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Bianchi et al. Modified fundoplication after Heller miotomy

Dysphagia recurrence over time
14

12
10
Years after surgery 8

6
4
2

0
0 10 20 30 40 50
Numbers of patients
Figure 4: Dispersion of patients with recurrence of dysphagia over time

may develop between the myotomy and anterior with dysphagia (P < 0.001). Gastric migrations through
fundoplication, resulting in fewer reinterventions for the hiatus have a tendency to to decrease the function
postoperative dysphagia [11,21,22] . Our fundoplication of the fundoplication due to the negative pressure in
covers the exposed mucosa, and we only had 4 the thorax. Perhaps this alteration of the anatomy also
cases requiring reintervention. There are few studies allows the edges of the myotomy to approach, and
evaluating endoscopic results. In a study comparing may be related to the difficulty of passage of the bolus
a Dor fundoplication group with a Toupet group, due to the ensuing deformities by the hiatal hernia
Katada et al. [23] demonstrated that the pHmetry study itself. We had 3 cases in which the reintervention was
was similar in both groups. However, both symptoms due to myotomy fibrosis and one where the deformity
and endoscopic findings were different; reinforcing the of the hernia clearly originated with dysphagia.
importance of endoscopic and clinical findings for the
evaluation of these cases. First, we thought that it was important to classify the
etiology of achalasia as chagasic or idiopathic because
Erosive esophagitis was found in 38.5% of the Toupet Chagas disease is very common in Brazil. However,
group and 8.8% of the Dor group, which was similar we observed that these two groups of patients behave
to the Toupet group in the same study [23] . Our study is in a similar manner during the treatment, with no
not a comparative one, however we find better results difference in outcome. Our study has the limitation
with our fundoplication, even taking into account that of being a retrospective, non-comparative study.
more than half of our cases were erosive esophagitis
Los Angeles A, which is a rather mild complication. In Because only medical records were obtained, it
our procedure, we performed a dissection of the entire was not possible to apply any specific questionnaire
circumference of the hiatus to create a large segment regarding reflux or dysphagia. Only information
of intra-abdominal esophagus and a large area for the reported by the patient was used and the severity of
myotomy. Simić et al. [24] found that Dor fundoplications the reflux or dysphagia was unable to be quantified.
in the setting of a complete hiatal dissection had The use of a proton pump inhibitor for reasons
a higher degree of abnormal esophageal acid other than reflux symptoms may also be a bias in
exposure (23.1%) than if a limited hiatal dissection the number of patients with endoscopic alterations.
was performed (8.5%). However, when we performed However, this number was small and patients had no
a more extensive fundoplication than the Dor, we reported reflux symptoms in their history.
achieved a good success rate (8.1%).
In conclusion, we have demonstrated that laparoscopy
One factor not routinely reported in other studies is the myotomy postero-latero-anterior fundoplication
migration of fundoplication to the thorax. Though we (Heller-Pinotti) has a good long-term outcome in
advocate the closure of the diaphragmatic hiatus after relation to dysphagia and in terms of reflux prevention.
esophagus dissection, we nevertheless observed a Furthermore, it could produce better results than other
11% rate of hiatal herniation. This event correlated with partial fundoplications, however it requires both a
the presence of reflux esophagitis (P = 0.047) and also prospective and comparative study.

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