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Surg Endosc. 2019 Oct 18. doi: 10.1007/s00464-019-07208-9. [Epub ahead of print]

Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis.

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Upper GI Department, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Foundation Trust, Hull, UK.
Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, Australia.
Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.
Faculté de Médecine, Paris Descartes University, Sorbonne Paris Cité, Paris, France.
Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK.
Department of Surgery, European University Cyprus, Nicosia, Cyprus.
Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus.
, Athens, Greece.



Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease.


Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease.


Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence.


Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective.




Antireflux surgery; Fundoplication; GERD; Network meta-analysis


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