Meta-analysis of laparoscopic posterior and anterior fundoplication for gastro-oesophageal reflux disease

Although laparoscopic posterior (Nissen) fundoplication (LPF) has the proven efficacy for controlling gastro-oesophgeal reflux surgically, there remain problems with postoperative dysphagia and the inability to belch or vomit. To decrease some of these postoperative complications, laparoscopic anterior fundoplication (LAF) was introduced. The aim of this study was to conduct a meta-analysis of randomized controlled trials (RCTs) to investigate the merits of LPF vs LAF for the treatment of gastro-oesophageal reflux disease (GORD). A search of Medline, Embase, Science Citation Index, Current Contents and Pubmed databases identified all RCTs comparing different types of laparoscopic posterior and anterior fundoplications published in the English Language between 1990 and 2008. The eight variables analysed included operative time, overall complications, rate of conversion to open, re-do operative rate, dysphagia score, heartburn rate, Visick grading of satisfaction and overall satisfaction. Five RCTs totalling 556 patients (LAF=279, LPF=277) were analysed. The analysis showed trends favouring LPF in terms of overall complication rate, conversion rate, incidence of postoperative heartburn and re-do operation rate. There was significant improvement in the postoperative satisfaction score in terms of reflux symptoms favouring LPF while there was significant reduction in the dysphagia score favouring LAF. No difference was noted in operating time and Visick's grading of satisfaction between the two groups. Based on this meta-analysis, LPF is associated with fewer complications, decreased rate of conversion, heartburn rate, re-operation rate and significantly higher overall satisfaction rate for controlling GORD symptoms. However the LAF was associated with a significantly lower incidence of dysphagia compared to its posterior counterpart. We therefore conclude that LPF is a better alternative to AFP at the expense of higher dysphagia rate.