There is no therapy for achalasia that can reverse the underlying neuropathology or associated impaired LES relaxation and aperistalsis 8. Therefore, all reported methods of therapy are directed to reduce the LES pressure. To improve esophageal emptying, esophageal myotomy is the most effective modality of treatment for achalasia 3,9,10. Since the introduction of minimal invasive surgery in children, it has gained wide acceptance. LE avoids the need for major surgery, is effective, and associated with rapid recovery, short hospital stay, and good long-term outcome 6,11–15.
The surgical objective in the treatment of achalasia is to disrupt the LES enough to eliminate dysphagia without causing excessive reflux 8,9. If the incision is not performed adequately on the distal esophagus and stomach, dysphagia will recur and persist after surgery 16,17. However, if the myotomy is too long on the gastric side, the risk of GER is high 17. A myotomy that extends more than 1 cm onto the cardia of the stomach has a higher incidence of postoperative GER 7,18. Indeed, extension of the myotomy more than 2 cm onto the cardia of the stomach is reportedly associated with 100% reflux 19. Therefore, it has been recommended to carry out intraoperative endoscopy at the time of LE to determine the exact site of gastroesophageal junction that allows extension of the myotomy on to the gastric body to be monitored precisely and to check for integrity of the esophageal mucosa 10,17,20. Extension of the myotomy only far enough to ensure complete division of the encircling musculature of the esophageal sphincter (LES) is recommended 7,18.
There is a debate on whether a fundoplication should be performed in addition to esophagomyotomy, and which is the best one 6,12,21,22. In several pediatric series, a concomitant fundoplication has been used selectively 7,23,24. Lemmer et al. 7 performed partial fundoplication in addition to esophagomyotomy in the cases where division of the obstructing gastroesophageal junction fibers required continuation of the myotomy well onto the stomach or when extensive dissection about the hiatus was performed. Payne and King 24 have been carrying out a concomitant fundoplication when a hiatus hernia is present. Richards et al.9 have reported certain situations in which anterior fundoplication should be added to LE: when there is mucosal perforation, sliding hiatus hernia, or where preoperative 24 h pH studies indicate pathologic reflux.
Many reports recommend a routine antireflux procedure to be added to esophagomyotomy 6,21,22,25–31. They have reported the advantages of a concomitant fundoplication, including a reduced risk of postoperative GER, protection of the herniated mucosa from the feeding injuries, and reduced risk of postoperative perforation 6,21,25–31. There is no consensus on the ideal operation to prevent GER, because of the controversy in terms of the relative merits of the procedures: the Floppy Nissen is believed to be potentially obstructing, the Toupet procedure is satisfactory, but requires additional time and dissection, and the Dor procedure is criticized as an unsatisfactory antireflux operation 32. Among the various fundoplications, anterior fundoplication is the most effective in reducing the risk of stenosis or recurrence of achalasia, and in preventing reflux 29,32,33. Patti et al.34 have reported that 17% of their patients who had LE and anterior fundoplication developed postoperative GER documented by a 24-h pH study. Even after the addition of partial fundoplication to LE, patients with achalasia may have postoperative pathologic GER 9. Pastor et al.35 have reported no significant difference in their patients who had LE with floppy Nissen fundoplication on achalasia outcomes including the subsequent development of GER.
The actual incidence of GER following surgery for achalasia is difficult to establish because it depends on the surgical approach, length of myotomy, associated pathologies, length of follow-up, and the methods used for assessment of postoperative GER 3,16. Moreover, pseudoreflux may occur before and after esophagomyotomy 33. This occurs when food stasis in the lower esophagus results in fermentation and the production of lactic acid, which reduces esophageal pH 32,33. Heartburn and regurgitation symptoms might be related to acid fermentation from poor emptying of the esophagus rather than true GER 32. There is an ∼13.2% risk of GER following esophagomyotomy alone by laparotomy, whereas with the addition of an antireflux procedure, the risk of GER is 7.4% 3,23,36,37. A recent meta-analysis study reported that the difference in the rate of GER diagnosed in post-LE pH studies in wrapped and nonwrapped patients was not statistically significant (7.9 vs. 10%, respectively) 33. Kumar et al.13 reported an incidence of 6.7% of GER after LE, and attributed this low incidence to the fact that lateral and posterior attachments of the esophagus are maintained intact. Iatrogenic GER will occur if extensive hiatal dissection is performed and if the incision onto the stomach is generously performed more than 2 cm onto the cardia of the stomach 16,18. Mobilization of the posterior esophageal wall will increase the incidence of postoperative GER 12,29. Limited anterior and lateral esophageal dissection eliminates the need for fundoplication 12.
The diagnosis of achalasia can be difficult in children as the symptoms can be confused with feeding aversion, failure to thrive, or GER 38. However, in patients older than 5 years of age, the clinical presentation is very similar to adults, as follows: vomiting, dysphagia, weight loss, recurrent pneumonia, failure to thrive, or nocturnal cough 38. In the current study, clinical evaluation, upper GI contrast study, and flexible upper endoscopy were enough to reach the diagnosis in all the cases. This approach was also reported by Tannuri et al.22; they used manometry only when esophageal dilatation was mild (stage I megaesophagus). They performed manometry in three out of 15 patients in their series, sparing most patients from esophagomanometry, which is a difficult, lengthy, and uncomfortable test, especially for children.
There has been a major concern of development of persistent or recurrent dysphagia after the addition of an antireflux procedure to esophagomyotomy in the treatment of achalasia, which is attributed to aperistalsis of the esophagus 3,9,13,18. Esposito et al.28 reported that one of the 10 patients who underwent LE and Dor fundoplication developed dysphagia 1 year after surgery. The first valve was released, and a Thal antireflux mechanism was performed. Donahue et al.32 have reported that 15 out of 58 patients who had undergone LE and Toupet or Dor fundoplication developed postoperative dysphagia. Two of these patients required reoperation and 13 patients underwent pneumatic dilatation. Richards et al.39 have reported that two patients out of 16 patients who underwent LE alone developed significant dysphagia postoperatively, and additional treatment in both these patients is being considered. The effective antireflux procedures (Nissen, Toupet, and Hill) all aim to increase LES pressure, which of course would be counterproductive in achalasia with an aperistaltic esophagus 32. It seems odd to perform a Heller’s myotomy, which weakens the LES, and then add an antireflux procedure that will increase the sphincteric pressure 3.
GER may occur in patients with achalasia whether they have undergone LE alone or LE plus fundoplication 9. Patients found to have pathologic reflux after esophagomyotomy with or without fundoplication can be effectively treated medically, but persistent dysphagia requires a more drastic and potentially hazardous treatment such as pneumatic dilatation or reoperation 9,20,32.
In the current series, we elected not to perform routine fundoplication with LE for achalasia for the following reasons:
This technique of LE without fundoplication in the treatment of achalasia is safe, effective, and yields excellent cosmetic results. The routine addition of fundoplication to LE for the treatment of achalasia in our series appears to be unnecessary. Yet, a multicenter study with a large group of patients should be carried out.
There are no conflicts of interest.
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