Toupet Fundoplication with Laparoscopic Heller Myotomy Is Associated with More Postoperative Dysphagia

Elizabeth J Honigsberg, MD, Gina L Adrales, MD, Jennifer E Tonneson, BS, William S Laycock, MD, Thadeus L Trus, MD. Dartmouth Hitchcock Medical Center

INTRODUCTION
Laparoscopic Heller myotomy (LHM) is the treatment of choice for achalasia. Its efficacy is largely defined by subjective outcome measures, with the majority of patients reporting good to excellent short and long term symptom improvement. However, 10 to 20% of patients experience postoperative symptoms of reflux or recurrent dysphagia on long-term follow-up. The aim of this study is to evaluate the efficacy of LHM with or without fundoplication at our institution by determining the incidence of patients requiring endoscopic intervention for postoperative reflux or recurrent dysphagia.

METHODS
A retrospective analysis of all patients treated for achalasia with LHM± fundoplication at a tertiary care center from 1996 to 2010 was performed. Main outcome measures include patient demographics, operative variables, postoperative symptoms, and postoperative endoscopic interventions.

RESULTS
During the study period, 116 patients (62 men, 54 women) with achalasia underwent LHM ± fundoplication. The mean age was 56 years (range 16-80). All LHM were completed laparoscopically and an anti-reflux procedure was performed at the discretion of the surgeon. Of the 116 operations performed, 43.1% were LHM alone (n=50), 46.6% were LHM with Toupet fundoplication (n=54), and 10.4% were LHM with Dor fundoplication (n=12). The mean operative time was 175.9 minutes (range 118-376). The mean LOS was 2 days (range 1-5). Fifteen minor complications occurred within 30 days and were classified as Grade 1 (n=12) and Grade 2 (n=3). There were no mortalities.

Follow up data was available for 110/116 patients (94.8%). Of these patients, 23 (20.9%) reported new-onset postoperative reflux and were managed as follows: 4 patients underwent diagnostic esophagogastroduodenoscopy (EGD), 18 were managed medically, and 1 was not treated. Recurrent dysphagia was reported by 18 patients (16.4%) after surgery. Of these, 16 underwent endoscopic intervention: 9 patients underwent dilation, 4 underwent dilation with botox injection, 2 underwent botox injection alone, and 1 patient had a diagnostic EGD. Two patients were not treated. The average time from surgery to symptom development was 4.4 years (range 0.1-11.7). Patients underwent an average of 2.4 endoscopies postoperatively (range 1-8). Overall, 18.2% (20/110) of our study population required one or more endoscopic interventions for new-onset reflux or recurrent dysphagia after LHM ± fundoplication.

There was a significant association between the operative procedure performed and the need for postoperative endoscopic intervention. The majority of patients (80%) requiring postoperative endoscopic intervention had undergone LHM with Toupet fundoplication, p<0.001 (Chi-square analysis). Conversely, significantly more patients developed reflux after LHM alone versus LHM with Toupet fundoplication (52% vs. 34.8%), p=0.007 (Chi-square analysis).

CONCLUSION
Laparoscopic Heller myotomy with Toupet fundoplication provides better reflux control postoperatively compared to Laparoscopic Heller myotomy alone, but this reflux control comes at a cost of significantly more postoperative dysphagia.