Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome?

Abstract

Objective: To determine whether the addition of anterior hemifundoplication to laparoscopic esophagomyotomy for achalasia yields better clinical outcomes than laparoscopic esophagomyotomy alone.

Summary background data: Although hemifundoplication may prevent gastroesophageal reflux after esophagomyotomy for achalasia, it may also lead to persistent dysphagia in these patients with esophageal aperistalsis.

Methods: This is a retrospective study of 51 consecutive patients (mean age 47.5 +/- 12.6 years) who had laparoscopic esophagomyotomy for achalasia by our group between August 1995 and January 2001. In 29 patients (57%) an anterior hemifundoplication was added to the esophagomyotomy. In 22 patients (43%), no wrap was added. Patients scored (0 = none; 1 = mild; 2 = moderate; 3 = severe) symptom severity (dysphagia, regurgitation, heartburn, chest pain) preoperatively and postoperatively. Weight gain, use of gastrointestinal (GI) medication, tolerance to food, and patient satisfaction were also assessed.

Results: Mean patient follow-up was 33 months, and there were no operative deaths. Four patients were converted to open operation (8%). The wrap and no wrap groups were similar in terms of esophageal dilation, preoperative symptom severity and duration (5.7 +/- 7.1 versus 6.1 +/- 7.0 years), and preoperative weight loss (18 +/- 15 versus 20 +/- 20 pounds). Both groups had similar improvement in symptom grade postoperatively and equivalent satisfaction rates (86%). Postoperative weight gain, GI medication use, and food intolerance was also similar. Postoperatively, patients in the wrap group did not have higher dysphagia scores or lower heartburn scores than the no wrap group.

Conclusion: The addition of anterior hemifundoplication to esophagomyotomy for achalasia does not improve or worsen clinical results.

FIGURE 1. Early in the series (cases 1 to 26), most patients were treated with laparoscopic esophagomyotomy with anterior hemifundoplication; later in the series (cases 27 to 51), most patients were treated without a hemifundoplication.

FIGURE 2. In the entire study population, preoperative symptoms improve significantly after operation. Also, patients graded the severity of preoperative dysphagia and regurgitation higher than preoperative chest pain and heartburn.

FIGURE 3. (A) The preoperative symptom severity was similar in the no hemifundoplication and hemifundoplication groups. (B) The postoperative symptom severity was similar in the no hemifundoplication and hemifundoplication groups.

FIGURE 4. Most patients gained weight postoperatively. The proportion gaining weight in the no wrap and wrap groups was similar.

FIGURE 5. (A) Postoperatively, about half the patients in both the wrap and no wrap groups continued to have intolerance for some types of solid food. (B) Postoperative intolerance to liquids was uncommon in both groups.

FIGURE 6. A postoperative regurgitation score of 2 or 3 predicted a dissatisfied patient.