Long-term result of total versus partial fundoplication after esophagomyotomy for primary esophageal motor disorders.

BACKGROUND

The selection of the type of fundoplication or the necessity for an added fundoplication after esophagomyotomy (Heller's operation) for the treatment of achalasia remains controversial. The present retrospective study was designed to compare the long-term results of total and partial fundoplication on the myotomized esophagus.

METHODS

Between 1978 and 1998, a total of 64 consecutive patients with achalasia or diffuse esophageal spasm underwent esophagomyotomy and an antireflux operation via a left thoracotomy approach. Twenty-one had a total fundoplication (Nissen Group) during the period 1978-1983. After 1984 and until 1998, the remaining 43 patients were treated with addition of a Belsey Mark IV partial fundoplication (Belsey Group) to protect the myotomized esophagus. Clinical, radiologic, radionuclide transit, manometric, 24-h pH monitoring, and endoscopic assessments were obtained before and after the operation.

RESULTS

There were no operative deaths or major complications in either group. After 6 years of follow-up the Belsey group was compared to the Nissen group. A higher frequency of dysphagia (7/18 versus 3/31; p=0.025), more barium stasis (9/13 versus 10/27; p=0.056), and increased radionuclide material retention (52.4% versus 29.2%; p=0.044) were observed in the Nissen group. These findings were confirmed by endoscopy, which showed increased esophageal lumen dilation (10/15 versus 8/26; p=0.026) and more frequent food retention (11/15 versus 6/26; p=0.002). Functionally, both operations successfully reduced the lower esophageal sphincter pressure gradient (from 23.8 to 7.7 mmHg for the Nissen group, and from 27.4 to 8.2 mmHg for the Belsey group; p=0.656). In the Nissen group, the esophageal diameter observed on radiology increased from 3.9 cm preoperatively to 5.5 cm postoperatively (p=0.012), whereas it remained identical for the Belsey group (ranging from 5.4 cm to 5.3 cm; p=0.695). Reoperation to relieve recurrent dysphagia and esophageal retention was necessary in 8 patients from the Nissen group and in 1 patient from the Belsey group (p<0.001).

CONCLUSIONS

When treating achalasia or diffuse esophageal spasm by esophageal myotomy and an antireflux operation, a total fundoplication adds too much resistance to allow esophageal emptying and is considered as inappropriate. A partial fundoplication provides proper antireflux effects without causing significant esophageal emptying difficulties.