Surg Endosc (2006) 20: 855–858
DOI: 10.1007/s00464-005-0501-2
Ó Springer Science+Business Media, Inc. 2006
Long-term outcome of laparoscopic Nissen, Toupet, and Thal
antireflux procedures for neurologically normal children with
gastroesophageal reflux disease
C. Esposito,1 Ph. Montupet,2 D. van Der Zee,3 A. Settimi,1 A. Paye-Jaouen,2 A. Centonze,1 N. K. M. Bax3
1
Chair of Pediatric Surgery, Magna Graecia University of Catanzaro and Naples, Via Tommaso Campanella 115, 88100 Catanzaro, Italy
2
Pediatric Surgery Unit, CCBB Boulogne, 7 Rue du Laos, 75015, Paris, France
3
Chiar of Pediatric Surgery, Willemina Children Hospital, Center University, P.O. Box 8509, AB Utrecht, 3508 Utrecht, the Netherlands
Received: 11 July 2005/Accepted: 20 January 2006/Online publication: 12 May 2006
Abstract
Background: Nissen fundoplication is the most popular
laparoscopic operation for the management of gastro-
esophageal reflux disease (GERD). Partial fundoplica-
tions seem to be associated with a lower incidence of
postoperative dysphagia, and thus a better quality of life
for patients. The aim of this study was to compare the
long-term outcome in neurologically normal children
who underwent laparoscopic Nissen, Toupet, or Thal
procedures in three European centers with a large
experience in laparoscopic antireflux procedures.
Methods: This study retrospectively analyzed the data of
300 consecutive patients with GERD who underwent
laparoscopic surgery. The first 100 cases were recorded
for each team, with the first team using the Toupet, the
second team using the Thal, and the third team using the
Nissen procedure. The only exclusion criteria for this
study was neurologic impairment. For this reason, 66
neurologically impaired children (52 Thal, 10 Nissen, 4
Toupet) were excluded from the study. This evaluation
focuses on the data for the remaining 238 neurologically
normal children. The patients varied in age from 5
months to 16 years (median, 58 months). The median
weight was 20 kg. All the children underwent a complete
preoperative workup, and all had well-documented
GERD. The position of the trocars and the dissection
phase were similar in all the procedures, as was the
posterior approximation of the crura. The short gastric
vessels were divided in only six patients (2.5%). The only
difference in the surgical procedures was the type of
antireflux valve created.
Results: The median duration of surgery was 70 min.
There was no mortality and no conversion in this series.
A total of 12 (5%) intraoperative complications (5 Nis-
sen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative
complications (3 Toupet, 4 Nissen, 6 Thal) were re-
Correspondence to: C. Esposito
corded. Only six (2.5%) redo procedures (2 Thal, 2
Toupet, 2 Nissen) were performed. After a minimum
follow-up period of 5 years, all the children were free of
symptoms except nine (3.7%), who sometimes still re-
quire medication. The incidence of complications and
redo surgery for the three procedures analyzed with the
Mann–Whitney U test are not statistically significant.
Conclusions: For pediatric patients with GERD, lapa-
roscopic Nissen, Toupet, and Thal antireflux procedures
yielded satisfactory results, and none of the approaches
led to increased dysphagia. The 5% rate for intraoper-
ative complications seems linked to the learning curve
period. The authors consider the three procedures as
extremely effective for the treatment of children with
GERD, and they believe that the choice of one proce-
dure over the other depends only on the surgeonÕs
experience. Parental satisfaction with laparoscopic
treatment was very high in all the three series.
Key words: Antireflux procedure — Children —
Gastroesophageal reflux — Nissen — Thal — Toupet
Laparoscopic antireflux procedures have replaced the
open approach to become the standard surgical proce-
dure for the treatment of gastroesophageal reflux disease
(GERD) in adults and children [15, 21]. Nissen fundo-
plication is the most popular laparoscopic operation
performed for the surgical treatment of GERD [2, 7].
However, for patients with weak esophageal peristalsis
documented preoperatively, a partial wrap, as in the
Toupet or Thal procedure, often has been used as
alternative to reduce the postoperative dysphagia that
sometimes ensues [9, 16, 23]. Some reports have criticized
the use of a partial wrap in children because of the higher
long-term failure rate than with NissenÕs approach,
especially in patients with severe GERD [18, 25, 26].
856
Because the results of antireflux procedures (ARP) in
neurologically impaired children are worse than in
normal children, it is necessary to analyze separately the
outcome for these patients after ARP to obtain homo-
geneous data [5].
This study aimed to compare the long-term out-
comes for neurologically normal children after laparo-
scopic Nissen, Toupet, and Thal procedures performed
in three European centers with a large experience in
laparoscopic antireflux procedures.
Patients and methods
We retrospectively analyzed the data of 300 consecutive patients with
GERD who had laparoscopic surgery. The first 100 cases treated by
each team were recorded. The three teams, respectively, used the
Toupet, Thal, and Nissen procedures. Overall, the three centers col-
lected data for more than 1,300 laparoscopic antireflux procedures
performed in children between 1993 and 2004. For the purpose of this
study, we analyzed only the records of the first 100 patients managed
by each team to obtain homogeneous data in terms of experience and
learning curve.
The only exclusion criteria in our study specified neurologic
impairment. For this reason, 66 patients (52 managed with Thal, 10
managed with Nissen, and 4 managed with Toupet) were excluded
from the study. Consequently, the data of only 238 children (137 girls
and 101 boys) were analyzed.
The patients varied in age from 5 months to 16 years (median, 58
months). The median weight was 20 kg (range, 5–65 kg). All the
children underwent a complete preoperative workup, and all had well-
documented GERD.
The position of the trocars and the dissection phase were similar in
all the procedures, as was the posterior approximation of the crura.
Short gastric vessels were divided in only six patients (2.5%). The only
difference in terms of surgical procedure was the type of antireflux
valve created.
All laparoscopic antireflux procedures included three steps: dis-
section of the gastroesophageal junction and the lower esophagus,
reconstruction of hiatal area, and finally the fundoplication. The first
two steps probably depend the most on the experience of the surgeon,
and in our series, these steps were performed in the same manner by
the three teams. We briefly describe the first two steps of our proce-
dures, considering that it is not necessary to describe the final aspect of
Nissen, Thal, and Toupet antireflux procedures because they are well
known among pediatric surgeons.
The intervention starts with the surgeon incising the upper part of
the hepatogastric ligament above the hepatic branches of the anterior
vagal nerve, which are preserved. By this maneuver, the right crus is
identified. Next, the fundus of the stomach is detached from the dia-
phragm, and the left crus is identified. The anterior phrenoesophageal
ligament then is transacted, preserving the anterior vagal nerve. By
pulling the fundus of the stomach to the right, the esophagus can be
detached from the left crus. The dissection on the left should be con-
tinued until the posterior part of the hiatus is cleared.
The right crus can best be dissected off the esophagus by entering
the pars flaccida of the hepatogastric ligament below the hepatic
branches of the anterior vagal nerve. Elevation of these branches ex-
poses a thin but strong membrane that covers both the right crus and the
esophagus. Opening of this membrane longitudinally makes the groove
between the esophagus and crus visible, enabling its blunt dissection.
When the esophagus is pushed anteriorly, the area behind the esophagus
opens up, and the posterior vagal nerve comes into view. An instrument
then is passed posteriorly to the nerve to enter the region above the
fundus of the stomach. A vessel loupe is inserted and passed behind the
esophagus and above the hepatic vagal branches. The ends of the loupe
are clipped together with two 5-mm clips, then grasped with ratcheted
forceps via the same cannula through which traction on the stomach has
been exerted. The distal esophagus is now mobilized further until a
sufficient part has reached an intraabdominal position. Next, the hiatus
is narrowed behind the esophagus with one or two separated stitches
using intracorporeal knotting of nonresorbable suture.
Preoperative diagnostic studies included barium swallow for all
patients, 24-h pH monitoring in 201 of 238 cases (84.4 %), manometry
in 147 of 238 cases (61.7%), and endoscopy in 95 of 238 cases (39.9%).
Patients with feeding problems underwent echographic evaluation of
gastric emptying.
Before surgery, 205 patients (86.1%) were given at least 4 weeks of
medical treatment with proton pump inhibitors.
During surgery, patients were positioned in a reverse Trendelen-
bourg position with the surgeon at the lower end of the table facing the
child who lay supine with the legs crossed and fixed to the table. A
nasogastric tube always was inserted before surgery. Either four or five
trocars were used, according to the surgeonÕs preference. Telescopes
and instruments with a diameter of 3 or 5 mm were used, depending on
both their availability and the surgeonÕs preference. The abdomen was
entered via the umbilicus according to the open technique. Pneumo-
peritoneum pressure was limited to between 8 and 10 mm Hg of carbon
dioxide. Nonresorbable 2-0, 3-0, and 4-0 sutures were used depending
on the surgeonÕs preference.
Results
The duration of surgery ranged from 60 to 300 min
(median, 70 min). The nasogastric tube was removed in
the first 24 h, and oral feeding was started the same day
as surgery or the day afterward. The hospital stay varied
from 2 to 5 days (median, 2.4 days).
There was no mortality and no conversion in our
series. We recorded 12 intraoperative complications
(5%) (5 Nissen, 5 Toupet, 2 Thal) and 13 postoperative
complications (5.4 %) (3 Toupet, 4 Nissen, 6 Thal). Of
the 238 patients enrolled in this series, all were available
for the 5-year follow-up assessment. As for the incidence
of dysphagia, only seven patients (2.9 %) (4 Nissens;
2 Toupet and 1 Thal) presented rare episodes of dys-
phagia that disappeared spontaneously in the first 6
months after surgery.
We recorded only six redo procedures (2.5 %) (2
Thal, 2 Toupet, 2 Nissen). At a minimum follow-up
period of 5 years, all the children were free of symptoms
except nine (3.7 %), who sometimes still require medi-
cation. The results are reported in Table 1.
Using the Mann–Whitney U test, we statistically
analyzed the data on the incidence of complications,
dysphagia, and redo surgery for the three procedures,
but the results were not statistically significant (Table 1).
Discussion
Laparoscopic surgery for the treatment of GERD in
children was first described in the early 1990s. Recently,
this procedure has become increasingly common, par-
ticularly in children, and currently is the third most
common pediatric surgical procedure performed lapa-
roscopically [21]. Although the outcomes of laparo-
scopic antireflux procedures for adults have been
reported extensively, only recently have large studies
with children become available [1, 6, 8]. Although no
randomized control trials with children exist to date,
many retrospective studies have been published [4, 20,
22].
There are two main problems with pediatric series on
ARP. The first is to determine which procedure is
preferable to adopt. Although the Nissen procedure is

Table 1. Long-term outcomes for 238 antireflux procedures performed in the three centers
Nissen (94 cases) Toupet (96 cases)
Intraoperative complications 5 5
Postoperative complications 4 3
Dysphagia 4 2
Redo surgery 2 2
ns, statistically not significant
the most commonly adopted all over the world, the
Toupet and Thal procedures also seem to yield good
results with a lower incidence of dysphagia than the
Nissen procedure [3, 16, 24, 25]. The second is that the
pediatric series of ARP reported in the literature always
include populations of both neurologically normal and
neurologically impaired children [7, 20]. For this reason,
it is extremely difficult to analyze the results of ARP
objectively because the outcome for neurologically im-
paired children certainly is worse than for neurologically
normal children.
The reports on the long-term outcomes of ARP for
children comparing different procedures and based only
on a population of neurologically normal children are
extremely scanty in the international literature [4, 20,
25]. For this reason, we analyzed three different series of
ARP performed in three European centers of pediatric
surgery with a large experience using three different
antireflux techniques: Thal, Toupet, and Nissen. In
addition, considering that the results of laparoscopic
antireflux procedures depend on the surgical experience
with this pathology, we analyzed the first 100 procedures
performed by each team to obtain homogeneous results
in terms of each teamÕs experience.
Another point of interest in our analysis was the
follow-up evaluation, which lasted at least 5 years for all
the patients. In fact, it is important to remember that a
long-term follow up evaluation is fundamental because,
as demonstrated by several series, some complications
can develop even 1 or more years after surgery [3, 10, 12,
14].
The analysis of our results with the three techniques
showed an extremely low complication rate, a compa-
rable failure rate, and most important of all, a nonsta-
tistically significant difference in the rates of
complications and redo surgery among the three pro-
cedures. We also analyzed the results for the incidence of
dysphagia, and there was no statistically significant
difference in the incidence of this condition among the
three procedures adopted.
As for the experience necessary to perform the pro-
cedure, although the learning curve is steep because of
the advanced laparoscopic skills needed, the procedure
can be performed quickly and effectively once the
technique is mastered [17]. It may be useful to seek the
857
Thal (48 cases) Total Mann–Whitney U test
2 12 Nissen vs Toupet (p = 0.990, ns)
Nissen vs Thal (p = 0.9093, ns)
Toupet vs Thal (p = 0.9179, ns)
6 13 Nissen vs Toupet (p = 0.8873, ns)
Nissen vs Thal (p = 0.4098, ns)
Toupet vs Thal (p = 0.3469, ns)
1 7 Nissen vs Toupet (p = 0.7841, ns)
Nissen vs Thal (p = 0.8281, ns)
Toupet vs Thal (p = 0.9982, ns)
2 6 Nissen vs Toupet (p = 0.9966, ns)
Nissen vs Thal (p = 0.8387, ns)
Toupet vs Thal (p = 0.8347, ns)
help of an expert laparoscopic surgeon for the first 10
procedures to reduce the complications related to the
learning curve period [3, 13, 17].
On the basis of our multicenter experience, we can
conclude that for pediatric patients with GERD, the
laparoscopic Nissen, Toupet, and Thal antireflux pro-
cedures all yield satisfactory results, and none of the
operations lead to increased dysphagia. Our 5% intra-
operative complication rate seems linked to the learning
curve period. We consider the three procedures ex-
tremely effective for the treatment of children with
GERD, and we believe that the choice of one proce-
dure over the others depends only on the surgeonÕs
experience in performing it. Parental satisfaction with
laparoscopic treatment was very high in all the three
series.
Considering the limitations of a retrospective study
such as ours, we strongly advocate the organization of
prospective studies on this topic aimed at providing
sound evidence on the surgical management of GERD
in neurologically normal children.
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