Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: Results of a randomised clinical trial

AbstractBackgroundThe optimal anti-reflux procedure after Heller cardiomyotomy for oesophageal achalasia remains unclear. The most commonly used procedure is the anterior partial fundoplication according to Dor, although during recent years the posterior counterpart (Toupet) has become popular.MethodsPatients with newly diagnosed achalasia and referred for cardiomyotomy were randomised to receive either an anterior or partial posterior fundoplication following a classical cardiomyotomy. The effect of surgery was assessed during the first postoperative year by Eckardt scores, EORTC QLQ-OES18 scores and HRQL questionnaires. Timed barium oesophagogram (TBO) and ambulatory 24-h pH monitoring were performed to determine oesophageal emptying and the degree of reflux control, respectively.ResultsForty-two patients were randomised into Dor (n = 20) and Toupet (n = 22) groups. Eckardt scores improved dramatically with both procedures, but the EORTC QLQ-OES18 (functional scales) scores revealed significantly better relative improvements in the Toupet group compared to the Dor repair (P = 0.044). Corresponding advantages in favour of Toupet were observed postoperatively in the percentage of oesophageal emptying at TBO (P = 0.011 in height and P = 0.018 in area), an effect not observed in the Dor group. There were no other significant differences recorded between the study groups concerning HRQL evaluations and objective assessment of gastro-oesophageal acid reflux.ConclusionsA partial posterior fundoplication after cardiomyotomy seems to achieve more improvement in oesophageal emptying and EORTC QLQ-OES18 functional scale scores than the anterior fundoplication. Otherwise no differences between the two anti-reflux repairs were noted.Trial registration numberClinicalTrials.gov Identifier: NCT01933373

Studies of preoperative evaluation and surgical procedures for gastroesophageal reflux disease

Introduction Gastroesophageal reflux disease (GERD) is defined as the non-physiological movement of gastric contents from the stomach to the esophagus, which causes various degrees of troublesome symptoms and/or esophageal mucosal injury. Symptoms of GERD such as heartburn and regurgitation are common and the prevalence has been reported to vary between 7-20 % in the Western world. Although pharmacological treatment is the primary choice, surgery is an alternative when the effect of acid reducing agents is unsatisfactory. Objectives The overall objectives of this thesis were to investigate different clinical aspects of preoperative evaluation and surgical procedures for the treatment of GERD. Methods and results Study I investigates the predictive ability of preoperative esophageal manometry on postoperative dysphagia in 191 patients who underwent open antireflux surgery. Dysphagia was a common preoperative finding, as was any type of preoperative esophageal motor abnormality. Postoperatively, dysphagia was reduced irrespective of the presence of preoperative dysmotility or not. Study II tests the hypothesis that laparoscopic partial fundoplication differs in clinical outcomes compared to open surgery in a randomized study including 192 patients with GERD. In the short term, open surgery was associated with a higher incidence of perioperative complications and a prolonged recovery. At 1 and 3 years postoperatively, esophageal acid exposure was reduced similarly after open and laparoscopic surgery, as was control of GER symptoms. During 3 years of follow up, the recurrence rate was higher in the laparoscopic group. However, total need for reinterventional surgery was at similar levels, due to increased rates of incisional hernia operations in the open group. Study III investigates the symptomatic and physiological effects of endoscopic gastroplication (EGP) in 46 patients with GERD in a randomized placebo-controlled setting. Endoscopic gastroplication resulted in significant reduction of PPI consumption and GER symptoms during 1 year of follow up. However, there was no difference between the EGP and the placebo treated controls. EGP did not alter esophageal acid exposure or LES pressure. Study IV investigates agreement, concordance of diagnostic yield, and subjective quality of life parameters between traditional 24 h catheter based and 48 h wireless esophageal pH monitoring in 55 GERD patients and 53 healthy volunteers. Wireless pH monitoring consistently underestimated esophageal acid exposure compared to traditional technique. Although there was a high correlation between the two techniques, the agreement between the methods as assessed by Bland-Altman analysis was low. Conclusions Preoperative esophageal manometry does not predict development of postoperative dysphagia. Open and laparoscopic partial fundoplication are equally effective alternatives for the surgical treatment of GERD. However, fewer complications and faster recovery makes laparoscopic approach the primary choice. EGP has no treatment effect,over placebo and should therefore not be recommended for the treatment of GERD. Wireless esophageal pH monitoring is not immediately interchangeable with traditional pH monitoring for use in clinical practice