title: Partial anterior vs partial posterior fundoplication following transabdominal esophagocardiomyotomy for achalasia of the esophagus: meta-regression of objective postoperative gastroesophageal reflux and dysphagia.
abstract: OBJECTIVE
  To review transabdominal esophagocardiomyotomy (surgical treatment of achalasia) of the esophagus and to compare outcomes of partial anterior vs partial posterior fundoplication.
  
  
  METHODS
  An electronic search was conducted among studies published between January 1976 and September 2011 using the keywords achalasia, myotomy, antireflux surgery, and fundoplication.
  
  
  METHODS
  Prospective studies of transabdominal esophagocardiomyotomy were selected.
  
  
  METHODS
  Outcomes selected were recurrent or persistent postoperative dysphagia and an abnormal 24-hour pH test result. Studies were divided into the following 3 groups: myotomy only, myotomy with anterior fundoplication, and myotomy with posterior fundoplication. Studies were weighted by the number of patients and by the follow-up duration. Event rates were calculated using meta-regression of the log-odds with the inverse variance method.
  
  
  RESULTS
  Thirty-nine studies with a total of 2998 patients were identified. The odds of postoperative dysphagia were 0.06 (95% CI, 0.03-0.12) for myotomy only, 0.11 (95% CI, 0.09-0.14) for myotomy with anterior fundoplication, and 0.06 (95% CI, 0.04-0.08) for myotomy with posterior fundoplication. The odds of a postoperative abnormal 24-hour pH test result were 0.37 (95% CI, 0.12-1.08) for myotomy only, 0.16 (95% CI, 0.11-0.24) for myotomy with anterior fundoplication, and 0.18 (95% CI, 0.13-0.25) for myotomy with posterior fundoplication. The increased odds of postoperative dysphagia in the group undergoing myotomy with anterior fundoplication compared with the group undergoing myotomy with posterior fundoplication were statistically significant (P < .001). However, the incidence of a postoperative abnormal 24-hour pH test result was statistically similar.
  
  
  CONCLUSIONS
  Partial posterior fundoplication when combined with an esophagocardiomyotomy may be associated with significantly lower reintervention rates for postoperative dysphagia, while providing similar reflux control compared with partial anterior fundoplication.
authors: Providence Portland Cancer Center, Portland, OR 97213, USA.
authors: Ashwin A
authors: AA
authors: Kurian
authors: Neil
authors: N
authors: Bhayani
authors: Ahmed
authors: A
authors: Sharata
authors: Kevin
authors: K
authors: Reavis
authors: Christy M
authors: CM
authors: Dunst
authors: Lee L
authors: LL
authors: Swanström
mesh_terms: D002299:Cardia / Q000601:surgery; D004931:Esophageal Achalasia / Q000453:epidemiology / Q000601:surgery*; D050782:Esophageal pH Monitoring; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000453:epidemiology / Q000517:prevention & control; D006801:Humans; D010535:Laparoscopy; D012008:Recurrence; D012044:Regression Analysis; D016896:Treatment Outcome