Overview
Definition:
Toupet fundoplication is a surgical procedure performed to treat severe gastroesophageal reflux disease (GERD) and associated complications, primarily by wrapping the gastric wrap partially around the lower esophagus (approximately 270 degrees) to create an antireflux barrier
It is a variation of the full Nissen fundoplication (360-degree wrap).
Epidemiology:
GERD affects a significant portion of the population globally, with a substantial subset requiring surgical intervention
While Nissen fundoplication is more common, Toupet fundoplication is often chosen in specific patient populations, such as those with a markedly dilated esophagus or impaired esophageal motility, to reduce the risk of dysphagia
Incidence data specific to Toupet fundoplication versus Nissen is not always clearly delineated in large databases.
Clinical Significance:
Toupet fundoplication offers a durable solution for patients refractory to medical management or experiencing complications of GERD, such as erosive esophagitis, Barrett's esophagus, or strictures
It aims to improve quality of life by alleviating troublesome reflux symptoms and preventing disease progression
Its specific indication in cases of impaired esophageal motility makes it a crucial technique in the surgeon's armamentarium for managing complex GERD.
Indications
Surgical Indications:
Failure of optimal medical management for GERD
Symptomatic GERD with proven objective evidence of reflux (e.g., 24-hour pH monitoring, impedance studies)
Complications of GERD including severe erosive esophagitis, peptic stricture, or Barrett's esophagus
Patient preference for definitive treatment over long-term medication
Certain cases of large paraesophageal hiatus hernia with significant GERD symptoms.
Patient Selection:
Patients with normal or near-normal esophageal motility on manometry are ideal candidates
Those with significant dysphagia or impaired peristalsis may benefit more from a partial fundoplication like Toupet to minimize postoperative swallowing difficulties
Thorough preoperative assessment, including upper endoscopy and esophageal manometry, is essential.
Contraindications:
Absolute contraindications are rare but include severe comorbidities precluding surgery, active peptic ulcer disease, or achalasia
Relative contraindications include severe esophageal dysmotility or a history of prior extensive upper abdominal surgery leading to significant adhesions.
Preoperative Preparation
Diagnostic Workup:
Upper endoscopy to assess the esophageal mucosa and rule out malignancy or complications
24-hour esophageal pH monitoring and/or impedance to objectively confirm reflux
Esophageal manometry to evaluate esophageal motility and peristalsis
Barium swallow may be used to assess anatomy, especially hiatal hernia size.
Medical Optimization:
Patients are typically advised to continue PPI therapy until surgery, although some surgeons may recommend stopping it for a period to allow for accurate pH monitoring
Smoking cessation is strongly encouraged
Dietary modifications and lifestyle changes are reviewed.
Anesthesia And Consent:
General anesthesia is required
Informed consent must detail the procedure, potential benefits, risks (e.g., bleeding, infection, dysphagia, gas bloat, dumping syndrome, recurrence of reflux, need for reoperation), and alternatives
Anesthesia team should be aware of potential anesthetic challenges related to GERD.
Procedure Steps
Approach:
Laparoscopic approach is standard
A few small incisions are made in the abdomen for trocars
Carbon dioxide insufflation is used to create a working space
The surgeon uses a camera and specialized instruments to perform the dissection and reconstruction.
Dissection:
The gastroesophageal junction is identified
The phrenoesophageal membrane is dissected to free the intra-abdominal esophagus
The short gastric vessels supplying the fundus of the stomach are carefully divided, usually with an energy device
Careful identification and preservation of the vagus nerves are crucial.
Fundoplication Creation:
The gastric fundus is mobilized
A 270-degree wrap is created, taking care to pass the fundus posteriorly around the esophagus
The wrap is sutured to the esophageal wall and/or the diaphragmatic crura to secure its position and provide tension
The anterior aspect of the esophagus remains uncovered by the wrap, which is the defining feature of the Toupet technique
Hiatus hernia repair, if present, is performed by approximating the diaphragmatic crura.
Closure:
The instruments are removed, and the incisions are closed with sutures and/or adhesive strips
A nasogastric tube may be placed temporarily for decompression.
Postoperative Care
Early Recovery:
Patients are typically hospitalized for 1-2 days
Pain management is provided with analgesics
Early mobilization is encouraged
Patients are started on a clear liquid diet and gradually advanced to a soft, then regular diet as tolerated
Monitoring for bleeding, infection, and complications is essential.
Dietary Progression:
A specific diet progression is crucial to avoid overwhelming the reconstructed valve
Initially, clear liquids are followed by full liquids, then pureed foods, soft foods, and finally a regular diet over several weeks
Patients are advised to eat slowly, chew thoroughly, and avoid large meals.
Discharge Instructions:
Patients receive instructions on wound care, pain management, activity restrictions (avoiding heavy lifting for 4-6 weeks), dietary progression, and recognizing signs of complications
Follow-up appointments are scheduled with the surgeon
Importance of avoiding gas-producing foods and carbonated beverages initially is stressed.
Complications
Early Complications:
Bleeding from dissection sites or short gastric vessels
Injury to the esophagus, stomach, spleen, or diaphragm
Pneumothorax or injury to adjacent organs
Wound infection
Trocar site hernia
Gastric or esophageal perforation.
Late Complications:
Dysphagia (difficulty swallowing), which is generally less common than with Nissen fundoplication but can still occur
Gas bloat syndrome (difficulty belching, early satiety)
Recurrence of reflux symptoms due to wrap dehiscence or inadequate repair
Diarrhea
Dumping syndrome
Esophagitis or ulceration of the wrap.
Prevention Strategies:
Meticulous surgical technique with careful dissection and appropriate use of energy devices
Accurate placement and secure fixation of the fundoplication wrap
Careful patient selection, especially regarding esophageal motility
Strict adherence to postoperative dietary guidelines
Prompt recognition and management of early complications.
Prognosis
Outcomes:
Toupet fundoplication generally offers good long-term relief of GERD symptoms in properly selected patients
Success rates are high, often exceeding 80-90% for symptom control
Recurrence rates are generally lower than with medical management alone, though some studies suggest slightly higher recurrence than Nissen fundoplication.
Factors Affecting Prognosis:
Patient selection (especially esophageal motility)
Surgeon's experience and technique
Resolution of hiatal hernia
Adherence to postoperative diet and lifestyle modifications
Presence of complications like strictures or Barrett's esophagus preoperatively can influence long-term outcomes.
Follow Up:
Regular follow-up with the surgeon is recommended, typically at 2 weeks, 1 month, 3 months, 6 months, and 1 year postoperatively, and then annually or as needed
Assessment includes symptom relief, dietary tolerance, and evaluation for any recurrent reflux or emerging complications
Long-term monitoring for Barrett's esophagus may be necessary if present preoperatively.
Key Points
Exam Focus:
Toupet fundoplication is a 270-degree wrap used for GERD surgery, particularly favored in patients with borderline or impaired esophageal motility to reduce dysphagia risk
Key steps involve dissection of the GE junction, division of short gastric vessels, and wrapping the fundus posteriorly around the esophagus
Complications include dysphagia, gas bloat, and reflux recurrence
Laparoscopic approach is standard
Contraindications are few, but severe dysmotility is a relative concern.
Clinical Pearls:
Always perform esophageal manometry before considering Toupet fundoplication in patients with significant swallowing complaints or a history suggestive of dysmotility
Preserve vagus nerves meticulously
A snug but not tight wrap is essential to prevent dysphagia and allow for belching
Gradual dietary advancement postoperatively is paramount for successful outcome
Consider this technique when significant hiatal hernia repair is also performed.
Common Mistakes:
Mistaking Toupet for a Nissen fundoplication in exam questions (different wrap degrees)
Inadequate mobilization of the gastric fundus leading to a tight or short wrap
Overly aggressive division of short gastric vessels causing fundic ischemia
Failure to recognize and manage significant esophageal dysmotility preoperatively
Releasing sutures on the wrap too early, leading to recurrence.