Intrathoracic periesophageal fundoplication for short esophagus: a 20-year experience.

BACKGROUND

Intrathoracic periesophageal fundoplication carries a high risk of treacherous technical complications such as spontaneous gastric perforation.

METHODS

An intrathoracic fundoplication was performed on 84 patients suffering from gastroesophageal reflux disease with the junction between upper gastric folds and the unwrinkled esophageal mucosa remaining above the diaphragm while the esophageal body was quite straight on barium swallow study. Particular attention was paid to the following steps: further enlargement of the hiatal sling to avoid any strangulation of the stomach, very careful manipulation of gastric tissues with the fingers rather than with forceps, and meticulous anchoring of the wrap to the hiatus with numerous sutures while mimicking diaphragmatic movements that arise on cough. Results were assessed by personal interview (n = 84; median follow-up, 51.5 months), barium swallow study (n = 84), 24-hour esophageal pH monitoring (n = 65), and esophageal stationary manometry (n = 56).

RESULTS

No patient had any symptoms of reflux; 5 (5.9%) had episodes of dysphagia, which were frequent in 2; and 31 (37%) had some degree of flatulence, which interfered with social life in 5. The mean percentage of total time that esophageal pH was below 4 at esophageal pH monitoring dropped significantly (p < 0.001) from 12.3% before fundoplication to 0.5% after. Lower esophageal sphincter resting pressure increased significantly (p < 0.0001) from 6.9 mm Hg to 20.6 mm Hg. Nine patients (10.7%) were reoperated on for spontaneous (n = 1) or anti-inflammatory drug-induced (n = 1) gastric perforation, further herniation of the stomach (n = 3), herniation of the colon (n = 3), or both (n = 1), into the chest.

CONCLUSIONS

Intrathoracic periesophageal fundoplication for short esophagus is amazingly effective for treating reflux. Strict observance of some critical technical details makes spontaneous gastric perforation very unlikely. Any sudden increase in abdominal pressure at early follow-up is to be avoided, and anti-inflammatory drugs are strictly forbidden.