the myotomy alleviates dysphagia symptoms by releasing the distal esophageal muscular layers , thereby limiting lower esophageal sphincter contraction . however , myotomy alone has been shown to increase gastroesophageal reflux disease ( gerd ) ; hence , it is now common practice to include an antireflux procedure . these patients have some degree of esophageal body dysmotility , and a 360 wrap can make esophageal emptying more difficult . thus , although nissen fundoplication is effective at controlling postoperative acid reflux , it is less favorable because of a high dysphagia recurrence rate . a partial fundoplication has the benefits of less dissection , decreased operative time , and improvement in dysphagia symptoms , while showing improvement in reflux rates comparable with 360 fundoplication . both dor and toupet fundoplications provide antireflux benefits with less risk for recurrent dysphagia in postmyotomy patients . our initial practice consisted of lhc in conjunction with routine toupet fundoplication for patients with achalasia . toupet fundoplication is advocated on the basis of better reduction of reflux and better outcomes because the 270 posterior fundoplication aids in keeping myotomy edges apart . however , we have since transitioned to performing dor fundoplication because it covers the exposed esophageal mucosa , and less extensive dissection is required , leaving the stomach attachments in place . additionally , dor fundoplication may be more amenable to a single - site surgical technique . the risk for pseudodiverticulum of the esophagus after myotomy is a concern raised primarily after the thoracoscopic approach ; however , this phenomenon has been described in other laparoscopic and endoscopic procedures and could be a risk in the toupet procedure secondary to an uncovered myotomy . given the current controversy regarding best surgical practice for the treatment of achalasia , the objective of our study was to compare the reflux - related and regurgitation - related quality - of - life outcomes between patients undergoing myotomy with toupet fundoplication and those undergoing myotomy with dor fundoplication . in addition , we investigated overall patient satisfaction after lhc in the treatment of achalasia . the study group consisted of 135 consecutive patients who underwent lhc with fundoplication between 1998 and 2010 by 1 surgeon at a single institution . before january 2010 , toupet fundoplication was performed for all patients unless there was suspicion of mucosal violation after myotomy . the study design and patient questionnaire were approved by the institutional review board of the penn state hershey medical center . the gastroesophageal reflux disease health - related quality of life scale ( gerd - hrql ) was used to assess the severity of reflux . the gerd - hrql is a disease - specific , 10-question , 6-point likert - type scale identifying symptoms such as heartburn and bloating . the scale ranges from 0 to 50 , with higher scores correlating with worse symptoms . additionally , the subjects were asked to rate how often they experienced symptoms of gerd or dysphagia . briefly , symptoms of gerd were rated as follows : 0 = none , 1 = once or twice a month , 2 = once or twice a week , 3 = once a day , and 4 = once a day and continuous . symptoms of dysphagia were rated as follows : 0 = no symptoms , 1 = dysphagia once or twice a month to bread or meat , 2 = dysphagia once or twice a week to thick food , 3 = dysphagia to thick liquids daily , and 4 = inability to swallow oral secretions . for the purposes of our study , patients were deemed to have resolution of their dysphagia symptoms if they reported a score of 0 or 1 . parametric data are presented as mean  sd , and nonparametric data are presented as median ( interquartile range ) . symptom scores after myotomy were analyzed using fisher 's exact test , chi - square statistics , and wilcoxon 's rank - sum test . intraoperative endoscopy was used to ensure adequacy of the myotomy and to rule out mucosal perforation with a leak test . toupet fundoplication was undertaken by passing the fundus posteriorly through the dissected retroesophageal space and anchoring it to the myotomy site and the right and left crura with serial sutures . for dor fundoplication , the fundus was brought anteriorly and sutured to the left crus and myotomy site . a second suture was used to affix the fundus to the left side of the myotomy without including the crus . this was repeated in the same fashion on the right side to complete the fundoplication . we do not routinely fully expose the retroesophageal crura or divide the short gastric vessels . the study group consisted of 135 consecutive patients who underwent lhc with fundoplication between 1998 and 2010 by 1 surgeon at a single institution . before january 2010 , toupet fundoplication was performed for all patients unless there was suspicion of mucosal violation after myotomy . the study design and patient questionnaire were approved by the institutional review board of the penn state hershey medical center . the gastroesophageal reflux disease health - related quality of life scale ( gerd - hrql ) was used to assess the severity of reflux . the gerd - hrql is a disease - specific , 10-question , 6-point likert - type scale identifying symptoms such as heartburn and bloating . the scale ranges from 0 to 50 , with higher scores correlating with worse symptoms . additionally , the subjects were asked to rate how often they experienced symptoms of gerd or dysphagia . briefly , symptoms of gerd were rated as follows : 0 = none , 1 = once or twice a month , 2 = once or twice a week , 3 = once a day , and 4 = once a day and continuous . symptoms of dysphagia were rated as follows : 0 = no symptoms , 1 = dysphagia once or twice a month to bread or meat , 2 = dysphagia once or twice a week to thick food , 3 = dysphagia to thick liquids daily , and 4 = inability to swallow oral secretions . for the purposes of our study , patients were deemed to have resolution of their dysphagia symptoms if they reported a score of 0 or 1 . parametric data are presented as mean  sd , and nonparametric data are presented as median ( interquartile range ) . symptom scores after myotomy were analyzed using fisher 's exact test , chi - square statistics , and wilcoxon 's rank - sum test . intraoperative endoscopy was used to ensure adequacy of the myotomy and to rule out mucosal perforation with a leak test . toupet fundoplication was undertaken by passing the fundus posteriorly through the dissected retroesophageal space and anchoring it to the myotomy site and the right and left crura with serial sutures . for dor fundoplication , the fundus was brought anteriorly and sutured to the left crus and myotomy site . a second suture was used to affix the fundus to the left side of the myotomy without including the crus . this was repeated in the same fashion on the right side to complete the fundoplication . we do not routinely fully expose the retroesophageal crura or divide the short gastric vessels . fifteen of the 20 eligible patients ( 75% ) with dor fundoplication responded , whereas 48 of the 115 patients ( 42% ) with toupet fundoplication participated . the mean age of patients was 57  17 years , with 33 men and 30 women . both treatment groups were similar in age , gender , and number and type of preoperative interventions . median operative time was shorter in the dor group than the toupet group ( 100 [ 92131 ] vs 129.5 [ 115162 ] min , p < .01 ) ( table 1 ) . the median follow - up time was 60 ( 3684 ) months for the toupet group and 19 ( 1422 ) months for the dor group ( p < .001 ) . patient characteristics of dor and toupet groups data are expressed as mean  sd , as numbers , or as median ( interquartile range ) . using gerd - hrql , no difference in the severity of postoperative gerd symptoms was seen between the toupet fundoplication and dor fundoplication groups . there was no difference in patient satisfaction in current postoperative condition between the 2 groups ( 88% toupet vs 93% dor , p = .60 ) . health - related quality of life scale . 0 = no symptoms ; 1 = symptoms noticeable but not bothersome ; 2 = symptoms noticeable and bothersome but not every day ; 3 = symptoms bothersome every day ; 4 = symptoms affect daily activities ; 5 = symptoms are incapacitating , unable to do daily activities . statistically significant ( p < .05 ) . however , 25% of toupet patients and 20% of dor patients reported having symptoms at least once or twice a week . there was no difference between dor and toupet fundoplication with respect to the incidence of postoperative gerd symptoms ( p = .49 ) . assessment of postoperative frequency of gerd symptoms there was no difference between the groups (  = 0.25 ) . gerd , gastroesophageal reflux disease . 0 = none ; 1 = once or twice a month ; 2 = once or twice a week ; 3 = once a day ; 4 = once a day and continuous . eighty percent of patients undergoing surgery for achalasia reported complete resolution of dysphagia symptoms as measured by patient questionnaire . eighty - seven percent of patients undergoing dor fundoplication and 78% of patients undergoing toupet fundoplication had complete resolution of their dysphagia symptoms . there was no difference between the dor and toupet groups ( p = .73 ) . assessment of postoperative dysphagia symptoms there was no difference between the groups (  = 0.73 ) . gerd , gastroesophageal reflux disease . 0 = no symptoms ; 1 = dysphagia once or twice a month to bread or meat ; 2 = dysphagia once or twice a week to thick food ; 3 = dysphagia to thick liquids daily ; 4 = inability to swallow oral secretions . the high incidence of postoperative reflux has led most surgeons to perform an antireflux procedure in addition to the myotomy . although a 360 nissen fundoplication has been shown to be effective , it may be associated with a high incidence of long - term postoperative dysphagia . thus , partial fundoplication has been advocated . in a review by abir et al , dysphagia resolution was achieved in 83% to 90% of patients undergoing lhc with toupet fundoplication and 77% to 91% of patients undergoing lhc with dor fundoplication . furthermore , a recent randomized control trial by rawlings et al demonstrated reduction in symptoms postoperatively in 90.9% in the dor group and 93.1% in the toupet group at 6-month to 12-month follow - up . patients undergoing toupet and dor fundoplications reported 81% and 87% resolution of dysphagia , respectively . there was no significant difference in gerd incidence or severity in patients undergoing toupet or dor fundoplication . the overall incidence of gerd was low , with a majority of patients reporting a score of 0 or 1 on the gerd assessment scale . however , 25% of toupet patients and 20% of dor patients reported having symptoms of gerd at least once a week or more . the overall severity of gerd symptoms was low in both groups , with > 75% of patients scoring 1 for all the questions on the gerd - hrql scale . we did not perform physiologic testing , but rawlings et al found abnormal acid reflux in 21.1% and 41.7% of the toupet and dor groups . although this result was not statistically significant , patients with abnormal ph test results reported significantly greater heartburn frequency and severity . the goal of our study was to investigate outcomes in our lhc patients to assess the difference between the toupet and dor groups . toupet fundoplication has been a popular antireflux procedure in achalasia patients . along with gerd control , proponents of toupet fundoplication believe it keeps the myotomy edges apart , thereby reducing recurrence of achalasia . several prospective studies have evaluated the outcomes between posterior fundoplication and anterior fundoplication . in a study by hagedorn et al , no differences in esophageal symptoms were found , but toupet fundoplication was associated with significantly lower rates of abnormal acid exposure . engstrom et al showed that patients with dor fundoplication had higher incidences of heartburn and regurgitation symptoms requiring a greater use of acid - reducing medications . rawlings et al found comparable degrees of alleviation of symptoms with both procedures and no statistically significant difference in pathologic acid reflux . however , as with nissen fundoplication , toupet fundoplication requires dissection posterior to the gastroesophageal junction , which increases operative time and potentially alters the posterior soft tissue attachments to the esophagus , possibly increasing postoperative gerd and dysphagia . dor partial anterior fundoplication allows preservation of the posterior gastroesophageal junction as well as the potential advantage of protection of the exposed mucosa at the myotomy site . finally , dor fundoplication has been successfully performed using a single - site technique . the longer follow - up for the toupet group compared with the dor group is consistent with our change in procedure of choice . it is known that a certain percentage of patients will have recurrence of symptoms requiring additional treatment . early recurrence is due to stenosis of the myotomy , best treated by repeat myotomy or dilations . late recurrence is considered irreversible progression of the disease with development of mega - esophagus . this type is traditionally treated with esophagectomy , but some groups are advocating repeat myotomy , even in this setting , as a safe treatment . in our analysis , we did not attempt to differentiate between symptoms of early stenosis and late recurrence . it is likely that several of our patients will fit into these categories , and it is a subject of future research . nonetheless , detailed quality - of - life data were available for 63 patients , or 47% of our study population . finally , our results are consistent with those found in previous studies and contribute to the existing body of evidence for dor and toupet fundoplication in conjunction with laparoscopic heller myotomy . patients undergoing dor or toupet fundoplication experienced no significant difference in dysphagia or gerd incidence or severity in the short term . this suggests that both are acceptable antireflux procedures when used as adjuncts to lhc in the treatment of achalasia .
background : laparoscopic heller cardiomyotomy ( lhc ) is standard therapy for achalasia . traditionally , an antireflux procedure has accompanied the myotomy . 
 this study was undertaken to compare quality - of - life outcomes between patients undergoing myotomy with toupet versus dor fundoplication . 
 in addition , we investigated overall patient satisfaction after lhc in the treatment of achalasia.methods:one hundred thirty - five patients who underwent lhc over a 13-year period were identified for inclusion . 
 symptoms queried included dysphagia , heartburn , and bloating using the gastroesophageal reflux disease  health - related quality of life scale and a second published scale for the assessment of gastroesophageal reflux disease and dysphagia symptoms . 
 the patients ' overall satisfaction after surgery was also rated . 
 data were compared on the basis of type of fundoplication . 
 symptom scores were analyzed using chi - square tests and fisher 's exact tests.results:sixty-three patients completed the survey ( 47% ) . 
 there were no perioperative deaths or reoperations . 
 the mean length of stay was 2.8 days . 
 the mean operative time for lhc with toupet fundoplication was 137.3  30.91 minutes and for lhc with dor fundoplication was 111.5  32.44 minutes ( p = .006 ) . 
 there was no difference with respect to the incidence or severity of postoperative heartburn , dysphagia , or bloating . 
 overall satisfaction with toupet fundoplication was 87.5% and with dor fundoplication was 93.8% ( p > .999).conclusions : lhc with either toupet or dor fundoplication gave excellent patient satisfaction . 
 postoperative symptoms of heartburn and dysphagia were equivalent when comparing lhc with either antireflux procedure . 
 dor and toupet fundoplication were found to have equivalent outcomes in the short term . 
 we prefer dor to toupet fundoplication because of its decreased need for extensive dissection and better mucosal protection .