F. Russo

A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up

Objective:The aim of this study was to evaluate the role and efficacy of a total 360° wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia. Summary Background Data:Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360° fundoplication is generally regarded as an obstacle to esophageal emptying. Matherials and Methods:Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12–79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry. Results:In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 ± 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 ± 1.1 days (range, 1–12 days). At a mean clinical follow up of 83.2 ± 7 months (range, 3–141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0–1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients. Conclusions:Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.

Total Fundoplication Does Not Obstruct the Esophageal Secondary Peristalsis: Investigation with Pre- and Postoperative 24-Hour pH-Multichannel Intraluminal Impedance

Aim: To determine the impact of total fundoplication on the spontaneous esophageal clearance, known as secondary peristalsis. Background: Although there is general agreement that total fundoplication is not an obstacle to bolus swallowing (primary peristalsis), whether it is an obstacle to spontaneous esophageal clearance (secondary peristalsis) is still not clear. Based on 24-hour monitoring, multichannel intraluminal impedance was used to calculate the time of spontaneous bolus clearance (BCT). Methods: Mean BCT was prospectively calculated in 15 consecutive patients before and after total fundoplication. BCT was calculated in seconds including all the gastroesophageal reflux episodes, whereas bolus swallows (solid meals and liquid swallows) were excluded from the analysis. Results: BCT was extrapolated from 1,057 episodes in the 623 h of study. Overall, BCT did not change after surgery (13.6 ± 4 vs. 15.2 ± 10 s; p = nonsignificant) and in the upright (12.2 ± 3 vs. 16.5 ± 7 s; p = nonsignificant) and recumbent position (22.9 ± 9 vs. 23.0 ± 9 s; p = nonsignificant). Conclusions: In this study total fundoplication did not affect the BCT by combined 24-hour ph monitoring and multichannel intraluminal impedance.