Pediatr Surg Int (2015) 31:925–929

DOI 10.1007/s00383-015-3770-4

ORIGINAL ARTICLE

Laparoscopic Toupet fundoplication for gastroesophageal reflux:

a series of 131 neurologically impaired pediatric cases at a single
children’s hospital
Go Miyano1 • Masaya Yamoto1 • Keiichi Morita1 • Masakatsu Kaneshiro1 •
Hiromu Miyake1 • Hiroshi Nouso1 • Mariko Koyama1 • Hideaki Nakajima1 •
Koji Fukumoto1 • Naoto Urushihara1

Accepted: 6 August 2015 / Published online: 19 August 2015

Ó Springer-Verlag Berlin Heidelberg 2015

Abstract Keywords Toupet fundoplication
Gastroesophageal

Purpose To present the medium to long-term outcome of
the largest pediatric series of laparoscopic Toupet fundo-
plications (LTF) performed at a single institution.
Patients and methods Subjects were 131 neurologically
impaired children (81 M, 50 F) who underwent LTF
between 2003 and 2013. Our LTF involves full dissection
of the crus of the diaphragm to allow the intraabdominal
esophagus to be mobilized at least 3–4 cm.
Results Preoperative mean fraction time for pH \4 was
14.6 %. Mean age at LTF was 6.7 years (3 months–
18 years). Mean duration of follow-up was 5.7 years
(range 1.2–12.1 years). One case required conversion to
open surgery. Intra-operative complications were all inju-
ries to the esophagus/gastric wall (n = 4; 3.0 %) including
full-thickness perforation (n = 1; 0.8 %). Postoperative
complications included pyloric stenosis (n = 4; 3.0 %),
dysphagia (n = 1; 0.8 %), incisional hernia (n = 1;
0.8 %), hemorrhage requiring transfusion (n = 1; 0.8 %),
recurrence (n = 3; 2.3 % at 11, 13, and 48 months,
respectively), and gastrostomy site infection (n = 7;
5.3 %). Mean operative time decreased significantly with
experience from 180.8 min for the first quarter of subjects
to 150.6 (2nd quarter), 128.6 (3rd) and 109.2 min (4th).
Conclusions Our LTF would appear to be safe for treat-
ing GERD in children because of reliable outcome and low
recurrence.
& Go Miyano
go1993@hotmail.co.jp
1 excluded neurologically normal patients from this study,
Department of Pediatric Surgery, Shizuoka Children’s
Hospital, 860 Urushiyama, Aoi-ku, Shizuoka 420-8660,
Japan
reflux
Laparoscopy
Introduction
Laparoscopy for treating gastroesophageal reflux disease
(GERD) was introduced during the 1980s, and then
developed so quickly some 20 years ago that anti-reflux
surgery began to be performed even in children in 1993 by
Lobe et al. [1] and Georgeson [2].
The Nissen fundoplication is the most popular laparo-
scopic operation performed for the surgical treatment of
GERD [3]. André Toupet also reported an original fundo-
plication from Paris in 1963 in which the fundus was
wrapped around three quarters of the esophagus behind the
cardia [4]. Today, in adults with GERD, the 2 techniques
are equally successful, but in children, only a few surgeons
are convinced of the advantages of the Toupet procedure
even though laparoscopic anti-reflux surgery is well
accepted [5]. Some reports have criticized the use of a
partial wrap in children because there is a higher long-term
failure rate compared with the Nissen fundoplication,
especially in patients with severe GERD [6, 7]. Thus, when
designing this study, we emphasized long postoperative
follow-up as a condition for subject selection. As such, our
assessment of mid- and long-term outcomes after laparo-
scopic Toupet fundoplication (LTF) is the largest series
reported to date.
It is generally believed that the outcome of anti-reflux
procedures in neurologically impaired children is worse
than in normal children. With this in mind we purposely
focusing only on neurologically impaired subjects and one
type of procedure, that is, laparoscopic Toupet

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fundoplication (LTF) to ensure our recommendations
would be as clinically relevant as possible [8].
For completeness, we included data from the medical
records of neurologically impaired children with GERD
who underwent laparoscopic Nissen fundoplication (LNF)
at our children’s hospital during the same study period.
Materials and methods
Approval for this retrospective assessment of medical
records was obtained from the local ethics committee at our
hospital (IRB approval no 2013-36). The medical records
of all patients who underwent anti-reflux surgery at our
children’s hospital from 2003, when LTF first began to be
performed, to December 2013 with a minimum of
12 months follow-up were reviewed. Neurologically nor-
mal patients, patients who had re-do Toupet fundoplication
after failed anti-reflux surgery, patients who had open anti-
reflux surgery, and patients over 18 years old were exclu-
ded from this study. Diagnosis of GERD was made if an
upper gastrointestinal barium study and 24 h pH-monitor-
ing were abnormal in symptomatic patients, with frequent
vomiting, failure to thrive, and poor response to conser-
vative medical management for at least 1 month. The
indication for surgery based on 24 h pH-monitoring was
pH less than 4 for more than 4 % of the monitored time
after all medications were ceased for at least 3 days.
In this series, we performed Toupet’s partial posterior
270° fundoplication, originally described as an open pro-
cedure [4], laparoscopically (i.e., LTF), irrespective of
esophageal motility. A summary of our LTF follows. The
patient is positioned in a reverse Trendelenburg position
with the surgeon standing either between the patient’s legs
or on the right side of the patient if there are severe hip
joint contractures. Four trocars with either 5 or 10 mm
scopes and 3 or 5 mm diameter instruments are used,
determined by the operating surgeon. Pneumoperitoneum
is maintained at an insufflation pressure of between 8 and
10 mmHg of carbon dioxide. For retraction of the left lobe
of the liver, a snake retractor inserted below the xiphoid
process was used in early cases and a Nathanson static liver
retractor is used now. The short gastric vessels are dis-
sected, the right and left crura of the diaphragm are iden-
tified, and the hepatogastric ligament is prepared. The
hiatus is fully dissected and the abdominal part of the
esophagus is mobilized over a minimum length of 3–4 cm.
Distal crurorraphy is performed with nonabsorbable dou-
ble, 3–0 (or 4–0) Ethibond sutures followed by placement
of 2–3 anchoring sutures between the anterior wall of the
esophagus and each crus of the diaphragm. The mobilized
anterior part of the gastric fundus is passed behind the
esophagus to the right, wrapped around the esophagus
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Pediatr Surg Int (2015) 31:925–929
anteriorly and fixed in 3 places on both sides using 3–0
Ethibond sutures to form a partial dorsal wrap covering 270
degrees of the circumference of the esophagus. Gastros-
tomy is performed after LTF and a gastrostomy tube
inserted because of neurological impairment.
Postoperatively, upper gastric imaging is performed
routinely before recommencement of feeding to confirm
the efficacy of LTF and exclude persistent reflux. Follow-
ing discharge from hospital, routine postoperative follow-
up involves out-patient clinic attendances at 2 weeks, 1 and
3 months after surgery, then 6 months. If patients became
symptomatic, upper gastric imaging and pH-monitoring
were performed to check for recurrence.
Data were analyzed using standard statistical methods.
Demographic data were compared using the Student’s
t test. The Chi squared test or Fisher’s exact test was used
for analyzing the incidence of complications. For all
statistics, 0.05 was used to determine significance. Analysis
of variance was used for comparing operative times for
each quarter of subjects and Bonferroni correction was
used to determine statistical significance. In this series no
comparison of surgical outcome between LTF and LNF
was performed because of disproportionate sample sizes.
Results
There were 131 LTF subjects reviewed in this study (81
males and 50 females). On preoperative 24 h pH-moni-
toring, the mean fraction time for pH \4 was 14.6 %.
Comorbidity included cardiac anomalies (n = 15), hydro-
cephalus (n = 5), major chromosomal anomalies (n = 12),
and esophageal atresia (n = 2). Three cases had had pre-
vious laparotomies for choledochal cyst, intestinal
obstruction, and pyloric stenosis. 19/131 had had previous
gastrostomy tube placement. Mean age at LTF was
6.7 years (range 3 months–18 years). Mean duration of
follow-up was 5.7 years (range 1.2–12.1 years). No
patients were lost to follow-up during the study period, and
no LTF related mortality was recorded. There were 4 intra-
operative complications (3.0 %) all involving injuries to
the esophagus or gastric fundus. Specifically, there was 1
case of full-thickness perforation of the stomach repaired
laparoscopically and 3 cases of injuries to the esophagus
early in our series, one case requiring conversion to open
Toupet fundoplication. Postoperative complications were
found in 13 (9.9 %). Recommencement of feeding post-
operatively was delayed in 4 cases (3.0 %) with pyloric
stenosis. Of these, 3 cases (2.3 %) were managed conser-
vatively with an esophagoduodenal tube and 1 case (0.8 %)
required open pyloromyotomy. Severe postoperative dys-
phagia developed in 1 case (0.8 %) necessitating endo-
scopic balloon dilatation of the wrap. Incisional hernia at a
Pediatr Surg Int (2015) 31:925–929 927

port site was observed in 1 case (0.8 %), and blood trans-
fusion was required postoperatively in 1 case (0.8 %). The
mean fraction time for pH \4 on postoperative pH-moni-
toring for patients complaining of recurrence related
symptoms (n = 11) was 0.6 %; recurrence of gastroe-
sophageal reflux was confirmed in 3 cases (2.3 %), at 11,
13, and 48 months respectively. These 3 patients were
treated by laparoscopic re-Do Toupet’s fundoplication
without further recurrence; two cases of hiatus hernia and
one case of wrap disruption were recorded. There were 7
(5.3 %) postoperative infections at the gastrostomy tube
site; 4 of these (3.0 %) required replacement of the gas-
trostomy tube (Table 1). Mean operative time for LTF
(excluding gastrostomy tube insertion) was 141.7 min.
There was a significant difference in mean operative times
for the first quarter of subjects (180.8 min for cases 1–30)
Fig. 1 Changes in mean operative times with experience. There was
versus, the second quarter (150.6 min for cases 31–60), the
a significant difference in mean operative times for the first quarter of
third quarter (128.6 min for cases 61–90), and the last subjects (cases 1–30) versus, the second quarter of subjects (31–60),
quarter (109.2 min for cases 91–131) p \ 0.05, p \ 0.01, the third quarter of subjects (61–90), and the last quarter of subjects
p \ 0.01, respectively (Fig. 1). (91–131). *p \ 0.05, **p \ 0.01
During the same study period there were 18 LNF per-
formed. Preoperative mean fraction time for pH \4 was recommencement of oral feeding was delayed in 1 case
13.6 %. Comorbidity included cardiac anomalies (n = 2), (5.6 %) because open pyloromyotomy was performed.
major chromosomal anomalies (n = 2), and hydrocephalus Severe dysphagia developed in 1 case (5.6 %) necessitating
(n = 2). Mean age at LNF was 6.2 years with 11 males and endoscopic balloon dilatation. Recurrence of GERD was
7 females (mean follow-up was 7.2 years). Injury to the confirmed in 2 cases (11.1 %), at 6 and 15 months,
muscle layer of the esophagus was recorded as an intra- respectively, both due to hiatus hernia and partial wrap
operative complication (n = 1; 5.6 %). Postoperatively, disruption.

Table 1 Summary of data

Number of subjects (neurologically impaired children) 131
Discussion
Pre-op 24 h Ph-monitoring; pH \4 14.6 %a
There are very few studies about long-term outcome of
Conversion to open 1 (0.8 %)
GERD surgery in children and our series is unique because
Recurrence (at 11, 13, 48 months postoperatively) 3 (2.3 %)
it focuses on Toupet fundoplication in neurologically
Complications
impaired children at a single children’s hospital over a
Intra-operative 4 (3.0 %)
b
maximum of 12 years. Complications after GERD surgery
Muscle injury 3 (2.3 %)
often develop 1 or more years postoperatively [9] and there
Full thicknessb 1 (0.8 %)
is general consensus that a partial wrap is not as effective
Postoperative 13 (9.9 %)
as a full wrap [10]. Jobe et al. [11] reviewed 100 adult LTF
EGJ stenosis 1 (0.8 %)c
patients and found there was a recurrence rate of 20 % after
Pyloric stenosis a mean follow-up of 22 months. They concluded that a
Grade-1 3 (2.3 %) partial fundoplication should not be performed in patients
Grade-2 1 (0.8 %) with normal esophageal motility, and existing data also
Incisional hernia 1 (0.8 %) support the hypothesis that total fundoplication provides
Wound infection superior long-term results in adults, compared with partial
Gastrostomy 7 (5.3 %) fundoplication [12]. However, in this study, our overall
Pyloric stenois grade-1: conservative management, grade-2: Ramstedt recurrence rate was 2.3 %, which is similar to the long-
procedure term outcome of LNF in the largest series on children in the
EGJ esophago-gastric junction literature [13, 14].
a
Percentage of mean fraction time for pH \4 In one adult study comparing Toupet and Nissen fun-
b
Impairment of the walls of the esophagus/stomach doplications both performed laparoscopically, the inci-
c
Dilatation was required dence of belching was found to be significantly different,

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with Toupet cases belching more easily [15]. It has also
been suggested that LTF reduces the prevalence of post-
operative dysphagia and gas-related symptoms compared
with LNF [16, 17]. There also seem to be more reports of
recurrence after LNF. Although the recurrence rate in our
series was low compared with other reports in the literature
[15, 18–20], we were not able to compare LTF with LNF in
this series because of sample size discrepancy. As belching
is known to be associated with easing unwanted reflex
coughing, gas bloat syndrome, and respiratory problems
[21], the Toupet fundoplication would seem to suppress
pressure build-up around the cardia which prevents suture
dehiscence and slipping that could cause recurrence of
GERD. It might be beneficial especially for neurologically
impaired children in whom myotonia is a constant problem,
thus preventing excessive pressure on the diaphragm,
esophagus, and gastric fundus.
While Rothenberg recommended that dissection be
focused around the crura and gastroesophageal junction
and not extend into the mediastinum [13], we believe our
relatively low recurrence rate is a direct result of more
extensive dissection of the lower esophagus; i.e., a mini-
mum of 3–4 cm for the abdominal part of the esophagus
which would appear to control recurrence especially in
neurologically impaired children. Although, there have
been critical comments about higher longer-term failure
rates following LTF compared with LNF, long-term results
of randomized clinical trial comparing open Nissen and
Toupet fundoplication have, however, demonstrated that
short-term reflux control is durable throughout 10-year
follow-up [22]. As there were no differences in short-term
and long-term reflux control between open and laparo-
scopic fundoplication, it seems unlikely that differences in
reflux control after LNF and LTF will develop with longer
follow-up. Longer follow-up with a larger sample size will
help establish factors associated with recurrence and con-
firm which technique is more efficient for treating GERD.
As a procedure, LTF is demanding because the Toupet
wrap requires more sutures and is difficult to master [23].
By dividing our subjects into quarters, we showed there is a
definite learning curve, with significant differences in mean
operative times observed between quarters. Reports in the
literature also support the notion that high-volume centers
with higher caseloads per surgeon have better outcome; in
other words, an annual case load of 10–20 LTF appears to
be mandatory to obtain good results [24]. Our recommen-
dation is a team approach where confidence can be
improved by studying videos of LTF performed by expert
surgeons, with pre and postoperative meetings to discuss
problems. This is different to how open surgery is studied
conventionally by a direct hands-on approach that can be
time consuming. Part of the time saved later in our series is
a direct result of our adoption of a team approach because
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Pediatr Surg Int (2015) 31:925–929
of improved efficiency because each member of the team
has a specific role.
Our LTF would appear to be safe for treating GERD in
children because of reliable outcome and low recurrence.
Acknowledgments We wish to express our appreciation to Dr.
Geoffrey J. Lane who reviewed this manuscript as a native English
speaker.
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