I read with interest the article by Khajanchee et al1 published in the ARCHIVES. In my opinion, this study was perfectly conducted and followed rigorous criteria. For this reason, I express my appreciation to the authors. They studied the effectiveness of posterior Toupet fundoplication for the prevention of gastroesophageal reflux (GER) after Heller myotomy for achalasia. The results, as far as the improvement of dysphagia is concerned, are good with a greater than 90% improvement. Unfortunately, GER was found in 33% of patients in the postoperative pH studies after a median 9-month follow-up. The authors bring forth 2 hypotheses to explain this finding: their “aggressive myotomy” technique and their “aggressive use of postoperative pH” studies. In my opinion, the explanation for these results could be Toupet fundoplication. This technique is effective in the treatment of primary GER, but it is well known that the majority of surgeons prefer Dor anterior fundoplication after myotomy for achalasia. If the surgeon chooses the Heller-Dor procedure, he/she can perform the myotomy without a circumferential dissection of the esophagus; in this way, the surgeon preservers the hiatal posterior attachments that play an important role in the valvular mechanism at the esophagogastric junction. In addition, in case of mucosal perforation, covering the myotomy with gastric serosa offers a great sense of safety. Finally, the suture of the wrapped fundus to the myotomy edges as well as to the right and left crural pillars strengthens the antireflux function of the lower esophagus, which is kept in the abdomen and exposed to abdominal pressure. The authors report a case of mucosal tear repaired thoracoscopically, but how is that possible without a thoracic migration of the myotomized esophagus?
Clemente G. The Choice of Fundoplication After Myotomy for Achalasia. Arch Surg. 2006;141(6):612. doi:10.1001/archsurg.141.6.612-b