Is the endoscopic Dor fundoplication definitely effective?

We read with great interest the article by Inoue et al. [1] titled “Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure.” The authors concluded that peroral endoscopic myotomy with the addition of endoscopic fundoplication (POEM + F) may help to mitigate the post-POEM incidence of gastroesophageal reflux and could serve as a minimally invasive endoscopic alternative to a laparoscopic Heller-Dor procedure. However, we have several concerns about these conclusions.

The Dor fundoplication is usually performed via laparotomy or laparoscopy. The novel endoscopic method described by Inoue et al. applied a single suture to anchor the gastric wall to the esophagogastric junction, an approach that is significantly different from the conventional Dor fundoplication which requires 3 – 5 interrupted stitches at each side via laparoscopy [2]. The single suture would be expected to result in postoperative slipped wrap, but 95.2 % (20/21) of the patients reported by Inoue et al. appeared to maintain the wrap across the esophagogastric junction on follow-up at 2 months postoperatively. However, this follow-up period was too short. In a review of articles on the outcome of combining a fundoplication with a laparoscopic myotomy, the median postoperative follow-up time in order to obtain reliable evaluation on postoperative outcome was approximately 3 years [3].

Meanwhile, postoperative assessments of symptom relief (dysphagia, reflux) were not mentioned clearly in the Inoue et al. article. Furthermore, Duranceau emphasized the role of objective evaluation on the outcome following antireflux surgery, including esophageal manometry and 24-hour ambulatory pH monitoring [4]. No objective evaluation was reported in the Inoue et al. article.

At this stage, it is perhaps too early and cursory to conclude the safety and efficacy of the endoscopic Dor fundoplication, which needs further long-term observation and research.

• References

• 1 Inoue H, Ueno A, Shimamura Y. et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019; 51: 161-164
• 2 Rebecchi F, Giaccone C, Farinella E. et al. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg 2008; 248: 1023-1030
• 3 Litle VR. Laparoscopic Heller myotomy for achalasia: a review of the controversies. Ann Thorac Surg 2008; 85: S743-746
• 4 Duranceau A. Massive hiatal hernia: a review. Dis Esophagus 2016; 29: 350-366