Watson et al. [10] reported in 1999 the short-term results of a prospective double-blind RCT that compared 53 GERD patients treated with LTF and 54 GERD patients undergoing an anterior 180° LPF. Patients with a severe esophageal motility disorder were excluded. Postoperative dysphagia, heartburn and patients satisfaction were assessed using standardized clinical grading systems. At 6 months, LPF patients experienced significantly less dysphagia for solid food (15 % vs. 40 %, p = 0.008), were more likely to belch normally, reported less flatulence, and their level of satisfaction was higher than in patients treated with LTF. No differences were observed in terms of heartburn (9 % in both groups), and mean acid exposure at 24-h pH monitoring. The authors concluded that anterior 180° LPF achieves equivalent control of reflux and is associated with improved clinical outcomes at 6 months.

The 5-year follow-up results of this RCT based on standardized questionnaires confirmed in 101 patients (51 LTF, 50 LPF) similar heartburn control in the two groups (10 % LTF vs. 20 % LPF, p = 0.172), lower incidence of dysphagia, abdominal bloating and inability to belch among LPF patients, with high patients satisfaction scores in both groups, proving the durability of anterior 180° LPF. [11]

Finally, 10-year follow-up data obtained in 89 patients (48 LTF and 41 LPF) using a standard clinical questionnaire showed that both LTF and anterior 180° LPF are durable, safe and effective, with no significant differences in terms of heartburn control, use of Proton Pump Inhibitors (PPIs), incidence of dysphagia, and overall satisfaction [12]. However, when patients were tested with manometry and ambulatory 24-h impedance- pH monitoring at 14 years follow-up, mean LES resting and relaxation pressures were lower and acid, weakly acidic, liquid and mixed reflux episodes were more common after LPF. LPF patients experienced more frequent heartburn than LTF patients, while dysphagia was less common. [13]

Similar results were obtained by Baigrie et al. [14] They randomized 163 GERD patients, regardless of motility findings, to a LTF (84 patients) or an anterior 180° LPF (79 patients), with no division of the short gastric vessels. There were no significant differences in heartburn according to the assessment by visual analogue scale between the two groups at 3, 12, and 24 months. Patients after LPF had significantly less dysphagia at each follow-up interval. No differences were reported in patient satisfaction scores.

Although postoperative dysphagia and gas-related problems are reduced after anterior 180° LPF compared to LTF, they are still reported in some patients. This led in the late 1990s to the development of a 90° anterior LPF, that was compared to LTF in several RCTs.

Watson et al. [15] published in 2004 the short-term outcomes of a multicenter, prospective, double-blind RCT: 112 GERD patients were randomized to anterior 90° LPF (60 patients) or LTF with division of the short gastric vessels (52 patients). Patients with esophageal motility disorders were excluded from the study. Clinical outcomes in terms of dysphagia, heartburn and overall satisfaction were measured using multiple clinical grading systems at 1, 3, and 6 months postoperatively. Esophageal manometry, 24-h pH monitoring, and upper endoscopy were performed 3–4 months after surgery. No significant differences were observed in terms of early postoperative morbidity and length of postoperative stay. At 6 months, dysphagia and flatulence were more frequently experienced by patients undergoing LTF. LES pressure, acid exposure and endoscopic findings were similar at 3–4 months after both procedures. The incidence of heartburn assessed by yes/no questions was similar in the two groups at 1 and 3 months, while it was significantly higher after LPF at 6 months (19 % vs. 4 %, p = 0.03). Overall satisfaction was higher after LPF. Based on these data, the authors concluded that anterior 90° LPF provides effective reflux control, and it is followed by less dysphagia and gas-related symptoms than LTF. The 12-month follow-up of clinical outcome based on analog scales showed that patients after LPF were less likely to experience dysphagia than patients treated with LTF, while no differences were observed at 5 years. A reduced incidence of heartburn was reported after LTF compared to LPF at 12 months and 5 years. Overall satisfaction was similar in both groups of patients over time. [16]

Spencer et al. [17] published in 2006 the short-term results of a RCT that compared 40 patients undergoing anterior 90° LPF and 39 patients treated with LTF without division of the short gastric vessels. Patients with severe esophageal motility that contraindicated a LTF were excluded from the study. At 1-year follow-up, LTF was associated with higher rates of dysphagia, while no differences were reported for the assessment of heartburn by the visual analogue scale. However, 24-h pH monitoring showed a significantly lower percentage time with pH less than four in the LTF group. At manometry, postoperative LES resting pressure was similar in the two groups, while LES residual relaxation pressure was significantly higher after LTF. Seventy-four patients were available for analysis of clinical outcome using standardized questionnaires at 5 years [18]. The authors found that the incidence of dysphagia and bloating was higher after LTF when measured by an analogue score. There were no significant differences in terms of heartburn control and overall satisfaction, although PPIs were more frequently used after LPF (29.7 % vs. 8.1 %). However, manometry and pH monitoring were not performed.

Broeders et al. [19] combined raw data sets from these 2 RCTs, and used the original data to determine the clinical outcomes at 5 years follow-up. Data were available from a subset of 90 patients undergoing LPF and 82 patients treated with LTF. Heartburn scores were significantly higher after LPF, and the use of PPIs was more common. In this group of patients, however, dysphagia and gas-related symptoms were less frequent. Overall satisfaction with the surgical outcomes was similar. No differences were observed in terms of endoscopic dilatations performed for dysphagia (2 % vs. 6 %, p = 0.202), and the number of reoperations (10 % vs. 4.9 %, p = 0.212). In particular, the most frequent indication for reoperation was recurrent reflux in the LPF group, and dysphagia in the LTF group.

Both 180° and 90° anterior LPF are associated with less postoperative dysphagia than LTF at 5 year follow-up. However, at 10 years after surgery, the outcome following anterior 180° LPF and LTF are not significantly different [12]. At 5 years, the incidence of reflux symptoms (i.e. heartburn) and use of PPIs after anterior 180° LPF and LTF were similar, but higher after 90° anterior LPF than LTF. Recurrent reflux is the most common indication for surgical revision of an anterior LPF, while persistent dysphagia is the leading cause for reoperation after LTF. However, the overall number of surgical revisions is not significantly different comparing LPF and LTF. Overall patient satisfaction rating is similar after both subtypes of anterior LPF and LTF.

However, these results should be interpreted with caution. Indeed, most RCTs included small number of patients, did not perform 24-h pH monitoring to evaluate the incidence of reflux at long-term follow-up, and used symptom control and use of PPIs as a marker of surgical outcome. Many studies have in fact shown that when ambulatory 24-h pH monitoring is performed to test patients with recurrent heartburn, pathological reflux is present in less than 40 % of cases [27–30]. On the other hand, long-term studies have shown a less effective control of gastroesophageal reflux with a LPF rather than a LTF. [1, 8, 9] Recurrence of gastroesophageal reflux confirmed by pH monitoring at 5 years is reported in more than 50 % of patients after LPF. [1, 8, 9] Based on these data, we feel that a LTF is the procedure of choice for the treatment of GERD in patients with normal esophageal motility.

Laparoscopic posterior fundoplication has been proposed as an alternative to LTF to reduce the incidence of postoperative dysphagia and gas-related symptoms in GERD patients with normal esophageal peristalsis. Several large RCTs have been published, but the results of these studies did not show significant differences and did not permit definitive conclusion (Table 36.2). Broeders et al. [7] recently published a systematic review and meta-analysis of RCTs that compared LTF to Toupet (posterior partial) for GERD, aiming to establish the best surgical procedure of choice according to the highest level of evidence. They identified 7 RCTs comparing 404 LTF patients and 388 Toupet patients [31–37]. The methodological quality of the included RCTs ranged from poor to excellent, with a median Jadad score of 2 (range, 1–5). Follow-up ranged between 12 (4 RCTs) and 60 months (1 RCT). LTF was associated with a significantly higher prevalence of dysphagia, inability to belch and gas bloating after surgery, more endoscopic dilatations and more surgical reoperations. No differences were observed for recurrent pathological acid exposure, esophagitis, reflux symptoms, and overall patient satisfaction.