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Surgical Endoscopy

, Volume 26, Issue 1, pp 18–26 | Cite as

Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial

  • Arthur Rawlings
  • Nathaniel J. Soper
  • Brant Oelschlager
  • Lee Swanstrom
  • Brent D. Matthews
  • Carlos Pellegrini
  • Richard A. Pierce
  • Aurora Pryor
  • Valeria Martin
  • Margaret M. Frisella
  • Maria Cassera
  • L. Michael Brunt
Article

Abstract

Background

The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy.

Methods

A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0–4, five-point Likert scale questionnaire) and 24-h pH testing at 6–12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann–Whitney U test, Wilcoxon signed rank test, and Freidman’s test.

Results

Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6–12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups).

Conclusion

Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.

Keywords

Achalasia Dor fundoplication Toupet fundoplication Heller myotomy 

Notes

Acknowledgments

The authors thank Mary Quasebarth, RN, and Kevin Costello for their extensive assistance with data entry and database management, Dr. Rick Schuessler for help with the overall statistical analysis, and Dr. Jie Zhang for statistical analysis of the SF-36 data. This study was supported in part by a research grant from the Society of American Gastrointestinal and Endoscopic Surgeons.

Disclosure

Dr. L. Michael Brunt has received educational grant support from Ethicon Endo-Surgery, honoraria for speaking/teaching from Lifecell Corporation, past honoraria for speaking/teaching from Cook Medical and Covidien, and past consulting fees from Stryker Endoscopy. Dr. Arthur Rawlings has received an honorarium from Lifecell Corporation for teaching/speaking. Dr. Nathaniel J. Soper was on the advisory boards of Covidien, TransEnterix, Boston Scientific, Miret Surgical, Inc. and has received educational support from Covidien and Ethicon Endo-Surgery and research support from Karl Storz Endoscopy-America Speaker’s Bureau, Covidien, and Ethicon Endo-Surgery. Dr. Brent Matthews has received research support from and did consulting for Atrium Medical, received research support and honoraria from Ethicon Endo-Surgery, did consulting for Ethicon, Inc., received research support and an honorarium from W. L. Gore, and received research support from the Musculoskeletal Transplant Foundation. Dr. Aurora Pryor has ownership interest in TransEnterix and Barosense, received honoraria from Cinemed, Covidien, and W. L. Gore, and has received research support from Covidien. None of the disclosures from the above authors are relevant to the study or the article. B. Oelschlager, L. Swanstrom, C. Pellegrini, R. Pierce, M. Frisella, V. Martin, and M. Cassera have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Campos G, Vittinghoff E, Rabl C, Takata M, Gadenstatter M, Feng L, Ciovica R (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249:45–57PubMedCrossRefGoogle Scholar
  2. 2.
    Stefanidis D, Hope W, Kohn G, Reardon P, Richardson WS, Fanelli R, SAGES Guidelines Committee (2010) Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 24(11):2647–2669PubMedCrossRefGoogle Scholar
  3. 3.
    Ben-Meir A, Urbach DR, Khajanchee YS, Hansen PD, Swanstrom LL (2001) Quality of life before and after laparoscopic Heller myotomy for achalasia. Am J Surg 181:471–474PubMedCrossRefGoogle Scholar
  4. 4.
    Richards WO, Torquati A, Holzman M, Khaitan L, Byrne D, Lutfi R, Sharp K (2004) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 240:405–415PubMedCrossRefGoogle Scholar
  5. 5.
    Burpee SE, Mamazza J, Schlacta CM, Bendavid Y, Klein L, Moloo H, Poulin EC (2005) Objective analysis of gastroesophageal reflux after laparoscopic Heller myotomy. Surg Endosc 19:9–14PubMedCrossRefGoogle Scholar
  6. 6.
    Patti MG, Fernando HA (2010) Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: What type? J Gastrointest Surg 14:1453–1458PubMedCrossRefGoogle Scholar
  7. 7.
    Zaninotto G, Costantini M, Rizzetto C, Zanatta L, Guirroli E, Portale G, Nicoletti L, Cavallin F, Battaglia G, Ruol A, Ancona E (2008) Four hundred laparoscopic myotomies for achalasia: a single center experience. Ann Surg 248:986–993PubMedCrossRefGoogle Scholar
  8. 8.
    Hunter JG, Trus TL, Branum GD, Waring JP (1997) Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg 225:655–664PubMedCrossRefGoogle Scholar
  9. 9.
    Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138:490–495PubMedCrossRefGoogle Scholar
  10. 10.
    Robert M, Poncet G, Mion F, Boulez J (2008) Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases. Surg Endosc 22:866–874PubMedCrossRefGoogle Scholar
  11. 11.
    Pellegrini CA, Wetter LA, Patti MG, Leichter R, Mussan G, Mori T, Bernstein G, Way LW (1992) Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg 216:291–296PubMedCrossRefGoogle Scholar
  12. 12.
    Kjellin A, Granqvist S, Ramel S, Thor K (1999) Laparoscopic myotomy without fundoplication in patients with achalasia. Eur J Surg 165:1162–1166PubMedCrossRefGoogle Scholar
  13. 13.
    Falkenback D, Johansson J, Oberg S et al (2003) Heller’s esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective, randomized trial. Dis Esophagus 16:284–290PubMedCrossRefGoogle Scholar
  14. 14.
    Rossetti G, Brusciano L, Amato G, Maffettone V, Napolitano V, Russo G, Izzo D, Russo F, Pizza F, Del Genio G, Del Genio A (2005) A total fundoplication is not an obstacle to esophageal emptying after Heller myotomy for achalasia: results of a long-term follow-up. Ann Surg 241:614–621PubMedCrossRefGoogle Scholar
  15. 15.
    Topart P, Deschamps C, Taillefer P, Duranceau A (1992) Long-term effect of total fundoplication on the myotomized esophagus. Ann Thorac Surg 54:1046–1051PubMedCrossRefGoogle Scholar
  16. 16.
    Chen LQ, Chugtai T, Sideris L, Nastos D, Taillefer R, Ferraro P, Duranceau A (2002) Long-term effects of myotomy and partial fundoplication for esophageal achalasia. Dis Esophagus 15:171–179PubMedCrossRefGoogle Scholar
  17. 17.
    Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M (2008) Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg 248:1023–1030PubMedCrossRefGoogle Scholar
  18. 18.
    Patti MG, Molena D, Fisichella P, Whang K, Yamada H, Perretta S, Way LW (2001) Laparoscopic Heller myotomy and Dor fundoplication for achalasia. Arch Surg 136:870–876PubMedCrossRefGoogle Scholar
  19. 19.
    Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB (2010) A single institution’s experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 210:637–647PubMedCrossRefGoogle Scholar
  20. 20.
    Perrone JM, Frisella MM, Desai KM, Soper NJ (2004) Results of laparoscopic Heller-Toupet operation for achalasia. Surg Endosc 18:1565–1571PubMedGoogle Scholar
  21. 21.
    Khajanchee YS, Kanneganti S, Leatherwood AEB, Hansen PD, Swanstrom LL (2005) Laparoscopic Heller myotomy with Toupet fundoplication: outcome predictors in 121 consecutive patients. Arch Surg 140:827–834PubMedCrossRefGoogle Scholar
  22. 22.
    Kilic A, Schuchert MJ, Pennathur A, Gilbert S, Landreneau RJ, Luketich JD (2009) Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery 146:826–833PubMedCrossRefGoogle Scholar
  23. 23.
    Simic A, Radovanovic N, Skrobic O, Raznatovic Z, Pesko P (2010) Significance of limited hiatal dissection in surgery for achalasia. J Gastrointest Surg 14:587–593PubMedCrossRefGoogle Scholar
  24. 24.
    Tsiaoussis J, Pechlivanides G, Gouvas N, Athanasakis E, Zervakis N, Manitides A, Xynos E (2008) Patterns of esophageal acid exposure after laparoscopic Heller’s myotomy and Dor’s fundoplication for esophageal achalasia. Surg Endosc 22:1493–1499PubMedCrossRefGoogle Scholar
  25. 25.
    Fein M, Bueter M, Thalheimer A, Pachmayr V, Heimbucher J, Freys S, Fuchs K (2008) Ten-year outcome of laparoscopic antireflux surgery. J Gastrointest Surg 12:1893–1899PubMedCrossRefGoogle Scholar
  26. 26.
    Ortiz A, Martinez de Haro L, Parrilla P, Lage A, Perez D, Munitiz V, Ruiz D, Molina J (2008) Very long-term objective evaluation of Heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia. Ann Surg 247:258–264PubMedCrossRefGoogle Scholar
  27. 27.
    Hagedorn C, Jonson C, Lonroth H, Ruth M, Thune A, Lundell L (2003) Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication: Results of a randomized controlled clinical trial. Ann Surg 238:189–196PubMedGoogle Scholar
  28. 28.
    Engstrom C, Lonroth H, Mardani J, Lundell L (2007) An anterior or posterior approach to partial fundoplication? Long-term results of a randomized trial. World J Surg 31:1221–1225PubMedCrossRefGoogle Scholar
  29. 29.
    Wright AS, Williams CW, Pellegrini CA, Oelschlager BK (2007) Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc 21:713–718PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Arthur Rawlings
    • 1
  • Nathaniel J. Soper
    • 2
  • Brant Oelschlager
    • 3
  • Lee Swanstrom
    • 4
  • Brent D. Matthews
    • 1
  • Carlos Pellegrini
    • 3
  • Richard A. Pierce
    • 4
  • Aurora Pryor
    • 5
  • Valeria Martin
    • 3
  • Margaret M. Frisella
    • 1
  • Maria Cassera
    • 4
  • L. Michael Brunt
    • 1
  1. 1.Department of SurgeryWashington University School of MedicineSt. LouisUSA
  2. 2.Department of Surgery, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  3. 3.Department of SurgeryUniversity of Washington School of MedicineSeattleUSA
  4. 4.The Oregon Clinic, Gateway Medical OfficePortlandUSA
  5. 5.Department of SurgeryDuke University School of MedicineDurhamUSA

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