Authors' reply: Systematic review and meta‐analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro‐oesophageal reflux disease (Br J Surg 2010; 97: 1318–1330)

Sir We have read the article by Broeders and colleagues, reviewing laparoscopic Nissen and Toupet fundoplication for the treatment of gastro-oesophageal reflux disease, with great pleasure, but would like to discuss the final conclusion. The authors concluded that they had reached level 1a evidence in favour of the Toupet fundoplication with their meta-analysis, particularly with respect to dysphagia and detection of dysphagia. However, when considering the results, it seems that the total risk ratios were all comparable with those in the study by Strate and co-workers, disregarding the risk ratios of the other studies in this analysis. They did grade the included studies with Jadad scores but, based on this article, the Strate trial had a Jadad score of only 2, which was not sufficient to allow such high weighting of this study. Therefore, this metaanalysis of laparoscopic Nissen versus Toupet fundoplication may be heavily skewed by a low-quality randomized clinical trial, and thus in our opinion does not provide level 1a evidence that the Toupet procedure is superior. Another issue in the comparison of postoperative dysphagia between these operative techniques is dissection of the short gastric vessels. In this metaanalysis there was no separate analysis of no or minimal dissection of the short gastric vessels versus total dissection (with proper dissection of the point of His), in either the Nissen or Toupet fundoplication. This part of the procedure could, however, be important in the prevention of postoperative dysphagia1 – 3. Another deficiency of most of the studies included in the meta-analysis is that no objective 24-h pH measurement showed the effectiveness of either operative treatment. Finally, it is probably not correct for the authors of a paper to judge the level of evidence themselves; this is up to the external assessor of the next meta-analysis. S. M. B. I. Botden and N. D. Bouvy Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands (e-mail: s.botden@mumc.nl) DOI: 10.1002/bjs.7402

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