The choice of optimal antireflux procedure after laparoscopic cardiomyotomy: two decades of clinical experience in one center.

Abstract

IntroductionTwo types of partial wrap are commonly performed in achalasia patients after Heller myotomy: the posterior 270° fundoplication (Toupet) and the anterior 180° fundoplication (Dor). The optimal type of fundoplication (posterior vs. anterior) is still debated.AimTo compare the long-term rates of dysphagia, reflux symptoms and patient satisfaction with current postoperative condition between two fundoplication groups in achalasia treatment.Material and methodsOur retrospective study included 97 consecutive patients with achalasia: 37 patients underwent laparoscopic posterior Toupet (270°) fundoplication followed by Heller myotomy (group I); 60 patients underwent laparoscopic anterior partial Dor fundoplication followed by Heller myotomy (group II). Long-term follow-up results included evaluation of dysphagia symptoms, intensity of heartburn and patient satisfaction with current condition.ResultsPatients in these two groups did not differ according to age, weight, height, postoperative stay or follow-up period. Laparoscopic myotomy with posterior Toupet fundoplication was effective in 89% of patients, while laparoscopic myotomy with anterior Dor was effective in 93% of patients (p > 0.05). 11% of patients after posterior Toupet fundoplication had clinically significant heartburn vs. 35% of patients after anterior Dor fundoplication (p < 0.05). Overall patient satisfaction with current condition was 88%, with no significant difference between the groups.ConclusionsAccording to our study results, the two laparoscopic techniques were similarly effective in reducing achalasia symptoms, but postoperative clinical manifestation of heartburn is significantly more frequent after anterior Dor fundoplication (35% vs. 11%). The majority of patients (88%) were satisfied with operation outcomes.

Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta‐Analysis

“…Two variables favored Toupet fundoplication compared to Dor procedure. A statistically significant shorter LOHS by 18 h was noted for Toupet compared to Dor based on 4 out of 7 studies [12–14, 16] (WMD 0.73, 95% CI 0.47 to 0.99, P < 0.0001) (Fig. 2), and QOL was found to be significantly better for Toupet compared to Dor based on two studies [12, 13] (WMD 1.68, 95% CI: 0.68 to 2.73, P < 0.001) (Fig.…”

“…Rawling et al in the first RCT comparing Dor versus Toupet after HM [4] reported 41.7% of Dor patients to be affected by GER compared to 21% in Toupet, while Kiudelis et al [14] reported a similar result (35% Dor vs 11% Toupet). Torres‐Villalobos et al [12] the latest RCT to be published showed initially at 6 months a significant difference between the groups (7% Dor vs 34% Toupet), but at 24 months there was no statistical difference (10.5% Dor vs 31.5% Toupet).…”

“…Seven comparative studies [4,6,[12][13][14][15][16] totaling 486 patients (Dor = 245; Toupet = 241) were analyzed. The details of the study are summarized (Table 1).…”

“…This yielded eight articles with one of them being a duplicate [9]. Finally, three RCTs [4,12,13] and four non-RCTs [6,[14][15][16] were selected for this meta-analysis (Fig. 1).…”

Tension-free hiatal hernia repair with biological mesh: A real-world experience

“…[ 24 ] Several studies confirmed that a laparoscopic 270° Toupet or a laparoscopic 180° Dor fundoplication provided similar control of GORD at follow-up, with no difference in post-fundoplication symptoms, and majority of patients (88%) were satisfied with operation outcomes. [ 25 , 26 ] A retrospective review of prospectively collected data reported that incidence of recurrent HH increased in direct correlation with the preoperative HH size (No HH: 0%, small HH (<3-cm): 10.1%, large HH (≥3-cm): 16.6%, paraesophageal hernia (PEH): 20%, p 0.032) after magnetic sphincter augmentation. According to a 5-year observation, patients who underwent laparoscopic repair of large (≥5-cm) type III HH, the 5-year recurrence-free probability was similar, but an earlier failure rate was noted in the non-mesh group at 12 months (p .299).…”