Preoperative determinants of an esophageal lengthening procedure in laparoscopic antireflux surgery.
BACKGROUND
In a minority of patients undergoing antireflux surgery, an esophageal lengthening procedure is required to reduce the gastroesophageal junction (GEJ) below the esophageal hiatus. We evaluated risk factors associated with an irreducible GEJ to identify clinical features that were predictive of the need for a Collis gastroplasty in patients undergoing laparoscopic antireflux surgery.


METHODS
Patients who required a Collis gastroplasty during a laparoscopic antireflux procedure (defined as the inability to reduce the GEJ > 2.5 cm below the esophageal hiatus despite extensive mobilization of the mediastinal esophagus) were compared to a random sample of patients who did not have a Collis gastroplasty. Predictors of the need for an esophageal lengthening procedure were identified using logistic regression modeling. Risks were expressed as odds ratios (OR) and 95% confidence intervals (CI).


RESULTS
Twenty patients who had a Collis gastroplasty were compared to 133 patients who had adequate esophageal length. The presence of a stricture (OR 3.0; 95% CI 1.0, 9.7), paraesophageal hernia (OR 3.5; 95% CI 1.3, 9.6), Barrett's esophagus (OR 3.7, 95% CI 1.3, 10.7), and re-do antireflux surgery (OR 6.4; 95% CI 2.0, 20.7) were associated with the need for gastroplasty. Patients with none of these factors were extremely unlikely to require a gastroplasty (OR 0.08; 95% CI 0.02, 0.34).


CONCLUSIONS
Patients undergoing laparoscopic antireflux surgery who are at high risk of needing an esophageal lengthening procedure can be easily identified preoperatively using simple clinical characteristics.
Urbach
D R
DR
Department of Health Policy, Management and Evaluation, University of Toronto, Room 8-332, 399 Bathurst Street, Toronto, Ontario M5T 258, Canada. david.urbach@uhn.on.ca
Khajanchee
Y S
YS
Glasgow
R E
RE
Hansen
P D
PD
Swanstrom
L L
LL
D000367:Age Factors; D000368:Aged; D001471:Barrett Esophagus / Q000209:etiology; D004940:Esophageal Stenosis / Q000209:etiology; D004943:Esophagogastric Junction / Q000601:surgery; D004945:Esophagoscopy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D005764:Gastroesophageal Reflux / Q000601:surgery*; D015391:Gastroplasty / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D006551:Hernia, Hiatal / Q000209:etiology; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology; D011300:Preoperative Care; D012307:Risk Factors