Dor fundoplication for achalasia of the esophagus: is it time to simplify the established technique? evaluation of clinical outcome

Abstract

Background: Surgery is the most efficient treatment to achalasia of the esophagus with a success rate estimated 90%. Laparoscopic myotomy is combined with a fundoplication. One of the most common types of wrap is the anterior partial fundoplication, also known as Dor fundoplication. The 10% of surgical failure has been attributed to incomplete myotomy and/or tight fundoplication. The present study describes a modified anterior partial fundoplication that may have the potential to improve the clinical outcome of surgical treatment for achalasia.Methods: In this prospective study, we describe a modification of the standardized technique of Dor fundoplication applied to twenty-nine achalasia patients with intention to decrease the rates of failure. Short-term clinical result was evaluated with preoperative and six- months postoperative Eckardt scores (ES).Results: The mean number of months from initial symptoms to the time of diagnosis was 35.5 months (range 3-156 months). According to the Chicago Classification (CC v3.0), 11 patients (37.9%) were classified as achalasia type I, 17 (58.6%) as type II and 1 (3.4%) as type III. The mean ES was diminished from 7.8 to 0.6 postoperatively.Conclusions: The modification proposed in the present study omits the fixation of the right side of the myotomy to the right crus. This alteration may have the potential to anatomically and functionally affect postoperative rates of dysphagia and antireflux result among patients surgically treated for achalasia.

Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients

“…Because of elevated pressures according to the HRM, Dor fundoplication was modified in thirteen patients (65%), either by the addition of an extra suture between the gastric fundus and the central tendon of the diaphragm (45%), or by relocation of one of the sutures (5%) that comprised the wrap. We also applied a modified technique in 3 patients (15%), concerning the last two sutures of the standardized Dor fundoplication, which consisted of fixation of the gastric fundus directly to the right crus of the diaphragm, as previously described [16]. In addition, in 7 patients (35%) we performed incision of the short gastric vessels because high pressures persisted after completion of the wrap.…”