J Thorac Cardiovasc Surg 2006;132:216-217
© 2006 The American Association for Thoracic Surgery
Dor fundoplication after myotomy for achalasia: Useful, unnecessary, or harmful?
Venanzio Porziella, MD
a
,
Alfredo Cesario, MD
a
,
b
,
Pierluigi Granone, MD
a
a Division of General Thoracic Surgery, Catholic University, Rome, Italy
b Pulmonary Rehabilitation, IRCCS San Raffaele, Rome, Italy
To the Editor:
We appreciated the interesting and accurate article from Rice and colleagues
1
that was recently published in the Journal. In this report, the authors emphasized the fact that addition of a Dor-type fundoplication procedure to a Heller myotomy increases both resting and residual lower esophageal sphincter (LES) pressure, reducing the adequacy of myotomy itself. Our group has established experience with this issue. We reported that the basal LES pressure, measured by intraoperative manometry, was always close to 0 mm Hg after myotomy and increased after Dor fundoplication.
2
On the basis of our own previous observations, we presume that pressure values recorded in patients undergoing myotomy alone remain somewhat high because of an underlying incomplete incision of muscular fibers as the result of technical difficulties (62% of patients in the study by Rice and colleagues
1
had prior nonsurgical treatments). Furthermore, in the report,
1
the addition of a Dor fundoplication increased both resting and residual LES pressure but did not impair esophageal emptying. In our experience, higher pressures recorded in the Heller-Dor group could be easily related to a newly established "high pressure zone" rather than to an inadequate myotomy.
According to this evidence and that outlined in the prospective, randomized, double-blind clinical trial by Richards and colleagues,
3
we advise the use of a partial anterior fundoplication after myotomy for several reasons. First, because the Dor-type procedure does not cause a significant postoperative dysphagia, and second, and most important, as also demonstrated by Costantini and colleagues,
4
because the associated procedure (Heller myotomy plus Dor fundoplication) proved to be superior to the Heller procedure alone when the incidence of postoperative gastroesophageal reflux at short- and long-term follow-up is considered. We believe that suturing the gastric wall to the edges of the myotomy with 3 stitches on each side, according to the Dor technique, maintains the edges of the myotomy open, thus preventing consequences of scar tissue repair, and covers any undetected perforation of the esophageal mucosal layer, thus preventing significant perioperative morbidity. According to our experience,
5
we advise the use of radionuclide esophageal transit study in evaluating the esophageal transit time and esophageal emptying after myotomy because it is more accurate than the analysis of changes in timed barium esophagograms as suggested by Rice and colleagues.
1
We appreciate the authors' feedback on the observations raised.
 |
References
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- Rice TW, McKelvey AA, Richter JE, Baker ME, Vaezi MF, Feng J, et al. A physiologic clinical study of achalasia. should Dor fundoplication be added to Heller myotomy?. J Thorac Cardiovasc Surg 2005;130:1593-1600.[Abstract/Free Full Text]
- Clemente G, D'Ugo D, Granone P, Nuzzo G, Picciocchi A. Intraoperative esophageal manometry in surgical treatment of achalasia. a reappraisal. Hepatogastroenterology 1996;43:1532-1536.[Medline]
- Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia. a prospective randomized double-blind clinical trial. Ann Surg 2004;240:405-415.[Medline]
- Costantini M, Zaninotto G, Guirroli E, Rizzetto C, Portale G, Ruol A, et al. The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 2005;19:345-351.[Abstract/Free Full Text]
- D'Ugo D, Valenza V, Castrucci G, Porziella V, Giacinto O, Galli G. What standardization should be adapted in scintigraphy to evaluate LES disfunction? The esophagogastric junction. Paris: John Libbey Eurotext; 1997.[Abstract/Free Full Text]
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