Background. The need of fundoplication while the Heller procedure is still controversial. It was proved, that fundoplication reduces the rate of gastroesophageal reflux, but increases surgery time and may increase the recurrence rate. Thus, we hypothesized that fundoplication must have exact indications, such as achalasia, associated with hiatal hernia and preoperative gastroesophageal reflux. So, this principal was used in our survey. The aim: to assess the results of laparoscopic Heller procedure with and without fundoplication.
Methods and procedures. From 1995 till 2004 laparoscopic Heller myotomy were performed in 50 patients with esophageal achalasia. There were 11 patients with spindle type of lesion, 25 patients with the flask type and 14 patients with sigmoid type of lesion. Heller procedure was completed by fundoplication in 28 patients (I group) (Dor fundoplication in 23 patients and Toupet fundoplication in 5 patients). No fundoplication was used in 22 patients (II group). The results were assessed by dysphagia and heartburn symptom rating scale, esophageal motility study, X-ray, endoscopy and 24-h pH-testing. Mean follow-up period was 5 years (range 3 -10).
Results. In the I group there was no gastroesophageal reflux, but 3 (10,7 %) patients with the sigmoid type of lesion had a relapse. Therefore, they required frequent balloon dilations. In the II group there was no relapses (including sigmoid type patients), but 1 patient (4,5 %) experienced moderate reflux. Thus, using accurate indications for adding fundoplication to cardiomyotomy, we improved the results of treatment of esophageal achalasia.
Conclusions. An antireflux procedure is necessary when the achalasia is associated with hiatal hernia and gastro-esophageal reflux. No antireflux procedure is advisable in patients without these factors to prevent the relapse of the disease, especially in sigmoid type of esophageal achalasia.
Program Number: P272