Fundoplication After Heller Myotomy: A Retrospective Comparison Between Nissen and Dor

Abstract

Objective: A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. Materials and Methods:From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. Results: Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off ), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. Conclusion:Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up. Bulgular: Dor fundoplikasyon tedavisi Nissen fundoplikasyondan daha fazla disfaji ve yetersizlik şiddet skorunu önemli (p<0.0001) ölçüde azaltmıştır. Sonunda, "disfajik" olarak değerlendirmenin DeMeester skorunun 3 (keyfi cut-off ) alındığı bir hastada, gerçekten de, Dor fundoplikasyon ile tedavi edilenlere göre floppy-Nissen ile tedavi edilen hastalarda disfaji insidansı oranı anlamlı derecede daha yük-sek bulunmuştur. Sırasıyla H+N ve H+D grubu grubundaki hastalarda %17.65 ve %0 (p=0.037) takip hastalığı (disfaji) oluşmuştur. Sonuç:Heller miyotomi-Dor fundoplikasyon güvenli ve değerli bir tedavi yöntemidir. Bu prosedür, postoperatif disfajiye karşı Nissen fundoplikasyon daha düşük bir insidans ve ihmal edilebilir bir oranda ameliyat sonrası uzun süreli bir takip de ameliyat sonrası GÖRH göstermiştir.

Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication

“…Achalasia is a primary disorder of esophageal motility with consequent loss of esophageal peristalsis and impaired or failed relaxation of the lower esophageal sphincter (LES) during swallowing [1,3].…”

“…All these symptoms can often become very debilitating and the quality of life can be negatively affected [1]. Even if the etiopathogenesis of achalasia is not yet explained, it can be defined as a neurodegenerative disorder of the muscles of the esophageal body and LES, which is due to an idiopathic and irreversible loss of postganglionic inhibitory neurons in Auerbach' s myenteric plexus [4,5].…”

“…Instrumental diagnosis is carried out by upper gastrointestinal barium meal, esophagogastroduodenoscopy, esophageal pH monitoring, and esophageal manometry [1,2,8].…”

“…Typical findings are dilatation of the esophagus, narrowing of the gastroesophageal junction, an absence of esophageal peristalsis, and a hypertensive LES that fails to completely relax during swallowing [1,2].…”

“…The first-line treatment is still debated in the medical community: some authors prefer pneumatic endoscopic dilatation, others the endoscopic injection of botulinum toxin, and yet others surgery [1,2,[9][10][11][12][13][14].…”