SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.
Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupt the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."
To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.
Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.
In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.
There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.
In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.
The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.
This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.