Background: The efficacy of laparoscopic Heller myotomy for achalasia is well established. The need for routine fundoplication is less clear. We hypothesized that routine fundoplication during laparoscopic Heller myotomy is unnecessary to achieve good outcomes when intraoperative endoscopy is used.
Methods: 100 patients undergoing laparoscopic Heller myotomy with intraoperative endoscopy from 9/92 to 4/00 for severe achalasia were prospectively followed. Fundoplication was selectively undertaken in patients with large hiatus hernias or as part of repair of esophageal perforation. Patients undergoing myotomy with (n=21) or without (n=79) concomitant fundoplication were compared for dysphagia, reflux symptoms, and overall outcome. Dysphagia and reflux symptoms were graded by the patients as 0 (none) to 5 (continuous). Dysphagia occurring more than weekly was considered significant. Outcomes were graded by patients as excellent (no symptoms), good (greatly improved), fair (slightly improved), or poor (no improvement). Data are mean ± SEM when appropriate.
Results: Follow up was similar for patients undergoing myotomy with and without fundoplication (18 months ± 2.5 vs 23 ± 1.9, p=NS). Symptoms improved following myotomy (Table). Preop and postop dysphagia, reflux scores, and dysphagia scores were similar for both groups of patients (Table). Overall improvement was reported by 95% of patients undergoing myotomy with concomitant fundoplication and 99% without fundoplication (p=NS).
Conclusion: When intraoperative endoscopy is used during laparoscopic Heller myotomy, disruption of natural antireflux mechanisms by undue dissection around the lower esophagus is avoided, adequacy of myotomy is assured, and excessive myotomy onto the cardia is averted. Routine fundoplication is not necessary with laparoscopic Heller myotomy and intraoperative endoscopy.
Fundoplication No Fundoplication
Preop Postop Preop Postop
Dysphagia 100% 29% 100% 14%
Dysphagia score 4.6 ± 0.3 1.2 ± 0.3 4.9 ± 0.1 0.8 ± 0.1
Reflux score 3.6 ± 0.4 1.0 ± 0.3 3.2 ± 0.2 1.4 ± 0.2
p<0.05 vs preop, Fisher's exact test
p<0.05 vs preop, Student's T-test