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Analysis of Predictors and Clinical Implications

Otávio L. Gastal, MD; Jeffrey A. Hagen, MD; Jeffrey H. Peters, MD; Guilherme M. R. Campos, MD; Majid Hashemi, MD; Jörg Theisen, MD; Cedric G. Bremner, MD; Tom R. DeMeester, MD

Arch Surg. 1999;134:633-638.

Hypothesis  Preoperative assessment can identify the predictors of esophageal shortening in patients with gastroesophageal reflux disease.

Design and Setting  Patient comparison study in a university-based tertiary care center.

Patients  A total of 236 patients with gastroesophageal reflux disease underwent primary antireflux procedures. Sixty-five patients were suspected of having a short esophagus and underwent a transthoracic approach. In 37 patients, a lengthening procedure was necessary to avoid tension on the repair. The remaining 28 patients were thought—after complete esophageal mobilization—to have sufficient length for a repair without needing a gastroplasty. An abdominal approach (laparoscopic Nissen fundoplication) was performed on 171 patients judged to have normal esophageal length.

Main Outcome Measures  Univariate and multivariate analyses of preoperative variables were performed to identify predictors of a short esophagus.

Results  On univariate analysis, manometric esophageal length below the fifth percentile of normal was associated with esophageal shortening. On multivariate analysis, only the presence of an esophageal stricture predicted the need for a Collis gastroplasty (odds ratio, 7.5). The presence of Barrett's esophagus of 3 cm or greater identified patients in whom the transthoracic esophageal mobilization alone was sufficient (odds ratio, 3.4).

Conclusions  The presence of a stricture was associated with esophageal shortening sufficient to require a gastroplasty. Transthoracic esophageal mobilization alone was usually sufficient to perform a safe repair without tension in patients with a Barrett's esophagus of 3 cm or greater.

From the Departments of Surgery (Drs Gastal, Peters, Campos, Hashemi, Theisen, Bremner, and DeMeester) and Cardiothoracic Surgery (Dr Hagen), University of Southern California School of Medicine, Los Angeles.

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