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Bianchi et al. Modified fundoplication after Heller miotomy

Erosive esophagitis (Los Angeles classification)
21

12

4
2

A B C D
Figure 3: Number of patients with erosive esophagitis. Distribution according to Los Angeles classification

(50.7%) and grade III in 175 (39.5%). Thirty-nine (8.7%) DISCUSSION
patients presented erosive esophagitis 5 years after
surgery. In relation to the Los Angeles classification, The need for an antireflux procedure after myotomy
21 presented esophagitis A, 12 B, 2 C and 4 D [Figure 3]. is no longer as controversial as it used to be. The
Two patients with esophagitis Los Angeles D also presence of a myotomy in the distal esophagus
presented peptic sub stenosis, while the other 2 counteracts the physiological function of the lower
patients were identified with Barrett esophagus esophageal sphincter that prevents the gastric
without atypia. With regard to the situation surrounding contents from going back to the esophagus. It is
the fundoplication wrap, all remained detectable on expected that gastro-esophageal reflux will occur and
endoscopic examination. However, 49 (11%) were become more severe postoperatively [4-6] .
partially migrated to the thorax due to hiatal hernia.
It was observed that 81 (18%) patients had regular In a meta-analysis in 2009, Campos et al.
[7]
use of a proton pump inhibitor. However, it was noted demonstrated an incidence of gastroesophageal reflux
that 42 patients were taking it per their cardiologist’s disease (GERD) among 31.5% of patients submitted
prescription. These patients were chagasic and used to myotomy without fundoplication. It is very difficult
various medications and presented dyspepsia and to completely suppress gastroesophageal reflux after
epigastric pain secondary to medication. The other laparoscopic myotomy even when some antireflux
39 were precisely the patients who had erosion procedure is associated. The rate of gastroesophageal
seen on endoscopy. Forty-one (9.2%) patients had reflux may range from 0% to 44% .
[7]
dysphagia and required some type of intervention to
improve this condition: 37 had experienced clinical The type of anti-reflux procedure varies according to
improvement with endoscopic dilation and 4 required the circumferential extension of the fundoplication. The
reinterventions; 1 case of dysphagia being considered most frequently used are the 180 anterior (Dor), 270
o
o
due to gastric migration and the other 3 due to (Toupet) and 360 (Nissen). Despite the good control
o
myotomy fibrosis. We can see the dispersion of cases of reflux, the Nissen technique and its modifications
of dysphagia by time [Figure 4]. are associated with a higher incidence of postoperative
dysphagia (up to 75%) and therefore it is not
The odds ratio was calculated and a chi-square test recommended for patients submitted to myotomy [8-10] .
conducted to determine the presence of erosive The choice of the best fundoplication post myotomy
esophagitis in relation to the degree of dilatation, is still controversial. The Dor repair uses 2 lines of
etiology, and valve migration [Table 1]. The same was suture anchored in both borders of the myotomy.
done for the presence of dysphagia in relation to the The coverage of the exposed submucosa in the
degree of dilatation and migration of the wrap [Table 2] myotomy with the Dor fundoplication allegedly has the
and finally to the presence of migration in relation to advantage of blocking an eventual perforation of the
the degree of dilatation [Table 3]. myotomy. On the other hand, the Toupet fundoplication
theoretically distances the edges of the myotomy,
It can be observed that when the fundoplication decreasing the risk of dysphagia recurrence [2,11,12] . The
migrated there was a higher risk of developing erosive fundoplication performed in our procedure has some
esophagitis (P = 0.047) and dysphagia (P < 0.001). advantages of both. It covers the exposed submucosa
There was no higher risk of migration when the because the gastric fundus is fixed at both edges of
esophagus was more dilated. the myotomy and keeps contact to the anterior face.

156 Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017