A 180° anterior (Dor) fundoplication is usually paired with an esophagogastric myotomy in the surgical treatment of achalasia. The traditional technique, however, is not easily reversible and the execution is variable. We present a simplified ”three stitch” Dor fundoplication that addresses these challenges and discuss our results.
A prospectively collected, longitudinal surgical achalasia database was queried for patients undergoing a Heller myotomy with ”three stitch” 180°fundoplication from 2008-2019. Pre and postoperative Eckardt score, postoperative DeMeester score (24/48 hour pH studies), and endoscopic evidence of esophagitis were collected and analyzed to determine the effectiveness and safety of the fundoplication. Length of stay and complications were also considered.
pH testing was performed in 296 patients, with 17% (50/296) demonstrating abnormal esophageal acid exposure. Of this group, only 8% (16/201) manifested clinical esophagitis on upper endoscopy. 14% (7/50) of patients with abnormal esophageal acid exposure were symptomatic. Total postoperative Eckhardt scores for this cohort were ≤ 3 in 92% of patients with a dysphagia specific score of 0 in 92%. The technical details of our modified 180° anterior fundoplication are described.
The ”three stitch” Dor fundoplication is an effective addition to a minimally invasive Heller myotomy, with good palliation of symptoms and an acceptable rate of acid reflux. The simplified construction anticipates the potential progression of esophageal dysmotility in achalasia patients and the modified technique is reproducible and readily teachable.
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