To the Editor:
We read the article by Smith et al published in a recent issue of Annals of Surgery1 with great enthusiasm, and we do agree with most of their statements. However, regarding their opinion on the connection between GERD and myotomy for achalasia, we would like to make some comments. “We do not consider GERD and its complications a failure of surgical myotomy. Indeed, we consider this a consequence of a successful myotomy...,” Smith et al claim.
Data published in the literature on functional esophageal diseases support the idea that GERD itself can be the causative factor for achalasia. Transient LES relaxations were detected in achalasia, 24-hour pH-metry proved significant length of time under pH 3 in the esophagus, and biochemical examinations on LES muscle specimens from GERD patients revealed muscle hypertrophy.2–4 Coexistence of achalasia and Barrett esophagus with adenocarcinoma has been described.5 The frequency of reflux-induced achalasia among all achalasia patients is considered to be around 6% to 11%.6 These values equal the frequency of reflux detected as a complication after Heller's myotomy or after dilation treatment of achalasia. One can assume that those patients who developed achalasia as a consequence of longstanding reflux disease will be susceptible to develop postoperative or postdilatation reflux. Development of achalasia in these patients can be considered as a protective reaction of the esophagus against reflux. We have reported on 2 cases like this recently.7
So, reflux after Heller's myotomy does not happen as a random fate, but it can be predicted. There are 3 factors that predict reflux as a likely complication after myotomy. First, if there is longstanding reflux in the history before a patient developed dysphagia, and reflux symptoms diminish after dysphagia developed. Another suspicious factor is a hiatal hernia accompanying achalasia. And third is an abnormal pH-metry, showing acid reflux. Twenty-four-hour pH-metry may be performed in all cases, but in the above cases it can prove especially useful. The setpoint for abnormal pH should be changed to pH 3 instead of pH 4 during 24-hour pH-metry for achalasia patients, so as to exclude artifacts from acidic fermentation in the esophageal lumen.
If preoperative examinations produce a strong suspicion of achalasia, which developed on the basis of reflux disease, dilatation treatment should be avoided and Heller's myotomy should be considered to be followed by a proper 360° fundoplication, as anterior hemifundoplication does not protect fully against reflux. In a recent study, it was demonstrated that a total fundoplication is not an obstacle to esophageal emptying after Heller's myotomy.8
Örs Péter Horváth, DSc
Katalin Kalmár, MD
Gábor Varga, MD
University of Pécs
Pécs, Hungary
Peter.O.Horvath@aok.pte.hu
REFERENCES
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