Toupet fundoplication versus fundopexy: Outcomes and need for postoperative dilation for dysphagia

To compare outcomes and the need for postoperative dilation for dysphagia in symptomatic patients who underwent laparoscopic hiatal hernia repair with Toupet fundoplication versus fundopexy.

A retrospective review of outcomes and symptomatic recurrence requiring reoperation in patients who underwent laparoscopic primary hiatal hernia repair with Toupet fundoplication versus fundopexy at a single center was performed. A radiographic classification for a narrow gastroesophageal junction was devised. Radiographic, endoscopic, and EndoFLIP findings at the time of the first dilation were compared.

Comparison of 150 consecutive Toupet procedures vs 150 consecutive fundopexy procedures showed a median age of 56.0 (45.0-65.0) vs 68.0 (57.0-72.0), P < .001. Hiatal hernia distribution was as follows: type I: 85 of 150 (56.7%) vs 31 of 150 (20.7%), P < .001; type IV: 29 of 150 (19.3%) vs 71 of 150 (47.3%), P < .001. Mesh was used in 54 of 150 (36.0%) vs 81 of 150 (54.0%), P = .003. Operative duration, hospital complications, same-day surgeries, and readmissions were comparable. Postoperative dilation was required in 32 of 150 (21.3%) vs 20 of 150 (13.3%), P = .093. Endoscopic evidence of esophagitis at the time of the first dilation was 1 of 32 (3.1%) vs 1 of 20 (5.0%), P = 1.000. An esophagram was obtained in 37 of 52 (71.2%) patients before dilation and showed comparable evidence of a narrow gastroesophageal junction, 15 of 24 (62.5%) vs 8 of 13 (61.5%), P = 1.000. EndoFLIP was obtained in 13 of 52 (25%) and showed esophagogastric junction outflow obstruction in 10/12 (83.3%) in the fundopexy group. At 66.1 months (30.6-75.0) vs 45.8 months (40.0-51.5), P < .001, symptomatic recurrence requiring reoperation was seen in 26 of 150 (17.3%) vs 2 of 150 (1.3%), P < .001.

The surgical outcomes of Toupet and fundopexy are comparable. Based on our preliminary data, fundopexy results in a similar rate of postoperative dilation for dysphagia, radiographic narrowing of the gastroesophageal junction, and postoperative endoscopic esophagitis at the time of dilation to those with Toupet fundoplication. Fundopexy results in fewer symptomatic recurrences requiring reoperation. Randomized studies are required to assess the advantages of fundopexy.