Does the addition of a fundoplication improve outcomes for patients undergoing laparoscopic Heller's cardiomyotomy?

Laparoscopic Heller's cardiomyotomy is a well-established technique in the treatment of achalasia. However, the addition of a routine fundoplication as part of this procedure remains controversial. A best evidence topic in upper gastrointestinal surgery was written according to a structured protocol. The question addressed whether the addition of a fundoplication improved clinical outcomes. Two hundred and seven papers were found using the reported search and of these, 8 papers were identified using a pre-determined criteria as representing the best answer to this clinical question. There were 2 meta-analyses, 3 randomised controlled trials and 3 prospective series. The author, journal, date and country of publication, patient group, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. Review of the data shows that the rates of gastro-oesophageal reflux both on pH monitoring and symptom reporting are all reduced when an anti-reflux procedure is added to a Heller's cardiomyotomy. In terms of the choice of the anti-reflux procedure, comparison between the Dor anterior and Toupet posterior fundoplications do not show any obvious clinical differences, however dysphagia appears to be lower in those undergoing partial fundoplication as compared to a Nissen fundoplication.