Department of Surgery, Gastrointestinal Research Unit of the University Medical Center Utrecht, Utrecht, The Netherlands.
Ann Surg. 2011 Jul;254(1):39-47. doi: 10.1097/SLA.0b013e31821d4ba0.
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).
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.
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).
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.
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.
通过对随机临床试验（RCT）的系统评价和荟萃分析，比较腹腔镜前路胃底折叠术（LAF）与后路胃底折叠术（LPF）的短期和长期疗效。
LPF 目前被认为是治疗胃食管反流病（GERD）的首选手术治疗方法。相反，LAF 据称可以减少令人困扰的吞咽困难和与气体相关的症状。
检索了 MEDLINE、EMBASE、Cochrane 图书馆和 ISI 网络知识 CPCI-S 四个电子数据库，以比较原发性 LAF 与 LPF 治疗 GERD 的 RCT。评估了方法学质量以评估偏倚风险。主要结局是食管酸暴露时间、烧心、Dakkak 吞咽困难评分（0-45 分）和再次手术率。分别对短期（6-12 个月）和长期（2-10 年）结果进行荟萃分析，得出风险比（RR）和加权均数差（WMD）。
共确定了 11 份关于 7 项合格 RCT 的报告（前路与后路全层[ n = 5]；前路与后路部分[ n = 2]），比较了 LAF（ n = 345）与 LPF（ n = 338）。短期（6-12 个月）食管酸暴露时间（3.3%比 0.8%：WMD 2.04；95%置信区间[CI] [0.84-3.24]；P < 0.001）、烧心（21%比 8%：RR 2.71；95%CI [1.72-4.26]；P < 0.001）和再次手术率（8%比 4%：RR 1.94；95%CI [0.97-3.87]；P = 0.06）在 LAF 后更高。相反，LAF 后 Dakkak 吞咽困难评分较低（2.5 比 5.7：WMD -2.87；95%CI [-3.88 至-1.87]；P < 0.001）。短期内食管炎、反流和围手术期结局没有差异。LAF 后烧心的高发生率在长期（2-10 年）随访中持续存在（31%比 14%：RR 2.15；95%CI [1.49-3.09]；P < 0.001），且更多使用质子泵抑制剂（PPIs）（25%比 10%：RR 2.53；95%CI [1.40-4.45]；P = 0.002）。LAF 后长期再次手术率是两倍（10%比 5%：RR 2.12；95%CI [1.07-4.21]；P = 0.03）。长期 Dakkak 吞咽困难评分、不能嗳气、气胀和满意度没有差异。
与 LPF 相比，LAF 后食管酸暴露时间和烧心的发生率更高。在短期内，这被更严重的吞咽困难所抵消。然而，在长期内，吞咽困难评分变得相似，LAF 后烧心的发生率持续显著增加，且 PPI 的使用也显著增加。LAF 后再次手术率也增加了一倍，主要是由于 GERD 的复发而进行的再次干预。与气体相关的症状的发生率相似。这些结果为 LPF 作为 GERD 的首选手术治疗方法提供了 1a 级证据支持。
