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Original Article
July 2003

Extended Transmediastinal Dissection: An Alternative to Gastroplasty for Short Esophagus

Author Affiliations

From the Department of Minimally Invasive Surgery, Legacy Health System, Portland, Ore (Drs O'Rourke, Khajanchee, Hansen, and Swanstrom and Ms Lockhart); Departments of Surgery and Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario (Dr Urbach); and Oregon Health Sciences University Medical School, Portland (Ms Lee).

Arch Surg. 2003;138(7):735-740. doi:10.1001/archsurg.138.7.735
Abstract

Hypothesis  The significance of short esophagus and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although patients with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of patients undergoing fundoplication, we hypothesize that patients with moderate esophageal shortening requiring extended mediastinal dissection make up a larger subgroup and that extended laparoscopic mediastinal dissection is a good treatment strategy for such patients.

Design and Setting  Retrospective comparative analysis in an acadmic and private practice–based tertiary referral center.

Patients  A total of 205 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernias over 4 years. Outcomes in patients requiring either a type I (<5 cm) or type II (>5 cm) mediastinal dissection were compared.

Interventions  Laparoscopic Nissen fundoplication with or without extended mediastinal dissection and esophageal physiology testing.

Main Outcome Measures  Symptom assessments, operative reports, and outcomes were prospectively recorded on standardized data sheets. Postoperative symptom assessment and esophageal physiology testing were performed.

Results  A total of 133 (65%) of the 205 patients underwent type I dissection, and 72 (35%) of the 205 patients underwent type II dissection. Failure occurred in 15 (11%) of 133 patients and 6 (10%) of 72 patients, respectively. The presence of a large hiatal or paraesophageal hernia predicted the need for type II dissection.

Conclusions  No difference was seen in failure rates between patients who required a type II dissection and those who did not. This finding suggests that aggressive application of laparoscopic transmediastinal dissection to obtain adequate esophageal length may reduce fundoplication failure in patients with esophageal shortening and provide a success rate similar to that of patients with normal esophageal length. More liberal application of Collis gastroplasty in these patients is not warranted.

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