Are there specific indications for adding an antireflux procedure to the myotomy?
A.L. DePaula (Goiania)
The treatment of esophageal achalasia is considered to be palliative. Even though clinical treatment may be used , the two most frequent ways of treatment are pneumatic dilation and surgical myotomy [2-5], which are most often indicated for non-advanced achalasia. Patients with advanced achalasia, sigmoid esophagus, usually need resection.
Both pneumatic dilation and myotomy, through open or laparoscopic approach, may result in relief of dysphagia. Evaluation of improvement after pneumatic dilation ranges from 50% to 100%, requiring new dilation sessions in 0% to 40% and subsequent myotomy in 3% to 22% . Comparative studies between endoscopic dilation and myotomy are rare and the choice between the two can be difficult. Okike et al. reported relief of dysphagia in 85% of patients submitted to myotomy against 65% of those submitted to dilation . Csendes et al. obtained 95% to 65% of improvement after myotomy and dilation respectively .
Once decided for the surgical treatment of esophageal achalasia, the surgeon is faced with a series of options and controversies. The universally accepted procedure is the Heller myotomy , modified by Zaaijer . It can be performed through an abdominal  or thoracic  approach, with variable extent to the esophagus and to the stomach. The major controversy, however, is related to its association with an antireflux procedure.
Most of the controversy is probably due to the technical variability in the performance of myotomy. Experiences such as the Mayo Clinic have demonstrated the occurrence of only 3% of gastroesophageal reflux in patients submitted to esophagomyotomy without the routinely used antireflux procedure . The evaluation of the technique used through thoracotomy demonstrates that the myotomy is usually limited to the complete section of the esophageal muscle, not carried onto the stomach or extending for less than 1 cm, and usually not associated to an antireflux procedure . Evaluation of the literature demonstrates gastroesophageal reflux (GER) rates ranging from 0% to 26%, average of 10.7% following myotomy through the thorax and associated with an antireflux procedure and 6% to 13%, average of 9.3%, without fundoplication .
Those who perform the myotomy through the abdominal approach, most of the times extend the myotomy onto the stomach for 1 to 3 cm with an additional fundoplication. There are a number of antireflux procedures varying from a simple suture of the fundus to the esophagus, a posterior partial fundoplication (Toupet) , an anterior fundoplication (Dor) , a posterior-left lateral and anterior fundoplication (Pinotti) , or even a Nissen fundoplication . The related mean incidence of reflux after abdominal myotomy with an antireflux procedure is 7.4% . Andreollo et al. reported, in an evaluation of a number of studies published in the literature, that the incidence of GER following myotomy through thoracotomy with or without antireflux procedure was 7.3 % and 7.7% respectively. After abdominal approach, the addition of fundoplication resulted in 7.4% of reflux against 13.4% for those who had not indicated it .
It has been our option to perform an extensive esophageal myotomy through the abdomen, extending it onto the stomach for 2 to 3 cms, associated with a partial fundoplication.
Therefore, we have considered that the answer to the question "Are there specific indications for adding an antireflux procedure to the myotomy" is NO, although it is highly advisable to add a fundoplication in the following circumstances:
1) abdominal approach, either open or laparoscopic ;
2) concomitant presence of a hiatal hernia;
3) perforation of the mucosa;
4) reoperation following an inappropriate Heller myotomy.