In the operative management of achalasia, the Heller myotomy involves longitudinal division of the lower oesophageal circular muscle fibres. To prevent post-operative gastro-oesophageal reflux, Heller myotomy is routinely combined with which anti-reflux procedure?
- A Nissen fundoplication (360° wrap)
- B Belsey Mark IV fundoplication (transthoracic 270° wrap)
- C Partial posterior fundoplication (Toupet, 270°) or partial anterior fundoplication (Dor, 180–200°) ✓
- D No fundoplication — only myotomy is performed
Explanation
Laparoscopic Heller myotomy (LHM) is combined with a partial fundoplication to prevent post-myotomy GERD without compromising the relief of dysphagia. A 360° Nissen wrap would be too tight on the aperistaltic oesophagus of achalasia, recreating outflow obstruction. Partial fundoplications — either Dor (anterior 180–200°, which also covers the myotomy defect) or Toupet (posterior 270°) — reduce GERD while maintaining adequate oesophageal emptying. Meta-analyses show comparable dysphagia outcomes between Dor and Toupet, though Toupet may marginally better reduce reflux. The choice depends on surgeon preference and the integrity of the oesophago-gastric dissection.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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