Minimally Invasive Solution for Duodenogastric Reflux: Toupet Fundoplication and Extramucosal Duodenal Myotomy
R. Octavio Rojas Díaz FACS* 1, Rafael Contreras Ruiz Velasco 1, José Farrera Grajales 1,
Martin Salvador Valencia Reyes 1, Sergio Antonio Coronado Ávila 1,
Andrés de Jesús Sosa López 1, Julio A. Pérez Sosa 1
*Correspondence to: R. Octavio Rojas Díaz FACS, Departments of Surgery, Anesthesia, and Endoscopy and Digestive Motility, Hospital ABC; Department of Endoscopy, Hospital Pemex. Mexico City, Mexico.
Copyright
© 2026 R. Octavio Rojas Díaz, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 03 September 2026
Published: 01 October 2026
DOI: https://doi.org/10.5281/zenodo.23079917
Abstract
Objective: To report the results of laparoscopic fundoplication plus extramucosal duodenal myotomy as treatment for pathological duodenogastric reflux, a functional, non-mutilating procedure indicated in patients with an intact stomach.
Material and Methods: Retrospective, multicenter, non-comparative study. Data were collected from 105 patients with pathological duodenogastric reflux, identified from a cohort of 3,000 patients with gastroesophageal reflux disease (GERD) admitted to five hospitals in Mexico City between May 1999 and December 2025. Demographic variables (age, sex), symptomatology, diagnostic studies (endoscopy, impedance-pH monitoring, nuclear medicine), the surgical procedure performed, complications, and follow-up were analyzed.
Results: One hundred five patients were included, 37 men and 68 women, with a mean age of 50 years (range 20-74 years). Upper digestive endoscopy showed bile pooling and gastritis in all patients, confirmed by pathology. Twenty-four-hour impedance-pH monitoring was performed in 58 patients, showing pathological non-acid or mixed reflux. Nuclear medicine confirmed duodenogastric reflux in 58 cases. All surgical procedures were laparoscopic, with no associated morbidity or mortality.
Conclusion: Laparoscopic fundoplication combined with extramucosal duodenal myotomy is a safe and effective method for treating pathological duodenogastroesophageal reflux.
Keywords: Duodenogastric reflux; Gastroesophageal reflux; Laparoscopic fundoplication; Duodenal myotomy; Duodenal motor dysfunction.
Introduction
Duodenogastric reflux (DGR) has been studied for almost 150 years [1], and its clinical relevance as a sequela of gastric surgery became more prominent following Billroth's descriptions of the complications of his own operations. Physiologically, it is a normal process: it occurs postprandially, at night, and during the interdigestive state, and it contributes to gastric alkalinization, pH maintenance, increased antroduodenal motility, and gastric clearance, without damaging the mucosa [2,3].
Pathological DGR is different. It is defined by the abnormal regurgitation of duodenal content into the stomach, mixed with gastric content, capable of reaching the esophagus and pharynx, known as duodenogastroesophageal reflux (DGER) [4,5,6,8]. It produces significant symptoms, damages the mucosa, and can induce severe histological changes [4,5,6].
Even in patients with an "intact stomach," a pathological DGER syndrome can develop: detailed manometric studies of the esophago-gastro-duodeno-jejunal tract have shown the central role of hypertonic duodenal dyskinesia in its etiology, along with delayed gastric emptying [9,10].
DGR is also a recognized risk factor for gastric intestinal metaplasia and is postulated as an initiator of gastric carcinogenesis; it has been associated with decreased survival in patients with gastric adenocarcinoma [18]. Bile acids that are part of the reflux can increase cell proliferation through activation of receptors such as TGR5, G(q)α, and Gα(i-3) [17]. DGER, in turn, contributes to reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma [19,20], and laryngopharyngeal reflux —sometimes referred to as Sherry syndrome— is a relevant comorbidity factor with asthma, pulmonary fibrosis, and laryngeal adenocarcinoma [21]. Given this clinical relevance, we propose a functional, non-mutilating, non-resective, non-diversionary technique —indicated in patients with an intact stomach— that combines fundoplication with extramucosal duodenal myotomy for the treatment of pathological duodenogastric reflux, originally described by Mattioli [12].
Material and Methods
A retrospective, multicenter, non-comparative study was conducted. Between May 1999 and December 2025, of 3,000 patients diagnosed with gastroesophageal reflux disease, 105 were identified with symptoms of pathological duodenogastric reflux.
The diagnosis was based on a comprehensive morphological and functional evaluation. The 105 patients included had at least two positive studies among the following:
Age, sex, predominant symptomatology, results of diagnostic studies, details of the surgical procedure (Toupet fundoplication and extramucosal duodenal myotomy by laparoscopy, using the continuous suture technique previously described by our group [22]), intra- and postoperative complications, and clinical follow-up were analyzed.
Results
105 patients were included: 37 men (35.2%) and 68 women (64.8%), with a mean age of 50 years (range 20-74 years). Demographic distribution and diagnostic findings are summarized in Table 1.
Upper digestive endoscopy was performed in all patients and consistently showed bile pooling and gastritis, confirmed by histopathology [18]. Twenty-four-hour impedance-pH monitoring demonstrated patterns of pathological non-acid or mixed reflux, confirming its biliary nature [10]. Hepatobiliary scintigraphy corroborated, in 58 cases, the passage of duodenal content into the gastric cavity.
All 105 procedures, Toupet fundoplication and extramucosal duodenal myotomy, were completed laparoscopically without conversion to open surgery. No intra- or postoperative morbidity or mortality was recorded in any patient, confirming that the technique is safe and reproducible. Rigorous patient selection, based on functional and morphological criteria, resulted in a notable long-term improvement in esophageal and gastric symptoms [7,9].
Discussion
The discussion of the surgical treatment of pathological duodenogastric reflux, supported by our experience over the past 15 years, by manometric studies of the esophago-gastro-duodeno-jejunal tract, and by our group's own experience in advanced laparoscopic surgery [23], highlights the importance of identifying correctable alterations in gastroduodenal motility [9,11,14].
In patients with an intact stomach and demonstrable duodenal motor alterations, a functional, non-ablative technique can be offered. The combination of fundoplication with extramucosal duodenal myotomy, as described by Mattioli and colleagues, fits precisely with this approach [9,11,12,13,14]; other interventions, such as duodenal switch or pyloroplasty, have also historically been considered for these same motor disorders. When the motor alteration is severe and irreversible, confirmed by a negative prostigmine test, or coexists with precancerous morphological alterations, demolition or diversion procedures become the only viable option, with total duodenal diversion being the preferred intervention.
In patients with an operated stomach (for example, after gastrectomy or ulcer surgery), the surgical outcome depends largely on the prior intervention and its complications [2,3]. Inadequate management or a postoperative complication of the initial surgery may weigh more heavily in the development of reflux syndrome than a pre-existing, undiagnosed motor disorder. In these cases, total duodenal diversion, through conversion from Billroth II to Roux-en-Y, has also proven to be a reliable and effective option [2,10]; recent studies in distal gastrectomy confirm that Roux-en-Y reconstruction consistently reduces residual gastritis and biliary reflux compared with Billroth II reconstruction [24,25].
Our retrospective study, with 105 patients treated by laparoscopic Toupet fundoplication and extramucosal duodenal myotomy, provides solid evidence of the safety and efficacy of this functional approach [7,9]. The favorable symptomatic response and the absence of morbidity and mortality reinforce the validity of the technique in the management of pathological DGER, and allow more complex resective surgeries to be avoided.
Conclusion
Laparoscopic fundoplication combined with extramucosal duodenal myotomy is a functional, non-mutilating, safe, and effective surgical approach for pathological duodenogastroesophageal reflux in patients with an intact stomach. By directly correcting the underlying gastroduodenal motor dysfunction, it offers a non-resective, non-diversionary alternative, preserves the patient's anatomy, and records no associated morbidity or mortality.
Its suitability depends on rigorous patient selection, supported by a comprehensive diagnostic evaluation combining morphological and histopathological criteria with complementary functional studies. Clinical-surgical results show a notable and lasting improvement in esophageal and gastric symptomatology, which establishes this procedure as the treatment of choice for patients with an intact stomach and correctable motor alterations.
References