Comparative Analysis of Postoperative Manometry Outcomes in Nissen vs Toupet Fundoplication

Preoperative Setting:

Before surgery, all patients underwent a thorough clinical assessment to evaluate the severity of their GERD symptoms, history of medication use, and the presence of extra-esophageal manifestations such as chronic cough or aspiration. A comprehensive diagnostic workup was conducted, including upper gastrointestinal endoscopy to assess mucosal integrity, rule out Barrett's esophagus, and evaluate the presence of a hiatal hernia. A barium swallow study was performed to assess esophageal motility, reflux severity, and anatomical abnormalities. The cornerstone of preoperative evaluation was high-resolution manometry (HRM), which provided precise measurements of lower esophageal sphincter (LES) pressure, esophageal peristalsis, and overall esophagogastric junction function.

Patients were deemed eligible for the study if they were between 18 and 65 years old and had documented low LES pressure on HRM. Those with persistent GERD symptoms despite at least 12 weeks of maximal medical therapy, intolerance to medication, or a desire to avoid lifelong proton pump inhibitor (PPI) therapy were considered suitable candidates. To ensure adequate postoperative esophageal motility, only patients with at least 30% esophageal peristalsis were included. Patients with esophageal motility disorders (such as achalasia), morbid obesity (BMI >35 kg/m²), a history of upper abdominal surgery, or a severely shortened esophagus were excluded. Patients classified as ASA III, IV, or V were also excluded due to the increased surgical risks associated with poor general health.

Patients were required to fast for at least 6-8 hours before surgery to minimize aspiration risk. Routine preoperative laboratory investigations, including a complete blood count (CBC), coagulation profile, and liver and kidney function tests, were performed. All patients underwent a pre-anesthesia assessment to determine their fitness for general anesthesia. On the day of surgery, prophylactic intravenous antibiotics were administered.

Intraoperative Setting:

The surgery was performed laparoscopically under general anesthesia. Patients were positioned in the modified lithotomy position with a reverse Trendelenburg tilt (head-up) to improve surgical exposure of the esophagogastric junction. The abdominal area was sterilized using antiseptic solution, and a CO₂ pneumoperitoneum was established (typically 12-15 mmHg) to facilitate laparoscopic access. A total of five to six laparoscopic ports were placed, with a 10-mm umbilical port for the camera and 5-mm ports for instruments and liver retraction.

For Nissen fundoplication, the procedure included circumferential dissection of the esophagus (ensuring 2-3 cm intra-abdominal length), crural closure with non-absorbable sutures, and mobilization of the gastric fundus (with division of short gastric vessels as needed). A 360° wrap was constructed and secured with four to five interrupted sutures. A 60F esophageal bougie was introduced intraoperatively to prevent a tight wrap.

For Toupet fundoplication, esophageal mobilization and crural closure were performed similarly. A 270° posterior wrap was constructed by positioning the gastric fundus posteriorly around the esophagus. It was secured with two to three sutures anchoring it to the right crura, two to three sutures attaching it to the esophagus, and two sutures securing it to the left crura. No esophageal bougie was used.

After the wrap, the surgeon ensured adequate tension, confirmed hemostasis, inspected for injury, and closed the abdominal incisions. Patients were extubated once fully recovered from anesthesia.

Postoperative Setting:

Following surgery, patients were monitored in the post-anesthesia care unit (PACU). Pain was managed with intravenous analgesics (e.g., paracetamol, NSAIDs, or opioids). Antiemetics such as ondansetron or metoclopramide were administered. Early ambulation was encouraged to reduce risks of deep vein thrombosis (DVT) and pulmonary complications.

Postoperative dietary advancement was structured to support healing. On the first postoperative day, patients were started on clear liquids. Over the next week, they progressed to a full liquid diet, then to soft/puréed foods by weeks 2-4, and finally to solids after four weeks while avoiding carbonated or hard foods.

All patients underwent high-resolution manometry (HRM) at six weeks postoperatively to assess LES pressure and esophageal motility. Data were collected and prepared for later analysis in accordance with study protocols.