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Revista do Colégio Brasileiro de Cirurgiões

Print version ISSN 0100-6991On-line version ISSN 1809-4546

Rev. Col. Bras. Cir. vol.42 no.3 Rio de Janeiro May/June 2015

http://dx.doi.org/10.1590/0100-69912015003005 

Original Articles

Predictive factors for short gastric vessels division during laparoscopic total fundoplication

Alexandre Chartuni Pereira Teixeira 1  

Fernando Augusto Mardiros Herbella 1  

Adorísio Bonadiman 2  

José Francisco de Mattos Farah 2  

José Carlos Del Grande 1  

1Departamento de Cirurgia, Escola Paulista de Medicina, Universidade Federal de São Paulo - SP - Brazil

2Departamento de Cirurgia Geral e Oncológica, Hospital do Servidor Público Estadual de São Paulo - SP - Brazil

ABSTRACT

OBJECTIVE:

to determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels.

METHODS:

we analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B).

RESULTS:

the section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B.

CONCLUSION:

the division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.

Key words: Fundoplication; Video-Assisted Surgery; Gastroesophageal Reflux; Gastric Fundus

INTRODUCTION

Laparoscopic total fundoplication is an effective procedure for the treatment of gastroesophageal reflux disease (GERD)1. However, some technical points are still controversial, especially the need for short gastric vessels (SGV) division2. While most authors believe this step brings better results3 - 5, others showed similar outcomes whether SGV are divided or not or even complications attributed to SGV division2 , 6 - 9.

This study aims to determine: (a) clinical variables that may predict the need of SGV division based on gastric fundus tension and (b) the outcomes in patients with or without SGV division.

METHODS

We retrospectively studied 399 consecutive patients (50% male, mean age 49 years) recorded in a prospectively kept database that underwent laparoscopic total fundoplication for the surgical treatment of GERD. This study was approved by the local institutional review board. (CEP 0742/11).

Patients were questioned before the operation regarding the presence of symptoms. These were grouped into esophageal symptoms (heartburn and regurgitation), extra-esophageal symptoms (thoracic pain, respiratory symptoms, such as cough and asthma or ear, nose and throat symptoms) or dysphagia. Anthropometric variables were also recorded. Individuals with partial fundoplication, paraesophageal hernia, previous foregut operation or conversion to conventional laparotomy were excluded from the analysis.

All patients were submitted to an upper endoscopy to evaluate the presence of hiatal hernia (HH), esophagitis and Barrett´s esophagus. HH was classified according to size in <4cm or >4cm. Modified Savary-Miller endoscopic classification10 was used for grading esophagitis. Barrett esophagus was defined by the presence of intestinal metaplasia and classified as short-segment (<3cm) or long-segment (>3cm). Esophageal manometry was available to review in 283 (71%) patients. Ambulatory 24-hour esophageal pHmonitoring was only performed in patients without esophagitis or with atypical symptoms. pHmonitoring results were available for review in 62 (15%).

Surgical technique has been previously described2. In summary, an extensive mobilization of the posterior wall of the gastric fundus followed the dissection of the distal esophagus and diaphragmatic crus in all patients. SGV division was done at the discretion of the surgeon based on tension of the gastric fundus after performing a specific maneuver ("drop-test" - Figure 1). A short-floppy total fundoplication was performed without the aid of a bougie. All procedures were performed by or under the supervision of a single experienced surgeon. Patients were grouped according to the necessity for SGV division (Group A - no division; Group B - SGV division).

Figure 1 - Gastric fundus in place without the need of traction - drop-test- (Arrows). 

Follow-up visits were scheduled for 15, 30, 90, 180 and 360 days after the surgery and then annually, irrespective of the presence of symptoms. Upper endoscopy was performed annually or earlier if the patient had any complaints related to the postoperative period. All selected patients had at least a 6-month postoperative follow-up period.

Chi-square, Student's t test and logistic regression were used when necessary. A value of p was considered significant at the 0.05 level. Variables are expressed as mean ± standard deviation.

RESULTS

SGV division was deemed not necessary in 364 (91%) patients (Group A) but required in 35 (9%) patients (Group B). Demographic data, symptoms distribution, endoscopic and manometric data are depicted in table 1. Group B had more males and a higher height. Endoscopic parameters were worse for group B, with larger hiatal hernias, higher proportion of hiatal hernias >4cm, more severe esophagitis (Grade IV-V), higher proportion of Barrett esophagus, and higher rate of long-segment Barrett esophagus. Manometric parameters also disfavored group B with decreased lower esophageal sphincter basal pressure. Only male gender and grade IV-V esophagitis stood as independent predictive factors for the need of SGV division at the multivariate analysis (Table 2).

Table 1 - Demographic data, symptoms distribution, endoscopic and manometric data. 

Variable No SGVD(n = 364) SGVD(n = 35) P Value
Male 47.3% 80% <0 . 001 X 2
Male-female ratio 0.89:1 4:1
Mean age (sd). years 49.77 ± 13.05 51.15 ± 13.46 0.564t-S
Mean weight (sd). Kg 74.56 ± 12.85 79.76 ± 16.86 0.084t-S
Mean height (sd). m 1.67 ± 0.10 1.72 ± 0.08 <0 . 001 t - S
Mean BMI (sd). Kg/m2 26.9 ± 4.39 26.86 ± 5.02 0.969t-S
% Typical symptoms 96.7% 100% 0.275X2
% Atypical symptoms 29.7% 14.3% 0.054X2
% Dysphagia 2.7% 8.6% 0.064X2
Mean duration of symptoms (sd). months 66 ±51.17 65 ±41.63 0.921t-S
% Hiatal Hernia 79.4% 71.4% 0.137X2
Mean hiatal hernia length (range). cm 3 ± 2-9 3 ± 2-10 0 . 004 t - S
% 2-4 cm 68.7% 48.6% 0 . 016 X 2
% > 4 cm 10.7% 22.9% 0 . 033