Aims: Anterior fundoplication is usually performed after Heller myotomy to control GER; however, the incidence of postoperative GER ranges between 10 and 30%. Total fundoplication may aid in reducing GER rates. Aim of the study is to compare in a prospective, randomized trial the long-term results of laparoscopic Heller myotomy plus Dor fundoplication versus laparoscopic Heller myotomy plus floppy-Nissen for achalasia. Methods: From December 1993 to September 2002, 153 patients with achalasia underwent Heller laparoscopic myotomy plus antireflux fundoplication. Of these, 9 were excluded from the study. The remaining 144 patients were randomly assigned to two treatment groups: Heller laparoscopic myotomy plus anterior fundoplication (Dor procedure) or Heller laparoscopic myotomy plus total fundoplication (floppy-Nissen procedure). The primary endpoint was incidence of GER at ph-metry after a minimum of 60 months follow-up. The secondary end points were recurrence of dysphagia and clinical GER. Follow-up clinical assessments were performed at 1, 3, 12, and 60 months using a modified DeMeester Symptom Scoring System (MDSS). Esophageal manometry and 24-h pH-monitoring were performed at 3, 12, and 60 months postoperative. Results: Of the 144 patients originally included in the study, 138 were available for long-term analysis: 71 (51%) underwent antireflux fundoplication plus a Dor procedure (H + D group) and 67 (49%) antireflux fundoplication plus a Nissen procedure (H + N group). No mortality was observed. The mean follow-up period was 125 months. No statistically significant differences in clinical (5.6% vs. 0%) or instrumental GER (2.8% vs. 0%) were found between the two groups; however, a statistically significant difference in dysphagia rates was noted (2.8% vs. 15%; P < 0.001). Conclusions: While both techniques achieved long-term GER control, the recurrence rate of dysphagia was significantly higher among the patients who underwent Nissen fundoplication. This evidence supports the use of Dor fundoplication as the preferred method to re-establish GER control in patients undergoing laparoscopic Heller myotomy.
Randomized controlled trial of laparoscopic Heller myotomy plus anterior fundoplication vs total fundoplication for achalasia: long-term results
REBECCHI, Fabrizio;GIACCONE, Claudio;MORINO, Mario
2009-01-01
Abstract
Aims: Anterior fundoplication is usually performed after Heller myotomy to control GER; however, the incidence of postoperative GER ranges between 10 and 30%. Total fundoplication may aid in reducing GER rates. Aim of the study is to compare in a prospective, randomized trial the long-term results of laparoscopic Heller myotomy plus Dor fundoplication versus laparoscopic Heller myotomy plus floppy-Nissen for achalasia. Methods: From December 1993 to September 2002, 153 patients with achalasia underwent Heller laparoscopic myotomy plus antireflux fundoplication. Of these, 9 were excluded from the study. The remaining 144 patients were randomly assigned to two treatment groups: Heller laparoscopic myotomy plus anterior fundoplication (Dor procedure) or Heller laparoscopic myotomy plus total fundoplication (floppy-Nissen procedure). The primary endpoint was incidence of GER at ph-metry after a minimum of 60 months follow-up. The secondary end points were recurrence of dysphagia and clinical GER. Follow-up clinical assessments were performed at 1, 3, 12, and 60 months using a modified DeMeester Symptom Scoring System (MDSS). Esophageal manometry and 24-h pH-monitoring were performed at 3, 12, and 60 months postoperative. Results: Of the 144 patients originally included in the study, 138 were available for long-term analysis: 71 (51%) underwent antireflux fundoplication plus a Dor procedure (H + D group) and 67 (49%) antireflux fundoplication plus a Nissen procedure (H + N group). No mortality was observed. The mean follow-up period was 125 months. No statistically significant differences in clinical (5.6% vs. 0%) or instrumental GER (2.8% vs. 0%) were found between the two groups; however, a statistically significant difference in dysphagia rates was noted (2.8% vs. 15%; P < 0.001). Conclusions: While both techniques achieved long-term GER control, the recurrence rate of dysphagia was significantly higher among the patients who underwent Nissen fundoplication. This evidence supports the use of Dor fundoplication as the preferred method to re-establish GER control in patients undergoing laparoscopic Heller myotomy.
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