Twenty-nine controlled trials (reported in 32 publications) were included in the review (n=6,236 patients); these included seven randomised controlled trials (RCTs), seven prospective cohort studies and fifteen retrospective studies. Sample sizes ranged from 19 to 1,470; most studies included over 100 patients. Length of follow-up ranged from three months to ten years; most studies followed patients for over one year. Concealment of allocation was adequate in nine of the studies, not adequate in 15 studies, and not reported for the other five studies.
The increase in lower oesophageal sphincter pressure was significantly higher after laparoscopic Nissen fundoplication than after laparoscopic Toupet fundoplication (OR 2.76, 95% CI 1.57 to 3.95; 13 studies).
Compared with laparoscopic Toupet fundoplication, laparoscopic Nissen fundoplication was associated with an increase in the prevalence of dysphagia (OR 1.68, 95% CI 1.12 to 2.52; 24 studies), moderate-to-severe dysphagia (OR 3.11, 95% CI 1.94 to 5.00; number of studies not reported), severe dysphagia requiring bougie dilatation (OR 3.67, 95% CI 1.90 to 7.09; number of studies not reported), gas bloating (OR 2.42, 95% CI 1.37 to 4.26; 12 studies) and inability to belch (OR 3.02, 95% CI 1.14 to 7.95; nine studies).
In subgroup analysis, the prevalence of dysphagia was not significantly different between laparoscopic Nissen and Toupet fundoplication in patients with normal motility prior to surgery (seven studies), but was significantly higher among patients with abnormal motility prior to surgery (OR 1.75, 95% CI 1.04 to 2.94; six studies). There was evidence of statistical heterogeneity for the analysis based on the prevalence of dysphagia (I2=65%), gas bloating (I2=64%), inability to belch (I2=81%) and for the prevalence of dysphagia in patients with normal motility prior to surgery (I2=72%).
There was no significant difference between laparoscopic Nissen and Toupet fundoplication for patient satisfaction (15 studies), remission of moderate-to-severe oesophagitis (five studies), perioperative complications (11 studies), postoperative heartburn (11 studies), reflux recurrence (nine studies) or reoperation (15 studies).