Laparoscopic Heller Myotomy and Fundoplication - IngentaConnect

Symposium

Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence? FABRIZIO REBECCHI, M.D.,* MARCO E. ALLAIX, M.D.,* FRANCISCO SCHLOTTMANN, M.D.,† MARCO G. PATTI, M.D.,† MARIO MORINO*

From the *Department of Surgical Sciences, University of Torino, Torino, Italy and †Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon’s experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.

T

1990S witnessed two significant changes in the surgical treatment of achalasia, first a shift from endoscopic pneumatic dilatation and open Heller myotomy to thoracoscopic Heller myotomy1 and then a shift from the thoracoscopic to the laparoscopic approach.2 One of the main controversies related to the functional outcomes after Heller myotomy is the risk of postoperative pathological gastroesophageal reflux. During the last 20 years, several studies have been conducted aimed at evaluating the need for a fundoplication, reporting controversial results, with some studies encouraging the addition of a fundoplication3–7 HE EARLY

Address correspondence and reprint requests to Francisco Schlottmann, M.D., University of North Carolina at Chapel Hill, 4030 Burnett Womack Building, 101 Manning Drive, CB 7081, Chapel Hill, NC 27599-7081. E-mail: [email protected]. Author contribution: Fabrizio Rebecchi and Marco E. Allaix conceived and designed the review; Fabrizio Rebecchi, Marco E. Allaix and Francisco Schlottmann performed the literature search; Fabrizio Rebecchi, Marco E. Allaix, Francisco Schlottmann, Marco G. Patti and Mario Morino analyzed the results reported in the selected manuscript; Fabrizio Rebecchi and Marco E. Allaix wrote the paper; Fabrizio Rebecchi, Marco E. Allaix, Francisco Schlottmann, Marco G. Patti and Mario Morino critically revised the manuscript.

and others suggesting that it is not necessary.8–11 The best type of wrap to prevent reflux without impairing esophageal emptying has also been investigated.12, 13 The aim of this review is to critically evaluate the current evidence available in terms of functional outcomes in patients undergoing laparoscopic Heller myotomy (LHM) with or without fundoplication. Literature Search and Study Selection

Two authors (FR and MEA) independently performed the literature search that was limited to articles published in English language. They searched the electronic PubMed/Medline databases and the Cochrane Library for articles published between January 1990 and June 2017 using the following medical subject headings and free-text words alone or in combination: “Heller myotomy,” “achalasia,” “partial,” “total,” “fundoplication,” “dysphagia,” “gastroesophageal,” and “reflux.” References listed in the included articles were manually checked and additional studies were included when appropriate. Studies were included if they reported on LHM for the surgical treatment of esophageal achalasia. When multiple publications on the

481

482

THE AMERICAN SURGEON

same data from a single institution were retrieved, the most recent study was considered. The following data were extracted from each publication: year of publication, study design, number of patients included, rates of postoperative gastroesophageal reflux, and dysphagia. The study selection process is reported in Figure 1. Evaluation of Evidence and Recommendation

Levels of evidence and grades of recommendation were evaluated according to the GRADE system (http://www.gradeworkinggroup.org/index.htm).14, 15 Laparoscopic Heller Myotomy: Is a Fundoplication Necessary?

Since the early 1990s, several case series and a few comparative studies have focused on functional outcomes after LHM with or without adding a fundoplication, reporting controversial results in terms of incidence of postoperative reflux. For instance, Kjellin et al.8 conducted a prospective audit in a teaching hospital in Sweden including 21 achalasia patients undergoing LHM without a wrap between 1991 and 1995. Three patients who were converted to open surgery and four patients who had a reoperation for persistent dysphagia were excluded from the analysis. As a consequence, the clinical evaluation, including the

FIG. 1.

Flow chart diagram of the study selection.

April 2018

Vol. 84

incidence of reflux symptoms and abnormal 24-hour pH monitoring, was performed in the remaining 14 patients at a median follow-up of 22 months (range, 6–47) after surgery. Dysphagia for both solids and liquids and chest pain were both significantly improved. Esophageal manometry showed that the lower esophageal sphincter (LES) pressure decreased significantly from a median value of 40 to 12 mm Hg. At a barium swallow obtained six weeks after surgery, there was a significant reduction in the median diameter of the esophagus, from 35 to 23 mm, with no retention of contrast medium in the esophagus. Pathologic esophageal acid exposure was observed in about 60 per cent of patients. Interestingly, five out of eight patients with abnormal pH monitoring were asymptomatic. The three patients with reflux-related symptoms were treated with acid-reducing medications. Similar results were reported by Burpee et al.9 A total of 66 achalasia patients underwent LHM between November 1996 and June 2002: a fundoplication was added in eight patients. Postoperative evaluation included a questionnaire assessing dysphagia, heartburn and regurgitation, esophagram, upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Recurrent dysphagia occurred in four patients (6%): two underwent a remyotomy with a Toupet fundoplication, whereas two other patients refused further surgery. With a median follow-up of 28 months, satisfaction was moderate to high in 87 per cent of the 62 patients who were available for analysis. The dysphagia and regurgitation scores significantly decreased postoperatively, whereas a more limited reduction in the heartburn score was observed. During the follow-up, three patients (4.5%) underwent a fundoplication for severe pathological reflux. Among the patients who had an LHM without concurrent or subsequent fundoplication, heartburn was reported by 30 per cent of them, whereas pathologic reflux was documented by 24-hour pH monitoring in 50 per cent of the 22 tested patients. Esophagitis was found in 62 per cent of the 21 patients who had upper endoscopy after surgery. Interestingly, about 40 per cent of patients with objective evidence of reflux did not complain of heartburn. The comparison between patients with reflux and those without reflux showed similar demographic data, preoperative management, manometric findings, and symptom scores. Lower LES pressures and the presence of a hiatal hernia after LHM were associated with postoperative reflux. Dempsey et al.4 published in 2004 a retrospective study comparing 29 patients undergoing LHM and anterior partial fundoplication and 22 patients treated with LHM alone between August 1995 and January 2001. The decision to add a wrap was made by the surgeon during the preoperative discussion with the patient and the referring gastroenterologist or by the surgeon

No. 4

?

LHM AND FUNDOPLICATION

during the operation. All patients were asked to grade dysphagia, regurgitation, heartburn, and chest pain during an interview in clinics or by telephone. Baseline patient characteristics were similar in the two groups: in particular, there were no significant differences in terms of age, duration of symptoms, and preoperative weight loss. The mean esophageal diameter measured on the upper GI series was also similar in the two groups. With a mean follow-up of 33 months, improvement of dysphagia, regurgitation, chest pain, and heartburn did not differ between the two groups. In particular, adding a fundoplication was not associated with higher postoperative dysphagia scores or lower heartburn scores. Patient satisfaction was 86 per cent regardless of the addition of a wrap. Based on these outcomes, the authors concluded that the construction of a partial fundoplication does not lead to better outcomes. However, the retrospective nature of the study and the small number of patients challenge the interpretation of these results. Opposite conclusions were reached in 2008 by Tapper et al.16 They compared 182 patients undergoing LHM without fundoplication between 1992 and 2004 and 171 patients who had LHM with anterior fundoplication between 2004 and 2007, aiming at evaluating whether the addition of an anterior partial fundoplication might reduce postoperative reflux symptoms without impairing esophageal emptying. There were no differences in gender distribution, duration of symptoms, and previous endoscopic treatment between the two groups, whereas patients who had a concomitant fundoplication were older. Postoperatively, all patients experienced a significant reduction in both frequency and severity of all symptoms. Patients who had LHM with a fundoplication reported significantly less frequent and severe postoperative heartburn, dysphagia, and choking than patients who had LHM alone. Based on these results, the authors concluded that the routine construction of a partial fundoplication should be promoted in patients with achalasia. To date, there are only two randomized controlled trials analyzing the outcomes in patients with or without fundoplication after LHM (Table 1). In 2003,

Rebecchi et al.

483

Falkenback et al.17 reported the long-term results of a randomized controlled trial comparing 10 patients undergoing Heller myotomy alone and 10 patients treated with Heller myotomy and total fundoplication for esophageal achalasia. A significantly higher rate of esophagitis according to the Savary–Miller classification occurred in patients treated with myotomy alone than in patients who had a fundoplication: 60 per cent versus 0 per cent, with two cases of Barrett’s esophagus developing postoperatively. At a median follow-up of 3.4 years, the total upright and supine percentages of time with pH < 4 were significantly higher in patients with Heller myotomy alone. Symptom evaluation revealed a higher rate of heartburn and regurgitation if a fundoplication was not added, with a greater need for acid-reducing medications, whereas no differences were observed in terms of dysphagia between the two groups. In 2004, Richards et al.18 published the results of a randomized controlled trial in patients undergoing Heller myotomy or Heller myotomy and Dor fundoplication. A total of 43 patients were enrolled between December 2000 and October 2003: 21 patients in the Heller-alone group and 22 in the Heller with Dor group. There were no significant differences in age, gender, dysphagia score, and LES pressure between the two groups. At a median follow-up of six months, esophageal manometry showed similar median LES pressure after Heller myotomy alone or Heller myotomy with Dor. The 24-hour pH monitoring showed abnormal reflux in almost 48 per cent of patients after Heller alone and in 9 per cent of patients after Heller with Dor fundoplication. Median distal esophageal exposure to acid refluxate and number of reflux episodes were significantly lower in the latter group of patients. Postoperative rates of dysphagia were similar in the two groups. Two years later, the same researchers published the results of a cost-effectiveness analysis, using a Markov simulation model to estimate the total expected costs of both surgical treatments over a 10-year time horizon.19 Even though the operative costs of Heller myotomy and Dor were significantly higher than Heller alone secondary to the longer

TABLE 1. The Evidence From Randomized Controlled Trials Reference Falkenback et al.

17

Year

No. of Patients

Median Follow-Up (Months)

Reflux

Dysphagia

2003

10 HM 10 HM + TF 21 LHM 22 LHM + AF 72 LHM + AF 72 LHM + TF 49 LHM + AF 36 LHM + PF

41

HM + TF < HM

HM + TF 4 HM

6

HM + AF < HM

HM + AF 4 HM

125

AF 4 TF

AF < TF

12

AF 4 PF

AF 4 PF

18

Richards et al.

2004

Rebecchi et al.26

2008

Rawlings et al.30

2012

HM, Heller myotomy; TF, total fundoplication; AF, anterior fundoplication; PF, posterior fundoplication.

484


operative time, the higher need for acid-reducing medications secondary to the increased incidence of postoperative reflux led to $2700 extra costs for Heller myotomy–alone patients. More recently, the need for a fundoplication has been challenged. Some authors have suggested that a “limited hiatal dissection,” consisting of mobilization of the anterior aspects of the abdominal esophagus only, thus preserving the lateral and posterior attachments, might allow an LHM without any fundoplication. Robert et al.20 assessed esophageal motility and esophageal exposure to acid two months after surgery and the presence of reflux symptoms every year for at least five years after surgery in 103 patients undergoing LHM with limited hiatal dissection. The 24-hour pH monitoring was abnormal in 9.4 per cent of patients at two months postoperatively. After a median follow-up of 48 months, objective signs of reflux based on 24-hour pH monitoring, upper endoscopy and symptom evaluation were present in 12 (11.3%) patients. Simic et al.21 conducted a randomized controlled trial including 26 patients treated with LHM and Dor fundoplication with complete hiatal dissection, 36 patients treated with LHM and Dor fundoplication with limited hiatal dissection, and 22 patients undergoing LHM alone with limited hiatal dissection. At three years after surgery, mean postoperative LES pressure was significantly lower in patients with LHM alone and limited dissection. Similarly to Robert et al., abnormal DeMeester score was found in 9.1 per cent of patients after LHM alone with limited hiatal dissection, whereas pathologic reflux was detected in 23 per cent of patients after LHM and Dor fundoplication with complete hiatal dissection. The incidence of postoperative esophagitis did not differ significantly among the three groups. Last, DeHaan et al.22 published in 2016 the results of a retrospective analysis on 31 achalasia patients undergoing LHM with limited hiatal dissection: 20 patients had LHM with Dor fundoplication and 10 patients had LHM alone. With a mean follow-up of 11 months, there were no differences in symptoms and patient’s satisfaction between the two groups of patients assessed with validated questionnaires: Achalasia Severity Questionnaire, Gastrointestinal Quality of Life Index, and gastroesophageal Reflux Disease-Health-Related Quality of Life. The main limitation of this study was the lack of objective functional tests. The authors of these three studies concluded that Heller myotomy alone meets the goal of resolving dysphagia without exposing the patients to higher risk of postoperative reflux than the patients who have a fundoplication. However, the nature of the studies, the short follow-up, and the small number of patients considered challenge significantly the interpretation of these data.

April 2018

Vol. 84

In conclusion, the current gold standard for the surgical treatment of achalasia is LHM with partial fundoplication. The results of the published randomized controlled trials show that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus (quality of evidence: HIGH; strength of recommendation: STRONG). Laparoscopic Heller Myotomy and Fundoplications: Partial or Total?

Based on the evidence that a total fundoplication compares favorably with a partial fundoplication in patients undergoing antireflux surgery for gastroesophageal reflux disease even in the presence of weak esophageal peristalsis,23 a total wrap has also been proposed in patients undergoing LHM for achalasia. The evidence from case series is controversial. Whereas Topart et al.24 found recurrence of symptoms in 82 per cent of achalasia patients at 10 years after Heller myotomy and total fundoplication, Rossetti et al.10 reported excellent outcomes in 195 achalasia patients, suggesting that a total fundoplication might not be an obstacle to esophageal emptying. They found that relief of dysphagia was achieved in almost 92 per cent of patients after a mean follow-up of 83 months. There are very few studies comparing partial and total fundoplication in patients undergoing LHM for achalasia. Di Martino et al.25 showed in a retrospective comparative study similar dysphagia relief but less reflux in patients undergoing a total fundoplication. They compared the functional outcomes in patients undergoing LHM with a partial anterior (N 4 30) or total fundoplication (N 4 26) for esophageal achalasia. The two groups were similar in gender, age, weight, previous endoscopic treatments, and duration of symptoms. At six months after surgery, symptoms were evaluated with questionnaires (composite symptom score combining frequency and severity of dysphagia, regurgitation and chest pain, and SF-36 questionnaire) and a barium swallow was also obtained. At one and two years after surgery, the patients answered a symptom questionnaire, underwent upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Median symptom scores significantly decreased after surgery, with no differences in the two groups. At the end of follow-up, the median gastroesophageal junction resting pressure was lower in the group of patients with a partial fundoplication, whereas the median percentage of time with esophageal pH below four was significantly higher. The authors concluded that whereas partial and total fundoplication achieve similar results in dysphagia relief, a total fundoplication might reduce the esophageal exposure to acid refluxate.

No. 4


However, the nature of the study and the short follow-up limit the interpretation of these findings. To date, only one randomized controlled trial has compared LHM with partial or total fundoplication (Table 1). Rebecchi et al.26 enrolled 144 patients: 72 had a partial anterior fundoplication and 72 underwent a total fundoplication (Fig. 2). Presence of gastroesophageal reflux was assessed with the modified DeMeester Scoring System and with the 24-hour pH monitoring. At five years after surgery, dysphagia was more frequent after total fundoplication: 15 per cent versus 3 per cent. Interestingly, the greater the preoperative diameter of the esophagus, the higher the risk of postoperative dysphagia. Esophageal manometry showed a significant decrease in LES pressure in both group; however, mean LES pressure was significantly higher in patients with a total fundoplication. In terms of reflux, there was a trend toward a higher number of patients with reflux symptoms after partial fundoplication; however, the 24-hour pH monitoring reported no significant differences in the DeMeester score, percentage of time with pH below 4, number of acid reflux episodes, and number of acid reflux episodes longer than five minutes between the two groups of patients. On the basis of these randomized controlled trials and the evidence showing that it is a valid option even for the treatment of end-stage achalasia27 and chest pain,28 LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia (quality of evidence: HIGH and strength of recommendation: STRONG).

?

Rebecchi et al.

485

FIG. 2. Heller myotomy with total fundoplication.

Laparoscopic Heller Myotomy with Partial Fundoplication: Anterior versus Posterior

There is no consensus about the most effective type of partial fundoplication. Some surgeons prefer the partial posterior (Toupet) fundoplication (Fig. 3) because it keeps the edges of the myotomy separated, thus reducing the risk of fibrosis and subsequent recurrent dysphagia, and it might lead to better reflux control. Other experts suggest that the use of a partial anterior (Dor) fundoplication is easier and quicker to perform because there is no posterior dissection, and note that it covers the exposed esophageal mucosa. Although several case series have investigated outcomes after partial anterior or posterior fundoplication, reporting dysphagia response in more than 90 per cent of patients and reflux in about 10 per cent regardless of the type of wrap,29 there are very few comparative studies. To date, only one randomized controlled trial comparing partial anterior and posterior fundoplication has

FIG. 3. Heller myotomy with partial posterior fundoplication.

been published (Table 1). Rawlings et al.30 reported in 2012 the results of a multicenter, prospective, randomized controlled trial enrolling 85 patients: 49 in the Dor arm and 36 in the Toupet arm. Outcome endpoints were rates of reflux symptoms, positive 24-hour pH monitoring rates and dysphagia at 6 to 12 months, postoperatively. Baseline characteristics did not differ between the two groups. Follow-up results were obtained in 60 patients: 36 with a Dor fundoplication and 24 with a Toupet fundoplication. Similar functional outcomes were observed regardless of the type of fundoplication: dysphagia and regurgitation decreased significantly after both procedures, with no differences between the two groups. The 24-hour pH monitoring studies revealed similar total DeMeester scores and percentage of time with pH below 4 after Dor and

486


Toupet fundoplication. Abnormal acid reflux was diagnosed in more patients after Dor (41.7%) than Toupet (21.1%) fundoplication, but this difference did not reach the statistical significance. However, this study was underpowered to detect any significant differences between the two study populations. Only a few retrospective comparative studies on functional outcomes after partial or total fundoplication are available in the literature. For instance, Wills et al.31 prospectively assessed symptoms in 62 achalasia patients undergoing LHM with a total (N 4 49) or an anterior (N 4 13) fundoplication with a minimum follow-up of one year (range 1–7 years), using a symptom questionnaire. They observed a significant increase in recurrent dysphagia over time, with higher scores among patients after a total than a partial fundoplication. Also, chest pain scores were significantly worse after a total fundoplication. Tomasko et al.32 recently reported the results of a survey including 63 achalasia patients. A total of 15 patients had an LHM with anterior fundoplication, whereas 48 patients underwent LHM with posterior fundoplication. The two groups of patients were similar in terms of age, gender distribution, and preoperative treatments. With the limitation of a significantly shorter median follow-up for the Dor group (19 vs 60 months) and the small sample size, overall patient’s satisfaction was similar after posterior or anterior partial fundoplication (87.5% vs 93.8%), as well as the incidence of symptoms. In particular, 25 per cent of patients in the Toupet group and 20 per cent of patients in the Dor group reported reflux symptoms at least once or twice a week. Complete resolution of dysphagia was reported by 78 per cent of patients after Toupet fundoplication and 87 per cent of patients after Dor fundoplication. In conclusion, the current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trials, the decision of performing an anterior or a posterior wrap is based on the surgeon’s experience and preference (quality of evidence: MODERATE and strength of recommendation: WEAK). At our institution, we prefer to perform an LHM with a partial anterior fundoplication.

April 2018

Vol. 84

and anterior vagus nerves are identified. Blunt dissection is then continued in the mediastinum on the lateral and anterior aspects to the esophagus to have about 4 to 5 cm of esophagus without any tension below the diaphragm. The posterior wall of the esophagus is not dissected. The operation continues with the dissection of the gastric fundus, with division of the gastrophrenic ligament. Before starting with the myotomy, the fat pad is removed and gentle traction is applied to expose the right side of the esophagus. The myotomy is performed on the right side of the esophagus in the 11 o’clock position using a hook cautery. The submucosal plane is first entered using the hook about 2 to 3 cm cranially to the gastroesophageal junction. Then, the myotomy is performed for a length of about 6 cm cranially on the esophageal wall and about 2.5 cm distally on the gastric wall. The partial anterior fundoplication is a 180 degrees anterior fundoplication that is constructed by applying two rows of sutures: the first row is on the left side of the esophagus and has three stitches that include the fundus of the stomach and the muscular layer of the left side of the esophagus and the left pillar of the crus. The gastric fundus is then folded over the exposed esophageal mucosa to have the greater curvature of the stomach close to the right pillar of the crus. The second row of sutures is on the right side of the esophagus and consists of three stitches including the gastric fundus and the right pillar of the crus (Fig. 4). Conclusions

The current evidence shows that the addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying. Therefore, we feel

Technical Aspects

After insufflation of the peritoneal cavity with CO2 at a pressure of 15 mm Hg, five trocars are inserted. The surgical procedure starts with the division of the gastrohepatic ligament from the pars flaccida all the way up to the right pillar of the crus. Then, the phrenoesophageal ligament is divided and the right and left pillars of the crus are gently dissected and the posterior

FIG. 4.

Heller myotomy with partial anterior fundoplication.

No. 4


comfortable confirming the recommendations provided by the SAGES in 201233: “Patients who undergo a myotomy also should have a fundoplication to prevent postoperative reflux and minimize treatment failures. The optimal type of fundoplication is debated (posterior vs. anterior), but partial fundoplication should be favored over total fundoplication because it is associated with decreased dysphagia rates and similar reflux control. Additional evidence is needed to determine which partial fundoplication provides the best reflux control after myotomy” (quality of evidence: HIGH and strength of recommendation: STRONG). REFERENCES

1. Pellegrini CA, Wetter LA, Patti MG, et al. Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg 1992;216:291–6. 2. Patti MG, Fisichella PM, Perretta S, et al. Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg 2003;196:698–705. 3. Wang PC, Sharp KW, Holzman MD, et al. The outcome of laparoscopic Heller myotomy without antireflux procedure in patients with achalasia. Am Surg 1998;64:515–20; discussion 521 82. 4. Dempsey DT, Delano M, Bradley K, et al. Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome? Ann Surg 2004;239:779–85; discussion 785–7. 5. Sharp KW, Khaitan L, Scholz S, et al. 100 consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg 2002;235:631–8; discussion 638–9. 6. Bloomston M, Rosemurgy AS. Selective application of fundoplication during laparoscopic Heller myotomy ensures favorable outcomes. Surg Laparosc Endosc Percutan Tech 2002; 12:309–15. 7. Diamantis T, Pikoulis E, Felekouras E, et al. Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure. J Laparoendosc Adv Surg Tech A 2006;16:345–9. 8. Kjellin AP, Granqvist S, Ramel S, et al. Laparoscopic myotomy without fundoplication in patients with achalasia. Eur J Surg 1999;165:1162–6. 9. Burpee SE, Mamazza J, Schlachta CM, et al. Objective analysis of gastroesophageal reflux after laparoscopic Heller myotomy: an antireflux procedure is required. Surg Endosc 2005; 19:9–14. 10. Rossetti G, Brusciano L, Amato G, et al. A total fundoplication is not an obstacle to esophageal emptying after Heller myotomy for achalasia: results of a long-term follow up. Ann Surg 2005;241:614–21. 11. Kumar V, Shimi SM, Cuschieri A. Does laparoscopic cardiomyotomy require an antireflux procedure? Endoscopy 1998;30: 8–11. 12. Patti MG, Herbella FA. Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: what type? J Gastrointest Surg 2010;14:1453–8. 13. Campos GM, Vittinghoff E, Rabl C, et al. For achalasia. A systematic review and meta-analysis. Ann Surg 2009;249:45–57.

?

Rebecchi et al.

487

14. Brozek JL, Akl EA, Alonso-Coello P, et al. GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy 2009:64:669–77. 15. Bro˙zek JL, Akl EA, Compalati E, et al. GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 3 of 3. The GRADE approach to developing recommendations. Allergy 2011;66: 588–95. 16. Tapper D, Morton C, Kraemer E, et al. Does concomitant anterior fundoplication promote dysphagia after laparoscopic Heller myotomy? Am Surg 2008;74:626–33. 17. Falkenback D, Johansson J, Oberg S, et al. Heller’s esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study. Dis Esophagus 2003;16:284–90. 18. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240:405–12. 19. Torquati A, Lutfi R, Khaitan L, et al. Heller myotomy vs Heller myotomy plus Dor fundoplication. Cost-utility analysis of a randomized trial. Surg Endosc 2006;20:389–93. 20. Robert M, Poncet G, Mion F, et al. Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases. Surg Endosc 2008;22: 866–74. 21. Simić AP, Radovanović NS, Skrobić OM, et al. Significance of limited hiatal dissection in surgery for achalasia. J Gastrointest Surg 2010;14:587–93. 22. DeHaan RK, Frelich MJ, Gould JC. Limited hiatal dissection without fundoplication results in comparable symptomatic outcomes to laparoscopic Heller myotomy with anterior fundoplication. J Laparoendosc Adv Surg Tech A 2016;26: 506–10. 23. Patti MG, Robinson T, Galvani C, et al. Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 2004;198:863–9. 24. Topart P, Deschamps C, Taillefer R, et al. Long-term effect of total fundoplication on the myotomized esophagus. Ann Thorac Surg 1992;54:1046–51; discussion 1051–52. 25. Di Martino N, Brillantino A, Monaco L, et al. Laparoscopic calibrated total vs. partial fundoplication following Heller myotomy for oeasophageal achalasia. World J Gastroenterol 2011;17: 3431–40. 26. Rebecchi F, Giaccone C, Farinella E, et al. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia. Long-term results. Ann Surg 2008;248:1023–30. 27. Herbella FAM, Patti MG. Laparoscopic Heller myotomy and fundoplication in patients with end-stage achalasia. World J Surg 2015;39:1631–3. 28. Perretta S, Fisichella PM, Galvani C, et al. Achalasia and chest pain: effect of laparoscopic Heller myotomy. J Gastrointest Surg 2003;7:595–8. 29. Patti MG, Andolfi C, Bowers SP, et al. POEM vs. laparoscopic Heller myotomy and fundoplication: which is now the gold standard for treatment of achalasia? J Gastrointest Surg 2017;21: 207–14.

488


30. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomizedcontrolled trial. Surg Endosc 2012;26:18–26. 31. Wills VL, Hunt DR. Functional outcomes after Heller myotomy and fundoplication for achalasia. J Gastrointest Surg 2001;5:408–13.

April 2018

Vol. 84

32. Tomasko JM, Augustin T, Tran TT, et al. Quality of life comparing dor and toupet after Heller myotomy for achalasia. JSLS 2014;18:pii: e2014.00191. 33. Stefanidis D, Richardson W, Farrell TM, et al. Society of American gastrointestinal and endoscopic surgeons. SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2012;26:296–311.