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Laparoscopic collis gastroplasty is the treatment of choice for the shortened esophagus
1LETTERS I
LAPAROSCOPIC COLLIS GASTROPLASTY IS THE TREATMENT OF CHOICE FOR THE SHORTENED ESOPHAGUS To the Editor: I was gratified upon opening my most recent copy of The American Journal of Surgery and turning to the table of contents to see that the authors of this article had solved the problem of shortened esophagus that has vexed so many esophageal surgeons and generated so much controversy in the past.’ The technique described by Swanstrom and colleagues is indeed interesting and may eventually be a significant advance in the care of these patients; however, I was surprised and disappointed upon reading the article to discover that such a definitive title was based upon an experience of only three patients with the technique recommended. I have some comments and a few questions. The ten patients described as having a Type I shortened esophagus in which the esophagus is “accordioned” are clearly not patients with shortened esophagus and few published authors on this subject would suggest anything more than a transabdominal fundoplication in these cases. It is difficult in the discussion to decipher which group had the complications in the postoperative period. It is only stated that no complications occurred in any of the three Collis patients. One cannot tell whether the complications were complications of the fundic mobilization, the gastropexy, or the hiatal closure. The authors describe quite a degree of variation in their Nissen repairs. Some wraps were sutured to the hiatus, some had “posterior” sutures, some did not. Which category dissections were these done in and did they correlate with complications? Some patients had what is described as a “Toupet” procedure; however, no sutures to the hiatus are described. Were these repairs a classic “Toupet” procedure or were they modified? No segregation of these repairs from the Nissen repairs is made in the results. Recurrent hiatal hernias were found in six patients, all type III or IV dissections. I can not find any reference to a type IV dissection in the manu-
script. Table I only refers to three types of dissections. In making their recommendation that this procedure replace others as the procedure of choice, the authors ignore Hanley’s Rule of Three for estimating the upper limit of the 95% confidence level when a hazardous event has not yet occurred.’ This simple rule states that when a hazardous event has not yet occurred the upper limit of the 95% confidence interval is 3/n, where n is the number of patients studied. Thus, the authors can state with 95% confidence that their incidence of mortality, esophageal leak, recurrent hiatus hernia, recurrent reflux and dysphagia is less than 100% if they consider the 3 patients reported, or less than 37.5% ifone also includes the additional five patients noted in the Comments. Surgeons who care for these patients have analyzed the conflicting experiences of authors who have reported their results with hundreds of patients and come to their own conclusions about how these difficult patients should best be managed. It is perhaps stretching a point to now suggest that these surgeons abandon their current methods on the basis of the authors experiences with eight patients. My purpose in writing is not to denigrate the authors contribution. This is a resourceful way of attacking a dif* ficult problem that maintains the advantages of a laparoscopic approach. It merits serious study and I congratulate the authors on their ingenuity. James W. Muher University of Iowa Hos@& and Clinics Iowa City, Iowa 1. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg. 1996;171:477-486. 2. Eypasch E, Lefering R, Kum CK, Troidl H. Probability of adverse events that have not yet occurred: a statistical reminder. Br Med J. 1995;311:619620.
The Reply: My thanks to Dr. Maher for his insightful comments regarding our report on the incidence and treatment of shortened esophagus in a laparostopic era. Dr. Maher raises many interesting questions, not the least of which is the fact that this early report
TO 7.HE\
is based on only a few patients. We considered the appropriate treatment of patients with shortened esophagus a pressing issue because of the increasing popularity and numbers of laparoscopic fundoplications being done. Many prominent investigators publishing large series of funcloplications minimize the importance of shortened esophagus, possibly because there are few viable minimally invasive treatments to deal with this finding. Obviously patients have not appreciably changed in the last six years and there has to be an incidence of truly shortened esophagi. These patients will, by necessity, need to be treated appropriately or poor outcomes will result. We felt that we had a good minimally invasive treatment corresponding well to the established open procedure and, therefore, we expedited presentation of our experience when the numbers were few. To respond to specific questions regarding our study: the ma:lority of our preoperative diagnoses were based on a standard definition ol’ shortened esophagus as a lower esophageal sphincter (LES) identified 5 cm or greater above the esophageal hiatus. During surgery, ten of these patients were found to have a normal length esophagus which was artificially shortened by displacement of the stomach. I agree with Dr. Maher that by strict definition these are not truly shortened esophagi, but operative decisions must be based on preoperative studies and the surgeon needs to be prepared when such studies show the possibility of an actual shortened esophagus. Regarding postoperativ’e complications in this group: these were either early postoperative problems (dysphagia, perforation, or gastroparesis) or late problems with reflux or re-herniation. The rate of postoperative complications in this very complex group of patients was much higher than in our overall series of fun.doplications (32% vs 8%). This is probably because of the extensive dissection needed and the difficulty in achieving a tension free repair. Failure to achieve a tensionless repair leads to all of the potential complications mentioned by Dr. Maher (wrap disruption, dysphagia, perforations). We have been impressed that the laparoscopic Collis hasn’t added to the complication rate and, in our current series of
THE AMERICAN JOURNAL OF SURGERY@’ VOLUME 172 NOVEMBER 1996
609
LAPAROSCOPIC COLLIS GASTROPLASTY IS THE TREATMENT OF CHOICE FOR THE SHORTENED ESOPHAGUS To the Editor: I was gratified upon opening my most recent copy of The American Journal of Surgery and turning to the table of contents to see that the authors of this article had solved the problem of shortened esophagus that has vexed so many esophageal surgeons and generated so much controversy in the past.’ The technique described by Swanstrom and colleagues is indeed interesting and may eventually be a significant advance in the care of these patients; however, I was surprised and disappointed upon reading the article to discover that such a definitive title was based upon an experience of only three patients with the technique recommended. I have some comments and a few questions. The ten patients described as having a Type I shortened esophagus in which the esophagus is “accordioned” are clearly not patients with shortened esophagus and few published authors on this subject would suggest anything more than a transabdominal fundoplication in these cases. It is difficult in the discussion to decipher which group had the complications in the postoperative period. It is only stated that no complications occurred in any of the three Collis patients. One cannot tell whether the complications were complications of the fundic mobilization, the gastropexy, or the hiatal closure. The authors describe quite a degree of variation in their Nissen repairs. Some wraps were sutured to the hiatus, some had “posterior” sutures, some did not. Which category dissections were these done in and did they correlate with complications? Some patients had what is described as a “Toupet” procedure; however, no sutures to the hiatus are described. Were these repairs a classic “Toupet” procedure or were they modified? No segregation of these repairs from the Nissen repairs is made in the results. Recurrent hiatal hernias were found in six patients, all type III or IV dissections. I can not find any reference to a type IV dissection in the manu-
script. Table I only refers to three types of dissections. In making their recommendation that this procedure replace others as the procedure of choice, the authors ignore Hanley’s Rule of Three for estimating the upper limit of the 95% confidence level when a hazardous event has not yet occurred.’ This simple rule states that when a hazardous event has not yet occurred the upper limit of the 95% confidence interval is 3/n, where n is the number of patients studied. Thus, the authors can state with 95% confidence that their incidence of mortality, esophageal leak, recurrent hiatus hernia, recurrent reflux and dysphagia is less than 100% if they consider the 3 patients reported, or less than 37.5% ifone also includes the additional five patients noted in the Comments. Surgeons who care for these patients have analyzed the conflicting experiences of authors who have reported their results with hundreds of patients and come to their own conclusions about how these difficult patients should best be managed. It is perhaps stretching a point to now suggest that these surgeons abandon their current methods on the basis of the authors experiences with eight patients. My purpose in writing is not to denigrate the authors contribution. This is a resourceful way of attacking a dif* ficult problem that maintains the advantages of a laparoscopic approach. It merits serious study and I congratulate the authors on their ingenuity. James W. Muher University of Iowa Hos@& and Clinics Iowa City, Iowa 1. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg. 1996;171:477-486. 2. Eypasch E, Lefering R, Kum CK, Troidl H. Probability of adverse events that have not yet occurred: a statistical reminder. Br Med J. 1995;311:619620.
The Reply: My thanks to Dr. Maher for his insightful comments regarding our report on the incidence and treatment of shortened esophagus in a laparostopic era. Dr. Maher raises many interesting questions, not the least of which is the fact that this early report
TO 7.HE\
is based on only a few patients. We considered the appropriate treatment of patients with shortened esophagus a pressing issue because of the increasing popularity and numbers of laparoscopic fundoplications being done. Many prominent investigators publishing large series of funcloplications minimize the importance of shortened esophagus, possibly because there are few viable minimally invasive treatments to deal with this finding. Obviously patients have not appreciably changed in the last six years and there has to be an incidence of truly shortened esophagi. These patients will, by necessity, need to be treated appropriately or poor outcomes will result. We felt that we had a good minimally invasive treatment corresponding well to the established open procedure and, therefore, we expedited presentation of our experience when the numbers were few. To respond to specific questions regarding our study: the ma:lority of our preoperative diagnoses were based on a standard definition ol’ shortened esophagus as a lower esophageal sphincter (LES) identified 5 cm or greater above the esophageal hiatus. During surgery, ten of these patients were found to have a normal length esophagus which was artificially shortened by displacement of the stomach. I agree with Dr. Maher that by strict definition these are not truly shortened esophagi, but operative decisions must be based on preoperative studies and the surgeon needs to be prepared when such studies show the possibility of an actual shortened esophagus. Regarding postoperativ’e complications in this group: these were either early postoperative problems (dysphagia, perforation, or gastroparesis) or late problems with reflux or re-herniation. The rate of postoperative complications in this very complex group of patients was much higher than in our overall series of fun.doplications (32% vs 8%). This is probably because of the extensive dissection needed and the difficulty in achieving a tension free repair. Failure to achieve a tensionless repair leads to all of the potential complications mentioned by Dr. Maher (wrap disruption, dysphagia, perforations). We have been impressed that the laparoscopic Collis hasn’t added to the complication rate and, in our current series of
THE AMERICAN JOURNAL OF SURGERY@’ VOLUME 172 NOVEMBER 1996
609