J Thorac Cardiovasc Surg 2006;132:217
© 2006 The American Association for Thoracic Surgery
Reply to the Editor
Thomas W. Rice, MD,
Eugene H. Blackstone, MD
Cleveland Clinic, Cleveland, Ohio
Reply to the Editor:
We thank Porziella and colleagues for their comments and suggestions. In our study, esophageal manometry was performed preoperatively and postoperatively, but not intraoperatively. Therefore, we cannot compare published intraoperative results with our results. As Dr Cesario pointed out, at least for fundoplication, there is poor correlation between intraoperative and postoperative manometry.
In our patients who underwent Heller myotomy alone, median resting pressure was 13.3 mm Hg, and median residual pressure was 1.8 mm Hg. Incomplete myotomy or rapid early healing of the nondistracted lower portion of the myotomy may account for the few elevated measurements. No doubt prior therapy can obliterate the plane between the muscularis propria and submucosa, making myotomy more difficult and perhaps incomplete. However, in patients who underwent Heller myotomy and Dor fundoplication, median resting pressure was 17.5 mm Hg (P = .02 compared with Heller myotomy alone), and resting pressure was 4.6 mm Hg (P = .002). Despite the identical myotomy technique, there were higher median lower esophageal sphincter resting and residual pressures, no doubt the result of Dor fundoplication. Despite this, esophageal emptying was not impaired. Therefore, Dor fundoplication can be added to Heller myotomy without adverse effects on esophageal emptying, the principal objective of therapy.
There are several theoretic reasons to add Dor fundoplication to Heller myotomy in treating achalasia: (1) Dor fundoplication provides a serosal patch over the myotomy, perhaps reducing postoperative leaks; (2) stitching the edges of a Dor fundoplication to the edges of a myotomy "holds" the myotomy open; and (3) Dor fundoplication provides a buttress to the myotomized esophagus and prevents formation of a pseudodiverticulum. However, the only proven effect of Dor fundoplication on Heller myotomy is reduction of gastroesophageal reflux. This is crucial in patients with myotomized achalasia who have no esophageal peristalsis to clear refluxed acid and bile.
We have abandoned nuclear medicine studies of esophageal emptying because they are costly and inconvenient, and lack anatomic definition. Timed barium esophagram is simple, fast, inexpensive, repeatable, and comfortable, and is an anatomic examination. We use it preoperatively, 8 weeks postoperatively, and in yearly follow-up in all our patients with achalasia.
Related Article
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Dor fundoplication after myotomy for achalasia: Useful, unnecessary, or harmful?
- Venanzio Porziella, Alfredo Cesario, and Pierluigi Granone
J. Thorac. Cardiovasc. Surg. 2006 132: 216-217.
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