Abstract
Gastroesophageal reflux disease (GERD) impacts 10-30% of the population in the Western world. Surgical interventions including Laparoscopic Fundoplication (LF), Transoral Incisionless Fundoplication (TIF), and Magnetic Sphincter Augmentation (MSA) have proven effective in managing GERD. This meta-analysis aims to compare short- and long-term outcomes of these surgical options.
A comprehensive search of PubMed, Embase, Scopus, Cochrane, and Medline from 1980 to 2024 was conducted to identify randomized control trials or cohort designs that included adults with GERD who underwent fundoplication (Nissen, Toupet), MSA, or TIF and had preoperative and post-operative acid exposure time (AET), DeMeester score, and/or relief score (e.g., GERD-HRQL); we considered all post-operative outcome measurements. We excluded studies with any surgical variations of the procedures, reoperations, and studies not published in English. Risk of bias was assessed using the Oxford scoring system for randomized control trials and the Newcastle-Ottawa scale (NOS) for cohort designs. A total of 3912 studies were identified initially, with our review including 78 unique studies providing 166 post-operative outcome measurements. Given studies could include multiple post-operative outcome measurements, we used multilevel random-effects meta-analysis. Between-procedure comparisons were made using multilevel meta-regression. For all outcomes, more positive values indicated greater improvement; mean differences (MD) were estimated for AET and DeMeester scores, whereas standardized mean differences (SMD) were estimated for relief scores.
A total of 9516 patients were included with an average age of 50.8 years (SD: 6.7) with 53.7% male and an average BMI of 27.1 (SD: 2.3). The median length of follow-up across all observations was 12 months (IQR: 6-24 months; range: 0.25-120.5 months). All procedures indicated a statistically significant mean improvement in AET, relief score, and DeMeester scores (Table 1). Compared to Nissen, TIF averaged significantly less mean improvement in AET (MD: - 4.06, 95% CI: - 8.03 to - 0.09, p = .045) and DeMeester score (MD: - 20.60, 95% CI: - 38.33 to - 2.88, p = .023), whereas MSA and Toupet averaged significantly better relief scores (SMD: 0.28, 95% CI: 0.01 to 0.56, p = .044 and SMD = 0.17, 95% CI: 0.01 to 0.32, p = .034, respectively). This review advances understanding of the objective and subjective improvement of the traditional and recent surgical anti-reflux procedures used for symptomatic GERD. Overall, Nissen fundoplication demonstrated significantly better improvement with acid exposure and DeMeester score compared to MSA and TIF. However, symptom relief scores are significantly improved with Toupet fundoplication and MSA compared to other surgical treatment options.