Gastro-esophageal reflux following myotomy for achalasia.

Evidence is not available for a surgeon to be certain that one form of procedure is better than another in preventing reflux after myotomy of the lower esophageal sphincter in patients with achalasia. Therefore, each surgeon should choose the procedure and approach which he performs most competently. Well respected authorities in this field continue to advocate the performance of an antireflux procedure, or advocate that it is unnecessary to use a routine antireflux procedure. It is the author's own practice to add an antireflux procedure in the form of a partial fundoplication, in all patients having a myotomy of the lower esophageal sphincter. Sometimes there are factors which dictate one or other of the thoracic or abdominal approach, e.g. previous surgery, very obese patient, etc. When no such factors are present I favor the abdominal approach in the belief that an abdominal incision provides less morbidity than a thoracic incision.