Up to 40% of patients with gastro-esophageal reflux disease (GERD) do not respond to medical therapy. Laparoscopic fundoplication (LF) for GERD provides suboptimal outcomes and risk of long-lasting adverse events. Transoral incisionless fundoplication (TIF) may be proposed as alternative treatment for GERD. TIF and LF long-term effects have not been compared so far, to assess the real efficacy of TIF in clinical practice. We aimed at comparing the long-term outcomes of TIF and 360° LF or partial (anterior 90° to 180° or posterior 270°) LF in GERD patients.

A systematic search of major databases was performed up to September 2025. Studies reporting 5- to 10-year outcomes of TIF and LF in patients with confirmed GERD were included. Randomized controlled trials comparing 360° and partial LF were considered. Pooled proportions and 95% confidence interval (95% CI) of patient satisfaction, GERD recurrence and proton pump inhibitor (PPI) discontinuation outcomes were calculated by random-effects meta-analysis, performed for each outcome and technique, and compared by N-1 Chi-squared test.

Eight studies on TIF (involving 447 patients) and ten studies on LF (involving 954 and 948 patients undergone 360° LF and partial LF, respectively), relevant to selection criteria, were included in the meta-analyses. Following TIF, the 5- to 10-year pooled proportions of patient satisfaction, GERD recurrence, and PPI discontinuation were 79.69% (95% CI: 72.64 to 85.62), 15.33% (95% CI: 9.66 to 22.63), and 67.47% (95% CI: 60.29 to 74.09), respectively. Following 360° LF, the 5- to 10-year pooled proportions of patient satisfaction, GERD recurrence, and PPI discontinuation were 81.27% (95% CI: 77.43 to 84.71), 17.9% (95% CI: 12.71 to 24.12), and 68.55% (95% CI: 64.69 to 72.23), respectively. Following partial LF, the 5- to 10-year pooled proportions of patient satisfaction, GERD recurrence, and PPI discontinuation were 81.31% (95% CI: 77.3 to 84.89), 17.2% (95% CI: 12.08 to 23.28), and 51.25% (95% CI: 47.02 to 55.46%), respectively. The pooled proportions of patient satisfaction and GERD recurrence did not significantly differ between TIF, 360° LF and partial LF. The pooled proportion of patients off-PPI following TIF was like 360° LF and significantly higher than partial LF (p = 0.0001), mainly compared to posterior 270° LF and anterior 180° LF (p < 0.0001).  

This meta-analysis reports that the 5- to 10-year patient satisfaction, GERD recurrence, and PPI discontinuation outcomes of TIF and LF are substantially comparable. Thus, TIF could offer a therapeutic option as clinically effective as LF in the long-term, without surgery-related side effects, for selected GERD patients, who refuse life-long medical therapy or surgery, are intolerant to PPI, or have some risk of persistent post-surgical side effects.