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Bianchi et al. Modified fundoplication after Heller miotomy

Table 1: Presence of erosive esophagitis in relation to Table 2: Presence of dysphagia in relation to the
the degree of dilatation, etiology and fundoplication presence of esophagitis and fundoplication status
status
Characteristics Odds ratio 95%CI P
Characteristics Odds ratio 95%CI P Esophagitis 1
Dilatation No esophagitis 1.14 (0.38-3.38) 0.814
I 1 Fundoplication status
II 0.58 (0.22-1.55) 0.274 Intra-abdominal 1
III 0.55 (0.2-1.53) 0.246 Wrap migration 3.54 (1.64-7.61) < 0.001
Ethiology
Idiopathic 1
Chagasic 1.85 (0.96-3.58) 0.065 Table 3: Presence of migration in relation to the degree
of dilatation
Fundoplication status
Intra-abdominal 1 Dilatation Odds ratio 95%CI P
Wrap migration 2.3 (1-5.33) 0.047 I 1
II 1 (0.39-2.58) 0.989
Additionally, it has a latero-posterior component III 0.46 (0.16-1.32) 0.143
with another suture line in the posterior part of the
esophagus, resulting in 270 of circumferential contact FP and abnormal pH results were found in 19 patients
o
with the esophagus and thereby providing a reflux (14%) overall, while abnormal acid exposure increased
control similar to Toupet. Both anterior (Dor) and over the course of follow-up from 8.1% at 1 year to
posterior (Toupet) are associated with good control 18.5% at 5 years and 23.7% at 10 years.
of dysphagia after myotomy with results ranging
between 77% and 96% [13-15] . In a review involving We used, as a marker of reflux, the presence of
more than 3,000 patients, dysphagia was resolved on erosive esophagitis because of the alteration in
[7]
average 89.3% of the time . With our technique, we the pH metry of these patients, and also because
demonstrated a long-term dysphagia resolution rate it is not routine to perform this test on patients with
of 91%. In contrast, issues related to reflux are less megaesophagus under our care.
reported after a Heller myotomy associated with a
partial fundoplication. There is still no consensus as to the best
fundoplication after this procedure. There are few
Clinically, it is often difficult to accurately diagnosis controlled multi-centric studies because it is a rare
gastro-esophageal reflux because of the reflux-like disease. The only randomized, multi-institutional
symptoms resulting from stasis and fermentation study comparing the 2 types of partial fundoplications
of esophageal contents retained in the esophageal showed gastroesophageal reflux in 41.7% of patients
lumen by ineffective or incomplete myotomy. One in the Dor group vs. 21% in the Toupet group. It was
component believed to contribute to this is the severity not possible to demonstrate a statistical difference due
of the esophageal dilatation. Once the obstacle in the to sample size and follow-up [20] .
distal esophagus is removed, the reflux of the gastric
contents will find an atonic esophagus with literally A meta-analysis of more than 2,500 patients
no contractility capable of promoting esophageal showed an approximate 14.3% rate of reflux with
clearance, relying mostly on gravity for emptying [16,17] . anterior fundoplication and 15.8% with posterior and
dysphagia indexes of 10% and 5.8%, respectively [21] .
The use of pH metry for the evaluation of reflux We had with our antero-latero-posterior fundoplication
in patients with achalasia after myotomy with a reflux rate of only 8.1% after more than 5 years of
fundoplication is the main tool for quantitative follow-up.
analysis. However, due to the production of lactic
acid secondary to the stasis of food and saliva in the This meta-analysis study demonstrated that both
distal esophagus the results can be misinterpreted. partial fundoplications are associated with an
Tsiaoussis et al noted that up to 66% of reflux events equivalent control of GERD. However, anterior
may be secondary to this phenomenon. Additionally, fundoplication is associated with higher reintervention
they noted that the diameter of the esophageal lumen rates for postoperative dysphagia compared
showed a positive correlation with a distal pH < 4 [18] . with posterior fundoplication. The authors note
that one of the reasons for this difference is that
Ortiz et al. [19] evaluated pH results in 136 patients with posterior fundoplication keeps the edges of the
a median 6-year follow-up after open myotomy; Toupet myotomy open and avoids potential adhesions that

Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017 157