Comparison of Symptomatic Outcomes of Endoscopic Fundoplication with Laparoscopic Nissen Fundoplication

Kellie McFarlin, MD, Vic Velanovich, MD. Henry Ford Hospital

Background: Endoscopic fundoplication with the Esophyx device for the surgical treatment of gastroesophageal reflux disease (GERD) is becoming an increasingly popular alternative to laparoscopic Nissen fundoplication in selected patients with small hiatal hernias. There have been no randomized trials comparing the two techniques. Anecdotal reports suggest that patients undergoing endoscopic fundoplication have less postoperative pain and bloating compared to patients treated with laparoscopic Nissen fundoplication. We sought to determine if such a difference exists.

Methods: All patients undergoing surgical evaluation for GERD complete the GERD-HRQL symptom severity questionnaire. This consists of 10 items scored on a Likert scale from 0 to 5. One question specifically deals with dysphagia and another with bloating. The total GERD-HRQL score is the sum of the scores of all the items. The best possible score is 0 and the worst score 50. Between 6 to 8 weeks postoperatively, patients once again complete the GERD-HRQL to assess for symptomatic improvement. We compared the postoperative dysphagia, bloating and total GERD-HRQL scores of all patients who underwent endoscopic fundoplication to a random sample of patients undergoing laparoscopic Nissen fundoplication. Ordinal data was analyzed using the Mann-Whitney U-test and nominal data analyzed using Fisher’s exact test.

Results: 27 patients underwent endoscopic fundoplication and 47 randomly selected patients with laparoscopic Nissen fundoplication. The postoperative median (with interquartile range, IQR) total GERD-HRQL for endoscopic fundoplication was 4 (1-9), compared to 3 (1-8) for laparoscopic Nissen fundoplication (p=NS). The median dysphagia scores were 0 (0) for endoscopic fundoplication and 0 (0-2) for laparoscopic Nissen fundoplication (p=0.03). 84% of endoscopic fundoplication patients score 0 for dysphagia, compared to 53% of laparoscopic Nissen fundoplication patient (p=0.02). The median bloating scores were 1 (0-3) for endoscopic fundoplication and 1 (0-3) for laparoscopic Nissen fundoplication (p=NS).

Conclusion: Patients undergoing endoscopic fundoplication with the Esophyx had similar postoperative overall and bloating scores compared to laparoscopic Nissen fundoplication patients. However, endoscopic fundoplication patients had less dysphagia compared to laparoscopic Nissen fundoplication patients. Clearly, these results are from short-term follow-up and a prospective randomize trial is needed to confirm these findings.