A laparoscopic Heller cardiomyotomy for achalasia is completed with a full-length myotomy extending onto the gastric side. Why must this operation be combined with a partial antireflux procedure such as a Dor fundoplication?

• A To prevent recurrence of achalasia symptoms
• B To reduce the incidence of mucosal perforation during myotomy
• C Because dividing the lower esophageal sphincter fibers destroys the antireflux barrier ✓
• D Because the crural repair alone is insufficient to maintain hiatal competence

Explanation

Heller myotomy deliberately divides the circular muscle of the lower esophageal sphincter, which constitutes the intrinsic antireflux barrier. Without reconstructive coverage, severe gastroesophageal reflux occurs postoperatively. A Dor anterior or Toupet posterior partial wrap restores reflux control while leaving the wrap too loose to cause dysphagia, which is why a full Nissen wrap is avoided. The fundoplication does not prevent myotomy failure, reduce perforation risk, or substitute for crural repair.

Reference: Shackelford's Surgery of the Alimentary Tract, 8th ed.

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