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J Thorac Cardiovasc Surg 2005;130:1593-1600
© 2005 The American Association for Thoracic Surgery

General Thoracic Surgery

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

^a Center for Swallowing and Esophageal Disorders and the Departments of Thoracic and Cardiovascular Surgery,
^b Gastroenterology,
^c Diagnostic Radiology,
^d Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, Ohio.

Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.

Received for publication March 25, 2005; revisions received July 19, 2005; accepted for publication July 26, 2005.

^_* Address for reprints: Thomas W. Rice, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195 (Email: ricet{at}ccf.org).

OBJECTIVE: 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.

METHODS: 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.

RESULTS: 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).

CONCLUSIONS: 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.

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				S. Baldi and E. Ruffini Reply to the Editor J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 216 - 216. [Full Text] [PDF]

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