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DOR VERSUS TOUPET FUNDOPLICATION AFTER LAPAROSCOPIC HELLER MYOTOMY: REPORT FROM A 2 YEARS RANDOMIZED TRIAL EVALUATED BY HIGH RESOLUTION MANOMETRY
Blanca A. Blancas Breña2, Gonzalo Torres-Villalobos*2, Fernanda Romero-Hernández2, Axel R. Palacios Ramirez2, Enrique Coss-Adame3, Miguel A. Valdovinos3, Daniel Azamar-Llamas1, Janette Furuzawa-carballeda1
1Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, DF, Mexico; 2Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, DF, Mexico; 3Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, DF, Mexico
Achalasia is characterized by esophageal aperistalsis and absence of relaxation of the LES. Heller's myotomy with partial laparoscopic fundoplication is the surgical treatment of choice for achalasia. However there is still controversy over which type of partial antireflux procedure is the most effective, the anterior partial fundoplication (Dor type) or the posterior partial fundoplication (Toupet).
Aim: To compare the postoperative results of anterior partial fundoplication type Dor vs posterior partial fundoplication type Toupet after laparoscopic Heller myotomy.
Patients with diagnosis of achalasia were treated by laparoscopic Heller myotomy and then randomized to receive either type Dor or Toupet fundoplication. Specific symptoms of dysphagia and gastroesophageal reflux were evaluated using pre-surgical GERD-HRQL, EAT-10 and ECKARDT questionnaires, as well as 1, 6 and 24 months postmyotomy. High resolution manometry (HRM) was performed 1 and 6 months postoperative. 24-h pH monitoring with impedance at 6, 12 and 24 months postmyotomy were done.
A total of 59 patients were randomized, 38 (64.4%) were women. The Dor group had 31 (52.5%) patients, while in Toupet group had 28 (47.5%) patients with a mean age of 41 ± 17 years and 40 ± 16 years, respectively. Both groups were similar at baseline. According to HRM, 41 (69.5%) had type II achalasia, 11 (18.6%) type I, 2 (3.4%) type III and 5 (8.5%) functional obstruction. No significant differences were found in the GERD-HRQL, EAT-10, and ECKARDT questionnaires between the two groups prior to surgery. There were no differences in resting pressure of the LES in the postoperative HRM performed at 1 (13.98 ± 8.81vs10.52 ± 10.20, p = 0.183) and at 6 months (15.09 ± 9.12vs11.25 ± 5.50, p = 0.355) when compared with both groups. There was no statistical significant difference in the postoperative IRP at 1 month (8.98±4.24 Dor vs 5.80±3.15 Toupet; p=0.156) and 6 months (10.25±3.39 Dor vs7.6±5.50 Toupet; p= 0.118) during the follow up.
In the 24-h pH monitoring with impedance pathological reflux (defined as a total time with pH <4 of >4.2%) was observed in 1 patient in the Dor group and in 2 patients in the Toupet group. Nevertheless, there was no significant difference in esophageal exposure to acid in post-surgical 24-h monitoring at 6, 12 and 24 months between groups.
There was also no significant difference between the DeMeester score at 6 (2.78 ± 3.70 Dor vs 4.31 ± 5.38 Toupet, p = 0.355), 12 (2.04 ± 4.13 Dor vs 4.45 ± 4.35 Toupet, p = 0.133) and 24 months (3.51 ± 3.25 Dor vs 2.14 ± 2.73 Toupet, p = 0.356).
No statistically significant differences between the two types of fundoplication were observed at 1, 6, 12 and 24 months during the follow-up regarding symptoms, IRP of the LES and the DeMeester score. Regarding to results obtained, we conclude that the procedure chosen do not affect the patient outcome.
Baseline demographic and clinical characteristics
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