Extended transmediastinal dissection: an alternative to gastroplasty for XXXX .

@entity1 @entity851 @entity357 @entity354
HYPOTHESIS: The significance of @entity851 and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although @entity1 with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of @entity1 undergoing fundoplication, we hypothesize that @entity1 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 @entity1 . DESIGN AND SETTING: Retrospective comparative analysis in an academic and private practice-based tertiary referral center. @entity1 : A total of 205 @entity1 underwent laparoscopic Nissen fundoplication for @entity354 or @entity357 over 4 years. Outcomes in @entity1 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 @entity1 underwent type I dissection, and 72 (35%) of the 205 @entity1 underwent type II dissection. Failure occurred in 15 (11%) of 133 @entity1 and 6 (10%) of 72 @entity1 , 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 @entity1 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 @entity1 with esophageal shortening and provide a success rate similar to that of @entity1 with normal esophageal length. More liberal application of Collis gastroplasty in these @entity1 is not warranted.
