title: Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: results of a randomised clinical trial.
abstract: BACKGROUND
  The 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.
  
  
  METHODS
  Patients 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.
  
  
  RESULTS
  Forty-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.
  
  
  CONCLUSIONS
  A 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.
  
  
  BACKGROUND
  ClinicalTrials.gov Identifier: NCT01933373.
authors.affiliation: Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; CLINTEC, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Koshi
authors.initials: K
authors.lastname: Kumagai
authors.affiliation: Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; CLINTEC, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ann
authors.initials: A
authors.lastname: Kjellin
authors.affiliation: Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; CLINTEC, Karolinska Institutet, Stockholm, Sweden. Electronic address: jon.tsai@ki.se.
authors.forename: Jon A
authors.initials: JA
authors.lastname: Tsai
authors.affiliation: Department of Surgery, Ersta Hospital, Stockholm, Sweden; Department of Clinical Science at Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Thorell
authors.affiliation: Department of Radiology, Ersta Hospital, Stockholm, Sweden.
authors.forename: Staffan
authors.initials: S
authors.lastname: Granqvist
authors.affiliation: Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; CLINTEC, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
authors.affiliation: Department of Surgery, Ersta Hospital, Stockholm, Sweden; Department of Clinical Science at Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Bengt
authors.initials: B
authors.lastname: Håkanson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004931:Esophageal Achalasia / Q000601:surgery*; D004947:Esophagus / Q000503:physiopathology / Q000601:surgery; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020127:Recovery of Function; D055815:Young Adult
keywords: Achalasia; Dor fundoplication; Toupet fundoplication