Post-operative outcomes of partial anterior fundoplication and posterior partial fundoplication following Heller myotomy for Achalasia

Asia Filatov, PhD1, Anastasia Postoev, BA1, Jane Chung, BA2, Ladoris Latin, BA1, Angel Farinas, MD2, Angelina Postoev, MD2, Christian Cruz, MD2, Christopher Ibikunle, MD2, Aliu Sanni, MD2. 11Department of Surgery, Caribbean Medical University, Chicago IL, 22Department of Surgery, UGA/GRU Partnership, Athens, GA

INTRODUCTION: Laparoscopic Heller myotomy is considered the most effective treatment for achalasia, improving quality of life and alleviating symptoms. The addition of a fundoplication prevents postoperative reflux and treatment failure. This study compares the postoperative outcomes of anterior partial fundoplication (Dor) with posterior partial fundoplication (Toupet) following laparoscopic Heller myotomy.

METHODS: A systematic review was conducted to identify relevant studies from 2011- 2014 with comparative data on Dor versus Toupet fundoplication following Heller myotomy. The primary outcomes were the incidence of post-operative dysphagia and reflux.  Other outcomes included operating time, inter-operative perforation, LES pressure and postoperative hospital stay. Clinical assessments were also performed using a standard grading system (Vantrappen & Hellemans). Results are expressed as standard difference in means with standard error. Statistical analysis was done using random-effects meta-analysis to compare the mean value of the two groups (Comprehensive Meta Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ).

RESULTS: Five studies were quantitatively assessed and included for meta-analysis, which included two prospective and three retrospective studies. Among the five studies, 127 patients underwent Dor fundoplication and 139 patients underwent Toupet fundoplication.

Post-operative dysphagia was significantly higher in the Dor fundoplication group when compared to Toupet fundoplication (-0.475 +/- 0.165, p<0.004).

The incidence of post-operative reflux (-0.170 +/-0.144, p=0.24), intra-operative perforation (-0.213 +/-0.154, p=0.17), LES pressure (0.268 +/- 0.182, p=0.15), OR time (0.12 +/- 0.13, p=0.34) and overall effectiveness (-0.291 +/-0.211, p=0.17) were similar in both groups.

CONCLUSIONS: Toupet fundoplication following Heller myotomy provides less post-operative dysphagia when compared to Dor fundoplication

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