Heller's myotomy without fundoplication: a series of 123 patients

Introduction: Surgical treatment of achalasia of lower oesophageal sphincter is Heller's myotomy, usually associated with a fundoplication due to an high risk of postoperative gastro-oesophageal reflux. The value of this fundoplication is discussed. The aim of this study was to evaluate retrospectively the results of Heller's myotomy without fundoplication but performed according to a precise technique preventing postoperative reflux. Patients and Methods: Between 1975 and 1999, 123 patients underwent Heller's myotomy without systematic fundoplication. Diagnosis of achalasia was performed clinically and confirmed by investigations: baryum meal, fibroscopy and manometry. Myotomy was performed through an abdominal approach in 117 (95%) patients. Dissection preserved fixity of abdominal oesophagus in all cases, particularly its posterior meso. Myotomy was performed on abdominal oesophagus but not below the cardia. Posterior fundoplication was associated in 2 patients. Results: One patient (0,8%) died from massive aspiration. Morbidity (1,6%) consisted in one peritonitis and one postoperative occlusion. At follow-up (mean = 5 years; range: 1-20), functional results were satisfying (excellent and good) in 112 (92%) patients. Seven patients (6%) developed postoperative reflux, including one who need surgical treatment. Dysphagia persisted in 3 patients (2%) who had to be reoperated. Conclusion: Results of this series show that systematic fundoplication is not necessary in Heller's myotomy for achalasia of lower oesophageal sphincter. (C) 2002 Editions scientifiques et medicales Elsevier SAS. All rights reserved.