SSAT - Dor Versus Toupet Fundoplication After Laparoscopic Heller Myotomy: First Report From a Randomized Trial Including High Resolution Manometry Evaluation

Back to 2015 Annual Meeting Program

Dor Versus Toupet Fundoplication After Laparoscopic Heller Myotomy: First Report From a Randomized Trial Including High Resolution Manometry Evaluation
Gonzalo Torres-Villalobos², Luis a. Martin-Del-Campo^*¹, Athenea Flores-Najera², Abraham Villa-BañOs², Alejandro E. Svarch², Enrique Coss-Adame³, Miguel a. Valdovinos³

¹Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran", Tlalpan, Mexico; ²Experimental Surgery Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico; ³Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Tlalpan, Mexico

Introduction
Laparoscopic Heller myotomy is the best treatment for most patients with primary esophageal achalasia. Given the high rates of gastro-esophageal reflux after myotomy, an antireflux procedure must be performed in every case. Partial fundoplications are preferred given the high frequency of dysphagia associated with 360° wraps. To date, there is no data that allows the surgeon to choose between the posterior 270° (Toupet) or the anterior 180° (Dor) fundoplications.
Objective
To prospectively identify which partial fundoplication leads to a lower esophageal acid exposure and a better post-operative symptom profile. A high resolution manometry (HRM) evaluation of the lower esophageal sphincter (LES) for both procedures will also be performed.
Methods
After approval from our institution's ethics committee, adult patients with a HRM esophageal achalasia diagnosis were included. Patients were randomized to a Heller myotomy plus a Toupet or a Dor fundoplication. Pre-operative clinical data (including GERD-HRQL, EAT and Eckardt questionnaires scores), barium swallow and HRM were obtained. Post-operative follow-up included clinical evaluation, HRM and 24 hours pH-metry. Data are presented as means, standard deviations and ranges. For group comparison, categorical variables were analyzed using the squared-chi test. For numerical variables, the Student's t-test or the Mann-Whitney U test were used according to data distribution. SPSS v17.0 was used for analysis.
Results
To date, we have randomized 31 patients; 14 in the Toupet group and 17 in the Dor group. Both fundoplication groups were similar at baseline (Table 1). After a mean follow-up of 15 months (up to 25 months), we found no differences in GERD-HRQL, EAT or Eckardt scores between surgical groups (Table 2). Although DeMeester score seemed lower for the Dor group (5.0±7.2 vs. 11.5±12.6), this was not statistically significant (p=0.116). HRM performed 6 months after surgery showed no differences for lower esophageal sphincter resting pressure (12.8±4.7 vs 14.7±6.6; p=.418),or integrated relaxation pressure(7.8±3.1 vs 10.1±3.7; p=.113) for the Toupet and Dor groups respectively.
Conclusion
So far, we have not found objective or subjective differences between Dor and Toupet fundoplication after laparoscopic Heller myotomy. Further clinical follow-up may help clarify which antireflux procedure is best for these patients.

Table 1. Pre-operative patient characteristics

Variable Toupet group Dor group p
Female gender 9/14 (64%) 12/17 (70%) .709*
Age (years) 41.42 (±12.94) 45.41 (±16.17) .462**
HRM Achalasia type
Type I
Type II
Type III .
2
11
1 .
4
11
2 .699*
Months from symptoms began to surgery 41.14 (±31.22) 31.64 (±22.32) .332**
Pre-operative dysphagia 13/14 (92%) 17/17 (100%) .263*
Regurgitation 13/14 (92%) 15/17 (88%) .665*
Pyrosis 8/14 (57%) 11/17 (64%) .667*
Kilograms lost 13.50 (±15.78) 11.94 (±8.07) .509***
Dilations performed .85 (±1.87) .70 (±.98) .637***
Preoperative barium swallow
-Stenosis
-Esophageal dilation
-Sigmoid esophagus .
2
11
1 .
2
10
5 .294*
Preoperative GERD HRQL score 25.35 (±14.70) 28.58 (±14.18) .540**
Preoperative EAT score 32.28 (±7.47) 33.05 (±7.28) .773**
Preoperative Eckardt score 10.71 (±5.20) 9.88 (±1.45) .544***
Preoperative LES resting pressure 37.63 (±17.06) 42.54 (±35.58) .654**
Preoperative IRP 26.85 (±8.72) 26.62 (±18.81) .972**

*Chi-square
**Students t-test
***Mann-Whitney U

Table 2. Post-operative clinical evaluation

Variable Toupet Dor p
GERDHRQL score
1 month
6 months
Last follow-up .
4.42 (±6.32)
9.78 (±11.45)
5.21 (±8.98) .
3.94 (±4.60)
6.86 (±8.62)
5.33 (±7.29) .
.952***
.443**
.780***
EAT score
1 month
6 months
Last follow-up .
3.71 (±4.63)
4.92 (±6.87)
3.21 (7.61) .
3.05 (±4.27)
5.06 (±9.55)
1.20 (±2.24) .
.686**
.780***
.505***
Eckardt score
1 month
6 months
Last follow-up .
1.78 (±1.84)
1.71 (±1.81)
1.42 (±1.82) .
1.76 (±1.98)
1.93 (±2.60)
1.00 (±1.13) .
.976**
.914***
.451**

**Student t-test
***Mann-Whitney U

Back to 2015 Annual Meeting Program