A physiologic clinical study of achalasia: Should Dor fundoplication be added to Heller myotomy?

Abstract

Myotomy for achalasia disrupts the lower esophageal sphincter, improving emptying at the expense of reflux. We hypothesized that surgical palliation of achalasia requires balancing desirable improvement in esophageal emptying with undesirable production of gastroesophageal reflux. Therefore, we objectively studied the physiologic effects of adding Dor fundoplication to Heller myotomy. From December 1996 to June 2004, 149 patients underwent Heller myotomy; 88 (59%) had additional Dor fundoplication. The adequacy of myotomy was assessed by premyotomy to postmyotomy change in lower esophageal sphincter pressures, esophageal emptying by change in timed barium esophagram, and gastroesophageal reflux by postoperative 24-hour pH monitoring. For adequacy of myotomy, postmyotomy resting lower esophageal sphincter pressure was higher with (median, 18 mm Hg) than without (median, 13 mm Hg) Dor fundoplication (P = .002), as was residual lower esophageal sphincter pressure (median, 4.6 vs 1.8 mm Hg; P = .01). For esophageal emptying, postmyotomy barium height and width were similar with or without Dor fundoplication (P > .1). For gastroesophageal reflux, percentage of upright time with a pH of less than 4 was lower with (median, 0.4%) than without (median, 2.9%) Dor fundoplication (P = .005), and percentage of supine time with a pH of less than 4 was lower with (median, 0%) than without (median, 5.8%) Dor fundoplication (P = .007). The addition of Dor fundoplication reduces the adequacy of myotomy without impairing emptying and reduces reflux. Heller myotomy and Dor fundoplication balance emptying and reflux and therefore should be the surgical treatment of choice for achalasia.