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Correspondence and Brief Communications |

The Choice of Fundoplication After Myotomy for Achalasia—Reply

Lee Swanstrom, MD
Arch Surg. 2006;141(6):612-613. doi:10.1001/archsurg.141.6.612-c.
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We thank Dr Clemente for his kind comments regarding our recent achalasia outcomes article.1 He nicely summarizes 2 decades-old controversies regarding the surgical treatment of achalasia—how long does the myotomy need to be and which is the preferred antireflux procedure to use? He advocates a “minimalist” approach with little esophageal mobilization, a relatively short myotomy, and a Dor anterior fundoplication. We, on the other hand, describe a series of long myotomies (8 cm minimum) with a posterior partial wrap (a Toupet). Both reports describe excellent results with dysphagia relief; 96% in Dr Clemente's open series and 92% in ours. I would argue that this is the most important outcome end point for these patients who are almost always having surgery for esophageal obstructive symptoms. Who had the better antireflux repair, André Toupet or Jacques Dor? Both have their defenders with Dor proponents usually arguing for its mucosal covering configuration and preservation of posterior attachments, while Toupet fans laud its tendency to hold open the myotomy and for the opportunity of mediastinal mobilization to straighten the distal esophagus. I use both repairs on occasion although the current article only included our Toupet experience, which in my hands seems to provide slightly better results.2 Although our postoperative pH studies did show a fairly high incidence of reflux (30%), it must be noted that only 40% of our patients had postoperative pH testing and these were more likely to be patients who had complaints or esophagitis on endoscopic examination. This likely makes our results look worse than they actually are. Regardless, I am less concerned about postoperative reflux than I am with dysphagia from an incomplete myotomy since there is no “purple pill” for dysphagia. The final answer to this controversy can obviously only be answered by a prospective randomized study comparing the 2 approaches, which is currently under way at 5 centers including ours. Once again, I thank Dr Clemente for raising these long-standing but always relevant issues.

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