Anterior fundoplication decreases esophageal clearance in patients undergoing Heller myotomy for achalasia

Anterior fundoplication (AF) following laparoscopic Heller myotomy (LHM) for achalasia may prevent esophageal leaks and gastroesophageal reflux but cause dysphagia. Our study attempts to determine the effect of AF on esophageal leaks, nuclear medicine esophageal clearance (EC), symptom frequency (SF), and Van Trappen symptom scores (SS) for dysphagia, regurgitation, and heartburn.

Between 1995 and 2004, pre- and postoperative (2-12 months) EC, SF, and SS scores were compared in 95 patients undergoing LHM for achalasia with AF (n = 71) and without (n = 24) AF.

There were no leaks or deaths. Laparoscopic Heller myotomy decreased the frequency of postoperative dysphagia, regurgitation, and heartburn with AF (96% preoperation versus 6% postoperation, 94% versus 3%, 58% versus 6%) (p = 0.001) and without AF (100% versus 0%, 83% versus 0%, 50% versus 4%) (p = 0.001). Laparoscopic Heller myotomy improved all SS in both groups. There was no difference between postoperative dysphagia (1.38 +/- 0.64 versus 1.17 +/- 38) p = 0.06, regurgitation (1.17 +/- 51 versus 1.04 +/- 0.20) p = 0.08, and heartburn (1.29 +/- 62 versus 1.53 +/- 0.80) p = 0.185 scores between the AF and no-AF group, respectively. There is a trend toward improvement in dysphagia and regurgitation in the no-AF group. Laparoscopic Heller myotomy improved EC in the supine and upright positions in both groups of patients (p = 0.001). There was an improved mean change in EC (10 min upright) in the no-AF group versus the AF group (50.7% +/- 30.8 versus 29.7% +/- 30.2) p = 0.004.

Laparoscopic Heller myotomy improves esophageal transit and the frequency and severity of dysphagia, heartburn, and regurgitation in a safe manner. Patients without AF show a statistically better upright EC with a trend toward improved dysphagia and regurgitation.