Anti-reflux operations recreate a high pressure area at the junction of the esophagus and stomach. This high pressure prevents the reflux of food and fluid from the stomach into the esophagus. Performed successfully since the 1950s, anti-reflux operations wrap the highest part of the stomach, the fundus, around the esophagus to create a partial or complete ring. This procedure is called a fundoplication. Two basic types of fundoplications are commonly performed today: the full, 360° wrap, or Nissen fundoplication; and the partial, 270° wrap, or Toupet fundoplication. A partial fundoplication is usually chosen following an esophageal myotomy.
Why is an anti-reflux operation needed in addition to a myotomy?
Many patients develop reflux or gastroesophageal reflux disease following a successful myotomy or dilatation. Gastroesophageal reflux disease results from a poorly functioning or wide-open lower esophageal sphincter. This allows fluid and food to reflux (or regurgitate) from the stomach into the esophagus.
Some patients, however, may experience difficulty swallowing after an anti-reflux operation. One would not want to get rid of difficulty swallowing as a result of achalasia, only to develop difficulty swallowing as a result of the anti-reflux operation. On the other hand, gastroesophageal reflux disease can become very symptomatic in some patients following a myotomy and can lead to difficulty swallowing.
Although gastroesophageal reflux disease can be treated with medications, these are expensive and may not always work. In the past, an anti-reflux operation was always added to myotomies in Europe and South America but rarely added in the United States. Today, the pendulum has swung; in the United States, most surgeons add an anti-reflux operation. The reason is that the addition of a partial fundoplication to an esophageal myotomy rarely produces difficulty swallowing and yet is very effective at preventing reflux.
However, each patient is an individual. For example, a short myotomy often does not produce reflux. Older patients are often treated with myotomy alone because the contraction of their esophagus is poorer and reflux is usually adequately treated with medications.