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General Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98111
(Email: gtsdel{at}vmmc.org).
The article by Houghton and colleagues [1] addresses an important question of whether using laparoscopic or open gastroplasty in patients with short esophagus has long-term symptoms and quality-of-life ramifications. This is a follow-up of the Mayo Clinic's initial presentation on the results of gastroplasty procedures, but is a much more comprehensive attempt to compare outcomes with patients undergoing standard antireflux procedures. Although a randomized trial or at least a prospective assessment of outcomes would have been optimal, the authors have gone to great lengths to produce two matched populations which have the major differences of an expected difference in hernia size in the gastroplasty group and the potentially more important difference of longer follow-up in their control group.
The authors should be congratulated that their mortality and major morbidity rate in both groups are at very favorable levels compared with the literature. It is interesting to note that in spite of the recognition that gastroplasty procedures typically take longer than standard repairs, and that the gastroplasty group had a higher percentage of large hiatal hernias and previous operations, the operative times between the two study groups were virtually identical. This would indicate either that the control group undergoing standard procedures had a degree of complexity that was not made clear in the article, or that the level of experience or criteria for doing gastroplasties may have varied between surgeons.
The authors report that objective follow-up involves imaging done 1 to 2 months after the procedure. Their anatomic recurrence rates are modest, even at this early stage postoperatively. All the recurrences in the control group required reoperation. Reoperations in gastroplasty patients can be extremely challenging. Although three anatomic recurrences occurred in the gastroplasty patients, there is no indication they required revisional surgery.
Surgeons have previously had to decide whether to respond to the intraoperative impression of short esophagus with a standard operation or a procedure such as gastroplasty for which there existed concerns regarding perioperative complications and postoperative symptoms secondary to an acid-secreting nonmotile neoesophagus. This article provides reassurance that in experienced hands, gastroplasty can be routinely applied in appropriate patients with the expectation of comparable perioperative results, symptom control, and short-term quality of life. The decision for adding a gastroplasty procedure should recognize that the designation of short esophagus should be made only after extensive mediastinal esophageal mobilization. This mobilization, which can be accomplished in both open and laparoscopic formats, can typically be done as high as the carina, especially in patients with large hiatal hernias. Once completed, it will commonly facilitate a tension-free standard repair with the expectation of low recurrence rates and good long-term results. Other options, such as an anchored intra-abdominal repair, specifically the Hill anti-reflux operation, should also be considered.
The results presented by Houghton and colleagues [1] provide preliminary reaffirmation that gastroplasty should remain an important component of the esophageal surgeon's armamentarium in dealing with complex benign esophageal surgery. However, this article should not be used as a resource to lower the threshold for the use of these procedures as the incidence of problems and complications with gastroplasty procedures has the potential for being much higher in less experienced hands.
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