title: Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial.
abstract: BACKGROUND
  The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy.
  
  
  METHODS
  A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test.
  
  
  RESULTS
  Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups).
  
  
  CONCLUSIONS
  Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.
authors.affiliation: Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave., Box 8109, St. Louis, MO 63110, USA.
authors.forename: Arthur
authors.initials: A
authors.lastname: Rawlings
authors.forename: Nathaniel J
authors.initials: NJ
authors.lastname: Soper
authors.forename: Brant
authors.initials: B
authors.lastname: Oelschlager
authors.forename: Lee
authors.initials: L
authors.lastname: Swanstrom
authors.forename: Brent D
authors.initials: BD
authors.lastname: Matthews
authors.forename: Carlos
authors.initials: C
authors.lastname: Pellegrini
authors.forename: Richard A
authors.initials: RA
authors.lastname: Pierce
authors.forename: Aurora
authors.initials: A
authors.lastname: Pryor
authors.forename: Valeria
authors.initials: V
authors.lastname: Martin
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Frisella
authors.forename: Maria
authors.initials: M
authors.lastname: Cassera
authors.forename: L Michael
authors.initials: LM
authors.lastname: Brunt
mesh_terms: D000328:Adult; D000368:Aged; D004931:Esophageal Achalasia / Q000601:surgery*; D005260:Female; D018662:Fundoplication / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008365:Manometry; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000601:surgery*; D017060:Patient Satisfaction; D011182:Postoperative Care / Q000379:methods; D011446:Prospective Studies; D011788:Quality of Life; D016896:Treatment Outcome; D055815:Young Adult