Floppy Dor fundoplication after esophagocardiomyotomy for achalasia

When esophagocardiomyotomy (ECM) is performed for achalasia, a complementary antireflux procedure of the surgeon's choice is usually performed to minimize postoperative gastroesophageal reflux. This retrospective analysis describes patients after laparoscopic ECM, most of whom had a modified Dor fundoplication.

Between 1994 and 2001, 81 patients with achalasia of the esophagus had laparoscopic ECM. We have previously described the use of intraoperative endoscopy to verify completion of ECM in a cohort of 48 patients who had either Toupet fundoplication (n = 25) or floppy Dor fundoplication (n = 23). Since then floppy Dor fundoplication has been the preferred antireflux procedure for ease of performance and safety reasons. This article describes the floppy Dor fundoplication as we have performed it since 1997, anchoring the wrap to both crura of the hiatus. In addition, the anterior gastric wall is sutured to the anterior rim of the esophageal hiatus, avoiding creation of the paraesophageal hernia that occurs if the gastric wall abuts the entire the length of a long ECM.

During the 1- to 70-month follow up period (mean 45 months), patients who were symptomatic were evaluated by radiographic, manometric, or endoscopic methods; pH studies were not done systematically. The 70% of patients who could be evaluated had postoperative quality of life and symptom assessment interviews that revealed willingness to repeat the operation. Overall satisfaction was high (8.4/10 where 10 is perfect); moderate dysphagia was seen in 11 (16%) 3 to 16 months postoperatively, but patients reverted to a satisfaction score of 8.2 after endoscopic dilation. Occasional heartburn was present in 15 (26%) patients with regular, 5-use proton pump inhibitors (PPI), including 1 with Barrett's esophagus. Others use these medications for gastric disorders. No patient has had cancer of the esophagus develop, but endoscopic surveillance has been inconstant.

Swallowing was improved in patients without sigmoid esophagus and overall satisfaction was high. New-onset heartburn is an unpredictable problem that can be treated in most patients. Endoscopic dilatation may be required at intervals after ECM-fundoplication for bridging fibrosis at the cardia, but has not required reoperation, as a rule. Laparoscopic ECM is an attractive operation for achalasia.