Reece K DeHaan, BA, Matthew J Frelich, MS, Matthew I Goldblatt, MD, Andrew S Kastenmeier, MD, Jon C Gould, MD. Medical College of Wisconsin
BACKGROUND: We sought to determine the impact of selective fundoplication following Heller myotomy on symptomatic outcomes and side effects of Heller myotomy for achalasia. Previous studies have demonstrated that partial fundoplication following Heller myotomy results in less pathologic acid exposure to the distal esophagus when compared to myotomy without fundoplication. In these studies a full hiatal dissection was performed in each treatment arm, disrupting the natural anatomic reflux barrier. Several recent studies have questioned the necessity of a fundoplication, especially when a limited hiatal dissection is performed and the angle of His is preserved.
METHODS AND PROCEDURES: This study is a retrospective review of prospectively maintained data. All patients underwent primary Heller myotomy for achalasia over a 30-month period. In select patients, a limited hiatal dissection was performed anteriorly (lateral and posterior phrenoesophageal attachments preserved). Symptomatic outcomes were assessed up to two years post-op using the Achalasia Severity Questionnaire (ASQ), Gastrointestinal Quality of Life Index (GIQLI), and GERD-HRQL (Health Related Quality of Life) questionnaires. A Wilcoxon rank-sum test was performed to compare the symptom scores between the two groups preoperatively, at 6 months post-op and at over 12 months post-op
RESULTS: A total of 31 patients underwent Heller myotomy during the study interval. The majority of patients underwent Heller myotomy with full hiatal dissection and Dor anterior partial fundoplication (table). Patient characteristics did not differ between the 2 study groups (age, sex, BMI, Chicago Classification, duration of symptoms, and symptom scores preoperatively). Symptom scores and patient satisfaction did not differ postoperatively (table).
Event (Score range from best possible score to worst) | HM + LHD (n=10) | HM + FHD and Dor (n=21) | P value |
| ASQ Preop (0-100) | 64.6 | 64.0 | 0.48 |
| ASQ 6 month (0-100) | 39.0 | 30.6 | 0.23 |
| ASQ >12 month (0-100) | 42.3 | 34.0 | 0.57 |
| GERD-HRQL Preop (0-50) | 22.8 | 25.9 | 0.50 |
| GERD-HRQL 6 month (0-50) | 9.0 | 7.7 | 1.00 |
| GERD-HRQL >12 month (0-50) | 10.2 | 17.4 | 0.21 |
| GIQLI Preop (144-0) | 77.8 | 81.1 | 0.87 |
| GIQLI 6 month (144-0) | 96.0 | 114.4 | 0.24 |
| GIQLI >12 month (144-0) | 107.2 | 88.8 | 0.14 |
Table: Mean symptom scores by group and p-values for Wilcoxon rank-sum test.
CONCLUSIONS: Heller myotomy with full hiatal dissection and partial fundoplication was associated with similar improvement in achalasia symptoms, gastrointestinal disease-related and GERD-related quality of life outcomes up to one year post-op to that seen with limited hiatal dissection and no fundoplication. Our study is limited by the retrospective nature and small sample size. Further study (including pH studies) is necessary to determine if fundoplication is a necessary step in selected patients in whom a limited hiatal dissection is possible.