Michael K Fishman, MD, Seth Judd, MD, Jerome Lyn Sue, MD, Jonathan Tomasko, MD, Christopher S Hollenbeak, PhD, Ann Rogers, MD, Randy Haluck, MD. Penn State Milton S. Hershey Medical Center
Laparoscopic Heller cardiomyotomy (LHC) has become the gold standard therapy for achalasia. Traditionally, an antireflux procedure has accompanied the myotomy. This study was undertaken to compare the outcomes between patients undergoing a myotomy with Toupet fundoplication vs. those undergoing a myotomy with Dor fundoplication. In addition, we investigated the overall patient satisfaction after LHC in the treatment of achalasia.
185 patients who underwent LHC between 1998 and 2010 were studied by telephone survey. Patient study design and data collection were approved by the Institutional Review Board of Penn State Hershey Medical Center. Symptoms queried included dysphagia, heartburn, and bloating utilizing the GERD-HRQL and a secondary GERD/dysphagia scale. Overall satisfaction after surgery as compared to before the myotomy was also rated. Data were compared based on type of fundoplication, Dor or Toupet. Symptom scores after myotomy were analyzed utilizing a Student t test and Fisher’s exact test.
25 patients completed the ongoing survey (13.5%). There were no perioperative deaths or reoperations. One patient required conversion from laparoscopic to open procedure. Mean length of stay was 2.8 days. Mean operative time for all LHC with fundoplication was 135.9 minutes. Mean operative time for LHC with Toupet fundoplication was 136.5 (±30.91) minutes and LHC with Dor fundoplication was 128.9 (±32.44) minutes. There was no statistical difference in operative time for Toupet vs. Dor fundoplication (p=0.379). There was no difference between Dor and Toupet fundoplication with respect to incidence and severity of postoperative heartburn, dysphagia, and bloating based on analysis using a Student t-test. Overall satisfaction for Toupet was 94.4 % and 100% (p>0.999) for Dor fundoplication.
LHC with Toupet or Dor fundoplication has excellent patient satisfaction. Post-operative symptoms of heartburn and dysphagia were equivalent when comparing LHC with both antireflux procedures. The Dor and Toupet fundoplication were found to have equivalent outcomes, however, we prefer the Dor over the Toupet due to its decreased need for extensive dissection. This may result in decreased operative times. As we accrue more patient responses, we may find more statistical differences between the two populations.
Program Number: S019