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16. Should Dor Fundoplication Be Added to Heller Myotomy?: A Physiologic Clinical Study of Achalasia
Thomas W Rice, Alicia A Mckelvey, Sudish C Murthy, David P Mason, Mark E Baker, Michael F Vaezi, Jingyuan Feng, Eugene H Blackstone; Cleveland, OH
Objective:
Myotomy for achalasia disrupts the lower esophageal sphincter, improving emptying at the expense of reflux. Addition of fundoplication to reduce reflux has unclear effects on the outcome of myotomy. Therefore, we physiologically assessed the impact of Dor fundoplication on Heller myotomy.
Methods:
From 12/1996 to 6/2004, 149 patients underwent Heller myotomy; 88 (59%) had additional Dor fundoplication. Adequacy of myotomy was assessed by pre- to postoperative change in lower esophageal sphincter (LES) pressures, esophageal emptying by change in timed barium esophagram (TBE), and gastroesophageal reflux by postoperative 24-h pH monitoring.
Results:
Adequacy of myotomy: Post-myotomy resting LES pressure was higher with (median 17.5 mmHg) than without (median 13.3 mmHg) Dor (P=.002), as was residual LES pressure (median 4.6 vs. 1.8 mmHg) (P=.02).
Esophageal emptying: Post-myotomy barium height and width were similar with or without Dor (P>.1).
Gastroesophageal reflux: Percent upright time pH <4 was less with (median 0.4%) than without (median 2.9%) Dor (P=.005), and supine time pH <4 was less with (median 0%) than without (median 5.3%) Dor (P=.007).
Conclusions:
Addition of Dor fundoplication to Heller myotomy minimally reduces adequacy of myotomy without adversely affecting esophageal emptying, but it beneficially reduces gastroesophageal reflux. Therefore, Dor fundoplication should routinely be added to Heller myotomy.
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