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Page 4 of 9 Kitamura et al. Mini-invasive Surg 2022;6:44 https://dx.doi.org/10.20517/2574-1225.2022.27

belch (98.4% vs. 88.9%; P = 0.007) or vomit (91.3% vs. 44.4%; P < 0.001) compared to LF patients.

One year propensity-matched studies continued to support this trend. Warren et al. compared 114 MSA
and 114 LF patients which also showed similar improvement in GERD-HRQL scores - and MSA patients
continued to report preserved ability to belch (96% vs. 69%) and vomit (95% vs. 43%), with less gas bloat
(47% vs. 59%) when compared to their LF counterparts . Mild dysphagia and resumption of PPIs (24 vs.
[23]
12; P = 0.02) were higher in the MSA group. These findings were supported by a similar study by Reynolds
et al. involving 50 MSA and 50 LF patients. However, severe dysphagia was reported at higher rates after LF
[14]
(10.6% vs. 0%; P = 0.022) . When compared to propensity-matched patients who underwent laparoscopic
Toupet (versus Nissen) fundoplication, there were no differences in GERD-HRQL scores, PPI cessation, gas
[9]
bloat, and dysphagia at one year .

Bonavina et al. conducted a large, multicenter registry study comparing 465 MSA to 166 LF over three
years . Both groups again improved similarly in total GERD-HRQL score and satisfaction. PPI rates
[4]
declined from 97.8% to 24.2% and 95.8% to 19.5% in the MSA and LF groups, respectively. Both groups were
able to belch, although the MSA group reported a better ability to vomit (91.2% MSA vs. 68.0%) successfully
when needed.

These outcomes are sustained when analyzed for a median 5-year follow-up of 25 MSA and 45 LNF
patients. Total GERD-HRQL scores, reported rates of dysphagia, and bloating were similar between
[24]
groups .

A recent study by Wu et al. attempted to better characterize the quantitative difference between MSA and
[25]
LF . Using impedance planimetry (EndoFlip™), measurements were taken at the gastroesophageal junction
after cruroplasty and either MSA implantation or fundoplication. This revealed a significantly lower
distensibility index (DI) for MSA patients (1.9 ± 0.8 mm /mmHg; N = 24) versus that of either laparoscopic
2
Toupet (3.5 ± 1.3 mm /mmHg; N = 59) or Nissen (3.5 ± 1.4 mm /mmHg; N = 24) fundoplication. Although
2
2
dysphagia rates were similar between all three groups, Toupet fundoplication GERD-HRQL scores were
significantly greater than in the MSA or Nissen group. It is not clear why the lower DI in patients receiving
MSA compared to that of the two surgical wraps does not translate into clinically significant dysphagia and
indicates more study is needed into the quantitative changes imposed at the GEJ by MSA versus surgical
wraps [Table 1].

Meta-analysis, reviews
When pooled, early data comparing MSA and LF are similar to the directly comparative studies. Six-to-
twelve-month follow-up of 7 observational cohort studies with combined cohorts of 585 MSA and 525 LF
patients, favored MSA in terms of gas bloat (OR: 0.39; 95%CI: 0.25-0.61; P < 0.001), ability to belch (OR:
5.53; 95%CI: 3.73-8.19; P < 0.001) and vomit (OR: 10.10; 95%CI: 5.33-19.15; P < 0.001). GERD-HQRL, PPI
cessation, dysphagia requiring endoscopic dilation, and reoperation rates were similar between groups.
Moreover, the authors point out that heterogeneity of GERD-HRQL was low in this pooled analysis
indicating a high level of agreement between studies for patient satisfaction findings [2,26] .

When comparative study data was combined with single cohort data, again, no significant deviations were
seen in GERD-HRQOL score, PPI cessation, dysphagia, and reoperation. Gas bloat and ability to belch
continued to favor those who had received MSA. In this pooled analysis of 632 MSA and 467 LF patients,
[19]
the rate of MSA erosion and reoperation was 0.3% and 3.3%, respectively . Most recently, a meta-analysis
inclusive of 1138 MSA patients reported rates of postoperative dysphagia and endoscopic dilation of 29%