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