|Year : 2005 | Volume
| Issue : 2 | Page : 73-84
|Partial posterior wrap (toupet)in patients with defective esophageal body motility
Nabil Ali Gad El-Hak, Mostafa Abo Zeid, Ahmed Aboelemen, Amjad Fouad, Talat Abd alla, Mohamed El Shoubary, Tharout Kandel, Emad Hamdy, Mohamed Abdel Wahab, Omar Fathy, Gamal El Ebidy, Ahmed Sultan, Amjad Elfiky, Nabih Elghwalby, Farouk Ezzat
Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
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|Date of Submission||14-May-2004|
|Date of Acceptance||22-Feb-2005|
| Abstract|| |
Background: The effectiveness of partial posterior wrap (Toupet procedure) in patients with defective esophageal body motility is controversial.
Aim of the study: To evaluate the effect of Toupet procedure upon the outcome of laparoscopic (LF) and open (OF) fundoplications in gastroesophageal reflux disease (GERD) patients with defective esophageal body motility.
Patients and Methods: This study included 32 patients with severe GERD who underwent Toupet procedure; 18 (56.25%) OF 'and 14 (43.75%) LF. Outcome measures included assessment of relief of the symptoms, results of repeated endoscopy, barium study, manometry and pH metry; both early (within six months) and late (two years at least).
Results: Relief of heartburn was achieved in 26 patients (81.3%). These include 14 (77.7%) and 12 (85.7%) patients who underwent OF and LF respectively. Occasional dysphagia developed in six patients (18.7%) early, and three (9.4%) late; all were managed conservatively. Endoscopic esophagitis healed in 26 patients (81.3%); 14 (77.7%) OF and 12 (85.7%) LF. Mean LES and body pressures improved (10.5 to 17.7 and 29.0 to 41.0 mmHg respectively). Persistent acid reflux was detected in six patients (18.7%); two (22.3%) OF and two (14.3%) LF.
Conclusion: Toupet fundoplication is an effective procedure for reflux control except in patients with severe GERD
Keywords: Partial posterior wrap, Toupet procedure, defective body motility.
|How to cite this article:|
El-Hak NA, Zeid MA, Aboelemen A, Fouad A, Abd alla T, El Shoubary M, Kandel T, Hamdy E, Wahab MA, Fathy O, El Ebidy G, Sultan A, Elfiky A, Elghwalby N, Ezzat F. Partial posterior wrap (toupet)in patients with defective esophageal body motility. Saudi J Gastroenterol 2005;11:73-84
|How to cite this URL:|
El-Hak NA, Zeid MA, Aboelemen A, Fouad A, Abd alla T, El Shoubary M, Kandel T, Hamdy E, Wahab MA, Fathy O, El Ebidy G, Sultan A, Elfiky A, Elghwalby N, Ezzat F. Partial posterior wrap (toupet)in patients with defective esophageal body motility. Saudi J Gastroenterol [serial online] 2005 [cited 2020 Jul 12];11:73-84. Available from: http://www.saudijgastro.com/text.asp?2005/11/2/73/33323
Gastroesophageal reflux disease is a common disorder affecting millions of people each year. Although powerful drugs are available to control symptoms of GERD and heal acute mucosal injury, many patients worry about side effects and longterm safety of potentially life-long medical treatment  . Surgical treatment became the standard management for patients with severe GERD. Fundoplication was first described by Nissen in 1956. While achieving good control of pathological reflux in the majority of patients, an incidence of adverse sequelae has led to the subsequent modifications of Nissen's original technique. Shortening the wrap to 1-2cm, dividing the short gastric vessels and modification of the complete wrap to a partial one have been advocated  . Impaired esophageal body motility is one of the most important factors associated with GERD, with a prevalence of up to 25% in patients with mild disease and 50% in patients with severe disease  . It is defined as peristaltic amplitude < 30 mmHg in the distal third and failed primary peristalsis with or without > 20% simultaneous contractions. All patients in this study had impaired or ineffective esophageal contractions.
Patients with poor esophageal body function are likely to be at greater risk of postoperative dysphagia. However, till now an argument has intensified about the effectiveness and durability of Toupet procedure. Stein et al, and Thor et al, showed that it restored esophageal body function with low incidence of postoperative dysphagia , , while Lundell et al, and Watson et al, assured that it is not durable, which is contrary to the complete wrap. ,
| Patients and Methods|| |
Between March 1994 and June 2000, 32 patients underwent Toupet procedure; 18 (43.75%) OF (ten males and eight females with mean age 39.7±10.3 years) and 14 (56.25%) LF (eight males and six females, mean age 38.7±10.3 years). Preoperatively, these patients were suffering from heartburn and regurgitation. All patients had received medical treatment including proton pump inhibitors for at least six months with improvement of symptoms, but early recurrence after discontinuation of treatment. Full data collection was made pre-operatively, early post-operative within six months and late at a mean period of follow up of 4±2 years.
All patients were thoroughly assessed regarding GERD symptoms as well as those specifically related to the fundoplication procedure. All symptoms were scored from 0 to 3 (0, no symptoms; 1, mild; 2, moderate and 3 severe). Mild symptoms were those easily controlled by dietary measures, occasional intake of antacids etc. Severe symptoms included reflux or symptoms occurring after fundoplication, which required continuous medical therapy or other therapeutic intervention. Endoscopic evaluation of the esophagus was performed grading esophagitis according to modified Savary-Miller classification (from 0 to IV) 
Barium study was done in both prone and Trendlenburg positions using provocative tests as straining and water siphon test to detect the degree of reflux (no reflux, mild, moderate or severe). Esophageal manometry was carried out using eightlumen water perfused catheters connected to a recording system (SmartLab Motility system, SANDHILL, USA). The highpressure zone was defined using a station pull-through technique as the mean of the highest pressure plateau recorded by each of the eight ports minus the mean pressure in the gastric fundus measured at the mid of respiration, and the patients was asked to take 5ml water to obtain % relaxation where the resting of the lower esophageal sphincter pressure falls to the level of the gastric base line for a period of greater than five seconds. The length of the intraabdominal part of the high-pressure zone was calculated from the pressure profile as the distance from the point of the first table pressure increase above fundus pressure to the first point of negative pressure to change at inspiration (PIP). All patients had pre-operative defective LES pressure and impaired esophageal body motility; a mechanical LES defect was defined as an average resting pressure < 8 mmHg and/or length of the intra-abdominal LES zone < 2cm. Impaired esophageal body motility was defined as peristaltic amplitude < 30 mmHg in the distal third and failed primary peristalsis with or without > 20% simultaneous contractions. Twenty-four hour pH monitoring was performed using digitrapper Mark III pH recorder (Synectics, Sweeden) with an antimony pH electrode, the probe was positioned 5 cm above the high-pressure zone as located by manometry. The data were collected using De-Meester score; reflux was considered with score (>14.7). All patients were asked to stop antireflux medication one-week before monitoring.
Operative technique: After general anaesthesia is induced, an upper midline incision is performed. A 270 degrees fundoplication is performed using 3-sutures with 2/0 silk suture on each side of the esophagus, with full-thickness bites of stomach and partial-thickness bites of esophagus.
In the laparoscopic procedure, the patient lies supine, thighs fully abducted and slightly bent. The operating table has a 20 degree reversed Trendelenburg tilt. The same principles of open surgery are followed. Doubtless, visualization of the esophageal hiatus is poor with laparotomy, irrespective of the incision used.
Oral intake was on the third day in OF and second day in LF in nearly all patients. The patients started on fluid diet and discharged home on the fourth and third postoperative day respectively if they were tolerating the diet. Patients were given instructions to change their food slowly over the ensuing three weeks. All values are expressed as mean. Paired values are compared with Student's t-test. Pvalue<0.05 was considered statistically significant.
| Results|| |
There were no per-operative or postoperative significant complications or deaths. No conversion to laparotomy during LF. Only two patients (6.3%) were reoperated upon; the first with LF explored two years postoperative due to recurrent reflux with wrap migration upward, while the second with OF explored one year postoperative due to recurrent reflux without wrap migration. Hiatal repair with refashioning of another floppy complete wrap was performed for both.
At a mean period of follow up of 4±2 years, relief of heartburn was achieved in 26 patients (8 1.3%); 14 (77.7%) OF and 12 (85.7%) LF, while persistent or recurrent heartburn was detected in six patients (18.7%); four (22.3%) OF and two (14.3%) LF. Patients with persistent or recurrent heartburn (six patients) were already out of 18 patients suffering from severe heartburn preoperatively (33.3%). Despite of being present in 17 patients (53.1%) preoperatively, it has decline down to six patients (18.7%) postoperatively; four (22.3%) OF and two (14.3%) LF. Six patients (18.7%) developed dysphagia early postoperative; three (16.7%) OF and three (21.45%) LF and improved to three patients only (9.4%) in the late postoperatively period; two (11.2%) OF (mild and moderate) and one (7.15%) LF (mild).
These patients were managed conservatively without the need for endoscopic or surgical interference. Significant distension was detected in 13 patients (40.6%) during the early postoperative period; eight (44.4%) OF and five (35.7%) LF and decline to five patients (15.6%) on late follow up; three (16.7%) OF and two (14.3%) LF. These patients required no further treatment but antiflatulent. Detailed result of clinical assessment is depicted in [Table - 1], indicating that both heartburn and regurgitation showed a significant improvement on comparing preoperative with early and late postoperative (p < 0.05 in OF and < 0.04 in LF both early and late). [Table - 1], also indicates that both dysphagia and distension showed a significant improvement on comparing early postoperative with late postoperative assessment (p < 0.05 for dysphagia and < 0.01 for distension).
Twenty-nine patients (90.7%) had esophagitis of various degrees preoperatively; five (15.6%) grade I, ten (31.3%) grade II, eight (25.0%) grade III and six (18.8%) grade IV. Late postoperatively, esophagitis was detected in six patients (18.7%); four (22.3%) OF and two (14.3%) LF. Those with persistent or recurrent esophagitis (six patients) were already out of 14 patients having grade III or IV esophagitis preoperatively (42.8%) [Table - 2] and [Table - 3].
Twenty-nine patients (90.7%) had various degrees of reflux preoperatively; 15 (46.9%) mild, eight (25.0%) moderate and six (18.8%) severe. On late postoperative follow up, gastroesophageal reflux was detected only in six patients (18.7%); four (22.3%) OF and two (14.3%) LF. Those with persistent or recurrent reflux (six patients) were already out of 14 patients having moderate or severe reflux preoperatively (42.8%) [Table - 2] and [Table - 3]. Lower esophageal sphincter pressure returned to normal in all patients in both groups (average 17.7 mmHg on late follow up) except in two patients one with OF (8 mmHg) and the other with LF (7mmHg); these were the patients with recurrent reflux who were re-operated upon. The mean LES pressure was similar in both groups; 19.0 mmHg in OF and 19.5 mmHg in LF on early follow up, while late 17.5 and 18.0 mmHg respectively. The length of LES increased in both groups to the same degree; 3.1 cm in the early postoperative period and 3.0 cm on late follow up. Also the LES relaxation was similar in both groups; 92.0% in OF and 91.0% in LF.
An important point is the significant improvement in esophageal body pressure; in OF, it increased from 30.5 mmHg up to 34.5 mmHg early and 40.5 mmHg late, while in LF, it increased from 27.5 mmHg up to 35.0 mmHg early and 42.0 mmHg late with a significant improvement (P< 0.01) for each group. However, there was no significant difference on comparing OF with LF [Figure - 1].
Esophageal acid exposure returned to normal in 26 patients (81.3%); 14 (77.7%) with OF and 12 (85.7%) with LF. Persistent or recurrent acid reflux was detected in the remaining six patients (18.7%); four (22.3%) with OF (three received medical treatment and the other was re-operated upon) and two (14.3%) with LF (one received medical treatment and the other was re-operated upon). These six patients were out of 12 patients having a very low DeMeester score (< 10.0) preoperatively (50%). In OF, DeMeester score decreased from 44.5 preoperatively down to 13.0 early and 12.5 late, while in LF, it decreased from 45.5 preoperatively down to 15.0 early and 12.0 late with a significant difference (P< 0.001) for each group. However, there was no significant difference on comparing OF with LF [Figure - 2].
| Discussion|| |
A number of successful refluxpreventing operations have evolved over the years. Each surgeon uses the procedure that works best in his hands, but not every exponent of a technique is as satisfied with the results as the originator. The majority of studies on antireflux surgery reports were with good to excellent results after various fundoplication procedures  . To achieve a consistently successful outcome, one needs an understanding of the pathophysiology of GERD, the recognition of patients with more severe disease, and the selection of the most suitable antireflux procedure. Patient selection and attention to technical details are essential for a gratifying outcome of antireflux surgery  . Impaired esophageal body motility with subsequent dysphagia is common in patients with longstanding gastroesophageal reflux. Acute esophagitis with submucosal edema, the loss of muscle fibres, and an increase in submucosal collagen due to chronic inflammation of the distal esophagus are potential causative factors for the impairment of esophageal peristalsis in GERD 
Although Nissen fundoplication is the standard operation for patients with normal esophageal peristalsis, it may not be the proper procedure for patients with impaired esophageal body function. Persistent dysphagia is rare after Nissen procedure in the presence of normal esophageal peristalsis, but it is found more frequently in the presence of impaired esophageal peristalsis and requires further interventions  . Nissen fundoplication does not improve esophageal peristalsis, and creates a high esophageal outflow resistance, thus causing further deterioration of esophageal clearance function  . In a previous study, it was demonstrated that both Nissen and Toupet procedures increased LES pressure significantly at six months postoperatively, with a more pronounced effect after Nissen fundoplication. However, the intraabdominal sphincter length was increased equally in both groups, but relaxation of the LES was normal after Toupet fundoplication and incomplete after Nissen fundoplication  . Both lower LES pressure and better LES relaxation after Toupet fundoplication compared with Nissen fundoplication are responsible for the lower outflow resistance of the esophagus. Increased outflow resistance is considered to be the reason for poor improvement in impaired esophageal peristalsis because it may prevent the esophagus from gaining muscle tone. Even though Nissen fundoplication can be performed in a very floppy fashion, the problem of impaired LES relaxation still remains  Therefore, data demonstrating improvement of impaired esophageal body motility after Nissen fundoplication with a low rate of postoperative dysphagia are controversial  .
Toupet procedure is advocated by many surgeons to reduce the likelihood of postoperative dysphagia and gas bloat symptoms especially in patients with esophageal dysmotility ,,. Effective healing of esophagitis is achieved leading to an improvement in esophageal peristalsis. Because of the multi-factorial pathogenesis of GERD, there may be additional factors involved in the nature of postoperative improvement of esophageal motility, such as reduction of a hiatal hernia. The hiatal hernia itself may cause deterioration of esophageal peristalsis. As a result of the loss of phrenoesophageal attachments, the longitudinal muscle may lose tension during contraction because of reduced opposing factors. However, stretching of the longitudinal esophageal muscle is important for the function of the circular muscle and, therefore, for esophageal contractility  . Other published outcome studies and previous trials do not support the routine or selective application of Toupet fundoplication in patients with poor body motility. At present, a short loose Nissen wrap is an appropriate surgical treatment for those patients ,,
.A fundamental question that has rarely been addressed is the extent to which gas bloat symptoms and other complaints typically seen after fundoplication are present before operation in patients with chronic GERD. It is important to know if preoperative gas bloat symptoms predict an unfavorable outcome of surgery and whether the method of fundic wrap affects these postoperative complaints. Postprandial adverse symptoms which occur after fundoplication are usually mild, and often less severe than preoperative reflux symptoms. Fundoplication may impair the ability to belch and thereby to relieve bloating. Inability to belch occurs more likely with Nissen fundoplication. A tendency to fewer gas bloat symptoms has been reported after Toupet procedure with a short and long term follow up. The only explanation for this observation is that patients who had a semifundoplication vented air from the stomach more easily than those who had a total wrap 
.In our study, there was no clinical or physiologic significant difference on comparing OF with LF. Relief of heartburn occurred in 26 of 32 patients (81.3%). This is a low incidence compared to our results of Nissen fundoplication, which ranges from 90 to 95%. On further analysis, it was found that improvement in heartburn occurred in all patients already suffering from mild to moderate degree preoperatively. Those with persistent or recurrent heartburn (six patients) were out of 18 patients suffering from severe heartburn preoperatively (33.3%). Regurgitation was also detected in the same six (out of 12) patients suffering from severe regurgitation preoperatively (50%). Therefore, Toupet procedure seems to be suitable in patients with mild or moderate degree of reflux rather than in those with severe disease. Impaired esophageal motility is common in patients with long standing GERD ,,,, . So far, it is unclear whether esophageal dysmotility is related to the acid reflux itself or whether it is caused by acid-induced esophageal inflammation with submucosal edema or loss of muscle fiber and increased submucosal collagen in chronic inflammation ,,, .
Patients with esophageal dysmotility had a greater prevalence and severity of dysphagia, respiratory symptoms, and heart burn than those with normal esophagus motor function, as described by others  . An important point is the low incidence of dysphagia; improved from six patients (18.7%) in the early, down to three (9.4%) in the late postoperative period (p < 0.05) ranging from mild to moderate degree without the need for endoscopic or surgical interference. Another important finding is the significant improvement in abdominal distension; 13 patients (40.6%) early down to five (15.6%) late (p-value was < 0.01) with no further treatment but anti-flatulent.
Fortunately, in this study the endoscopic and barium studies correlated with the clinical assessment. Persistent or recurrent gastroesophageal reflux was evident in six patients (42.8%) out of 14 having severe reflux esophagitis preoperatively (42.8%). Previous studies showed that it is not necessary that endoscopic and barium study express the clinical findings. This may be explained by the fact that wrap problems may occur without clinical impact.
Both Nissen and Toupet fundoplication significantly increased postoperative LES pressure, with a more pronounced effect after Nissen fundoplication, as described previously by other researchers , . In this study following Toupet fundoplication, LESP increased (average 17.7 mmHg), LES length increased to (3cm) as well as observed improvement in esophageal contraction amplitude from 29.0 to 41.0 mmHg, (p <0.01).
Despite the improvement, esophageal contraction amplitude and primary peristalsis usually do not return to normal values after either Nissen or Toupet fundoplication  . Our findings that esophageal motor dysfunction was not corrected by reflux control are at odds with previous reports ,,,,, Some of these studies had insufficient statistical power to demonstrate a difference, and few have analyzed the outcome of the dysmotility group separately from that of the normal motility group. Moreover, few studies have compared the influence of or reported normalization rather than improvement of esophageal dysmotility. Persistent and/or recurrent esophageal acid reflux by 24hours pH study was detected in 6 patients out of 12 (50%) with high DeMeester score (< 40) preoperatively; this is of course another finding supporting our result that Toupet procedure is not suitable for those with severe form GERD preoperatively.
In conclusion, despite Nissen fundoplication being the gold standard of antireflux surgery in patients with normal esophageal peristalsis, Toupet fundoplication is an effective procedure for reflux control in patients with defective body motility except in patients with severe GERD. Toupet procedure restores esophageal body function and therefore prevents the development of postoperative dysphagia. Disabling gas bloat symptoms and other complaints typically seen after fundoplication are uncommon and seem to be related to reduced belching capacity after operation. However, long-term outcomes following antireflux surgery must be available and awaited before the final status of the various antireflux procedures can be confirmed. In the meantime, the large clinical caseload that is now commonplace in many surgical departments should provide an opportunity for clinical trials to determine more fully the optimal approach for antireflux surgery.
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Nabil Ali Gad El-Hak
Gastroenterology Surgical Center, Mansoura University, Mansoura
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3]
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