An antireflux procedure should not routinely be added to a Heller myotomy

Achalasia is a disease that can only be palliated, not corrected, by surgery. The philosophy at Vanderbilt has been to maximize the relief of dysphagia through myotomy that is measured using intraoperative endoscopy while minimizing the mechanical factors that may increase gastroesophageal reflux. Only a few of our patients (3 [13%] of 24) have developed pathologic reflux after Heller myotomy without an antireflux procedure, and all have been treated medically with excellent results. The addition of an antireflux procedure would inappropriately treat the 87% of patients who have no objective measurement of gastroesophageal reflux. Because gastroesophageal reflux does occur in patients who have undergone Heller myotomy and Dor fundoplication, we have chosen not to add a procedure that may increase dysphagia. Our argument against the routine use of fundoplication rests on the concept that a fundoplication, either total or partial, increases resistance to flow across the LES and therefore decreases symptom relief. Our studies, as well as others, indicate that esophageal clearance is an important aspect of reflux after Heller myotomy, and postoperatively patients with achalasia are more prone to long periods of acid exposure caused by inadequate clearance. Symptoms of GERD in patients with achalasia do not correlate with objective measurements of acid exposure in the esophagus; therefore they cannot be used to follow up patients after Heller myotomy. Gastroesophageal reflux can be a significant problem in patients whether they have undergone Heller myotomy alone or Heller myotomy plus fundoplication. We recommend 24-hour pH studies to monitor acid exposure in the distal esophagus postoperatively to identify pathologic GERD after Heller myotomy. Patients found to have pathologic reflux after Heller myotomy with or without fundoplication should be treated medically. In short, acid reflux after a myotomy can be controlled simply with medication, but dysphagia requires more drastic and potentially hazardous treatment such as pneumatic dilatation or reoperation.