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Does previous fundoplication alter the surgical approach to esophageal adenocarcinoma?

^a Department of Surgery, Royal University Hospital and the College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada
^b Department of Community Health and Epidemiology, Royal University Hospital and the College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada

Received 25 May 2008; received in revised form 22 July 2008; accepted 25 July 2008.

^_* Corresponding author. Tel.: +1 306 966 8641; fax: +1 306 966 8026. (Email: alan.casson{at}usask.ca).

Objective: The primary aim of this study was to test the widespread assumption that the viability of the gastric fundus is compromised by fundoplication, thereby limiting the use of stomach to reconstruct the upper gastrointestinal tract after esophageal resection. Methods: Between February 1991 and February 2006, a consecutive series of 142 patients with esophageal adenocarcinoma (EADC) underwent esophageal resection. To reconstruct the upper gastrointestinal tract, all patients had a narrow gastric tube (greater curvature of stomach based on the right gastroepiploic artery) transposed through the posterior mediastinum to the left neck where an anastomosis to the cervical esophagus was performed. From a prospective database, 15 patients were identified to have undergone an ‘open’ fundoplication (transabdominal Nissen, n = 11; transthoracic Belsey, n = 4) from 12 to 23 years earlier. Outcomes were compared between patients with EADC who had undergone previous fundoplication, and patients with EADC who never had antireflux surgery. Results: Gastric transposition and cervical esophagogastrostomy were technically feasible in all patients. No significant differences in outcome were found between patient groups. Gastric necrosis developed in only one patient, who had not undergone previous fundoplication. Anastomotic leak rates after esophageal resection and reconstruction were not statistically different based on whether patients had undergone previous fundoplication (2/15, 13.3%) or not (16/127, 12.6%; p = 0.99). Conclusions: With careful attention to surgical technique, previous fundoplication does not preclude the use of stomach to reconstruct the foregut after esophageal resection, refuting the notion that previous antireflux surgery is a relative contraindication to, or alters the approach to esophageal cancer surgery.

Key Words: Esophagus • Adenocarcinoma • Fundoplication