Laparoscopic Anterior Versus Posterior Fundoplication for Gastroesophageal Reflux Disease Systematic Review and Meta-Analysis of Randomized Clinical Trials

Objective: To compare short- and long-term outcome after laparoscopic anterior fundoplication (LAF) versus posterior fundoplication (LPF) through a systematic review and meta-analysis of randomized clinical trials (RCTs). Summary of Background Data: LPF is currently considered the surgical therapy of choice for gastroesophageal reflux disease (GERD). Alternatively, LAF has been alleged to reduce troublesome dysphagia and gas-related symptoms. Methods: Four electronic databases (MEDLINE, EMBASE, Cochrane Library, and ISI web of Knowledge CPCI-S) were searched for RCTs comparing primary LAF versus LPF for GERD. The methodological quality was evaluated to assess bias risk. Primary outcomes were esophageal acid exposure time, heartburn, Dakkak dysphagia score (0-45) and reoperation rate. Short- and long-term results were pooled separately in meta-analyses as risk ratios (RRs) and weighted mean differences (WMDs). Results: Eleven reports on 7 eligible RCTs (anterior vs. posterior total [n = 5]; anterior vs. posterior partial [n = 2]) comparing LAF (n = 345) versus LPF (n = 338) were identified. Short- term(6-12 months) esophageal acid exposure time (3.3% vs. 0.8%: WMD 2.04; 95% confidence interval [CI] [0.84-3.24]; P <0.001), heartburn (21% vs. 8%; RR 2.71; 95% CI [1.72-4.26]; P <0.001) and reoperation rate (8% vs. 4%; RR 1.94; 95% CI [0.97-3.87]; P = 0.06) were higher after LAF. In contrast, the Dakkak dysphagia score was lower after LAF (2.5 vs. 5.7; WMD -2.87; 95% CI [-3.88 to -1.87]; P <0.001). There were no short- term differences in prevalence of esophagitis, regurgitation and perioperative outcomes. The higher rate of heartburn after LAF persisted during long-term (2-10 years) follow-up (31% vs. 14%; RR 2.15; 95% CI [1.49-3.09]; P <0.001) with more PPI use (25% vs. 10%; RR 2.53; 95% CI [1.40-4.45]; P = 0.002). The long-term reoperation rate was twice as high after LAF (10% vs. 5%; RR 2.12; 95% CI [1.07-4.21]; P = 0.03). Long-term Dakkak dysphagia scores, inability to belch, gas bloating and satisfaction were not different. Conclusions: Esophageal acid exposure time and the prevalence of heartburn are higher after LAF compared with LPF. In the short- term this is counterbalanced by less severe dysphagia. However, dysphagia scores become similar in the long-term, with a persistent substantial increase in prevalence of heartburn and PPI use after LAF. The reoperation rate is twice as high after LAF as well, mainly due to reinterventions for recurrent GERD. The prevalence of gas-related symptoms is similar. These results lend level 1a support for the use of LPF as the surgical treatment of choice for GERD