study

Background: Incontinence or hypercontinence of the fundic wrap depends primarily on the length of the valve or the type of procedure. Much less attention has been paid to the fundic wrap length. This study aimed to compare the effectiveness of two different wrap lengths among the patients undergoing partial or total fundoplication.

Methods: For this study, 153 patients were randomized to either Nissen (1.5- or 3-cm wrap) or Toupet (1.5- or 3-cm wrap) laparoscopic fundoplication. The groups were compared according to intensity of dysphagia, esophageal manometry data, ambulatory 24-h pH monitoring data, postoperative esophagitis rate, and overall treatment failure rate.

Results: In all the groups, the tone of the lower esophageal sphincter was significantly increased and the DeMeester score significantly decreased, reaching normal levels. At 6 months after surgery, the Toupet 1.5-cm group had significantly more cases of esophagitis than the 3-cm wrap group (24.2% vs 3.3%; p<0.05). At 12 months after surgery, only one patient in the Nissen 3-cm group had moderate to severe dysphagia. In all cases, failures were associated with persistent erosive esophagitis. At the 12-month follow-up assessment, treatment failures were significantly more common in Toupet 1.5-cm group than in the Toupet 3-cm group (17.5% vs 2.7%; p<0.05). However, such differences were not observed in the Nissen groups (7.8% for 1.5 cm and 15.6% for 3 cm; p>0.05).

Conclusions: Evaluation of the treatment results suggests that the wrap length is important in partial Toupet fundoplication to avoid treatment failures. The 3-cm wrap is superior to the 1.5-cm wrap in cases of partial posterior Toupet fundoplication. The influence of wrap length on treatment failure remains unconfirmed for the Nissen procedure.