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The Split-Stomach Fundoplication After Esophagogastrectomy
Vic Velanovich, Henry Ford Hospital, Detroit, MI

Background:
One of the most devastating complications after esophagogastrectomy is anastomotic leak. A variety of anastomotic modifications have been proposed to decrease the occurrence of this complication. In addition, patients with intrathoracic esophagogastrostomies have a high incidence of reflux-related symptoms, leading to significant quality of life issues. The split-stomach fundoplication was designed to address these needs.

Description of the Operation:
After completion of the esophagogastrectomy, the stapled cut end of the stomach is oversewn with interrupted silk suture. Using a linear stapler, the fundus of the stomach is divided in the long axis of the organ for approximately 5 cm to produce two "wings". A gastrotomy is made 2 cm caudad to the apex of this split, and a esophagogastrostomy performed with interrupted silk suture. The "wings" of the split stomach are brought around the anastomosis and sutured together to form a wrap. This wrap is secured to the esophagus superior to and to the stomach inferior to the anastomosis.

Methods:
All patients undergoing the split-stomach fundoplication were compared to all patients undergoing standard Ivor-Lewis, transabdominal, and transhiatal esophagogastrectomies. The incidence of in-hospital mortality, anastomotic leak, postoperative reflux-like symptoms, and postoperative stricture requiring endoscopic dilation were recorded. Statistical analysis was done using Fisher's exact test.

Results:
19 patients underwent the split-stomach fundoplication (WRAP group), compared to 53 patients undergoing standard resection (NO WRAP group). 84% of WRAP patients were male with an average age (+/- SD) of 65+/-9 yrs., compared to 77% of NO WRAP patients, average age 63+/-12 yrs. In-hospital mortality 5.2% in WRAP group vs. 7.5% in NO WRAP group (p=NS). Anastomotic leak: 0% in WRAP group vs. 17% in NO WRAP group (p=0.05). Reflux-like symptoms: 21% in WRAP group vs. 62% in NO WRAP group (p=0.002). Stricture occurrence: 47% in WRAP group vs. 28% in NO WRAP group (p=0.05).

Conclusions:
The addition of the split-stomach fundoplication to esophagogastrectomy does decrease the incidence of anastomotic leak and postoperative reflux-like symptoms. However, the price for this is a higher incidence of anastomotic strictures requiring dilation. As all of these strictures were successfully treated with endoscopic dilation, this appears to be a reasonable trade-off.


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