Collis Gastroplasty Research Articles

Retrospective cost analysis of robotic and laparoscopic anti-reflux surgery and paraesophageal hernia repair.

Increased adoption of robotics in foregut surgery evokes questions regarding efficacy, safety, and cost. To many, cost remains a barrier to adoption of a robotic approach. The authors' aim to determine the difference in cost of a robotic (R-) vs laparoscopic (L-) approach for paraesophageal hernia repair (PEHR). Patients 18years and older who underwent PEHR between July 2016 and June 2021 at a university health network were included. Variables of interest included 30 day outcomes, 1 year recurrence rates, and several cost variables including hospital length of stay, operating room (OR) time, chargeable supplies and implants, non-chargeable supplies, and indirect cost. Cost data were stratified by type and the presence of fundoplication, as well as the elective versus urgent nature of the procedures. Statistical analysis consisted of parametric and non-parametric analyses, with p < 0.05 denoting statistical significance. 405 patients were included in the study (n = 188 for R-, n = 217 for L-). Significant differences were observed in the type of anti-reflux procedure performed (p < 0.001), use of mesh (R- 70.2% vs. L- 59.0%, p = 0.019), and whether a Collis gastroplasty was performed (R- 4.3% vs. L- 10.2%, p = 0.023). No differences in 30-day readmission or reoperation rates, Clavien-Dindo complication rates, or 1-year hernia recurrence rates were observed. For elective cases, regardless of the type of anti-reflux procedure performed, a robotic approach was associated with a significantly greater cost (p < 0.002). Comparing all procedures, a statistically significant increase in cost was seen with a robotic approach (R- $29,706.88 vs. L- $23,457.07, p < 0.001). Complication rates and surgical outcomes between the two approaches were similar; however, cost is significantly increased when a robotic approach is utilized. Future studies are needed to delineate which drivers of cost are modifiable with the robot.

Five-Year Outcomes from a Prospective Study on Safety and Efficacy of Phasix ST Mesh Use at the Hiatus During Paraesophageal Hernia Repair.

Laparoscopic paraesophageal hernia (PEH) repair has a high hernia recurrence rate. The aim of this study was to assess the 5-year hernia recurrence rate after PEH repair using a combination of bioresorbable mesh and advanced surgical techniques to address tension as needed in a prospective group of patients. In 2016, a prospective database was established for 50 patients undergoing primary, elective PEH repair with a new bioresorbable mesh (Phasix ST). Intraoperatively, tension was addressed with Collis gastroplasty and diaphragm relaxing incisions as needed. All 50 patients from the initial study were tracked and asked to return for objective follow-up. Recurrence was considered present for any hernia more than 2 cm in size. Objective follow-up was conducted in 27 of the original 50 (54%) patients at a median of 5.25 years after their PEH repair. Before the 5-year follow-up, 5 patients had a known recurrent hernia. Objective evaluation at 5 years identified an additional 3 recurrences, for a total recurrence rate of 25% (8 of 32 patients). The hernia recurrence rate in patients with a Collis gastroplasty was significantly lower than in those without a Collis (7% vs 54%, p = 0.008). Two patients underwent reoperation for hernia recurrence. No patient had a mesh infection or mesh erosion. The combination of Phasix ST Mesh and tension-reducing techniques during PEH repair led to a 25% hernia recurrence rate at 5 years. The addition of a Collis gastroplasty led to significantly fewer hernia recurrences and is indicative of the potential for esophageal shortening in many patients with a PEH. The long-term safety and efficacy of Phasix ST Mesh in combination with surgical technique for PEH repair is confirmed.

Invited Commentary: Can More Liberal Use of Collis Gastroplasty in Laparoscopic Paraesophageal Hernia Repair Reduce Recurrence?

Invited Commentary: Can More Liberal Use of Collis Gastroplasty in Laparoscopic Paraesophageal Hernia Repair Reduce Recurrence?

Laparoscopic proximal sleeve gastrectomy as an alternative for management of giant hiatal hernias

Background and aim: Large anatomic defects of the diaphragmatic hiatus known as giant hiatal hernias could be associated with reflux esophagitis disease (GERD) and other life-threatening complications such as gastric volvulus, ischemia and perforation, thus surgical repair is warranted. Although usually the key steps to surgical repair are reduction of the herniated stomach, complete excision of the sac, hiatus repair, and an antireflux procedure, surgery in these cases is associated with a great rate of anatomic and functional failure, therefore different techniques have been described since the original description of Collis gastroplasty designed to lengthen the short esophagus. Methods: We report here the technique and results performing proximal vertical gastrectomy or proximal sleeve gastrectomy (PSG) as an alternative in cases in which the possibility of recurrence of the hiatal hernia (HH) is high. Results: After years of follow-up after surgery, all the case patients presented here are free of gastroesophageal reflux or dysphagia symptoms, with no necessity for acid suppression medication, and no side effects of the surgery. Conclusion: The treatment of giant HH is a complex and challenging disorder to treat. PSG seems to be a good surgical alternative for the treatment of some special cases of giant HH minimizing the GERD symptoms and possible recurrences.

Short term safety of magnetic sphincter augmentation vs minimally invasive fundoplication: an ACS-NSQIP analysis

PurposeMagnetic Sphincter Augmentation (MSA) is an FDA-approved anti-reflux procedure with comparable outcomes to fundoplication. However, most data regarding its use are limited to single or small multicenter studies which may limit the generalizability of its efficacy. The purpose of this study is to evaluate the outcomes of patients undergoing MSA vs fundoplication in a national database.Materials and MethodsThe 2017–2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Registry was utilized to evaluate patients undergoing MSA or fundoplication. Patients requiring Collis gastroplasty, paraesophageal hernia repair, and emergency cases, were excluded. Patient outcomes included overall complication rates, readmissions, reoperations, and mortality.ResultsA total of 7,882 patients underwent MSA (n = 597) or fundoplication (n = 7285). MSA patients were younger (51 vs 57, p < 0.001), and more often male (49.6 vs 34.3%, p < 0.001). While patients undergoing MSA experienced similar rates of reoperation (1.0 vs 2.0%, p = 0.095), they experienced fewer readmissions (2.2 vs 4.7%, p = 0.005), complications (0.6 vs 4.0%, p < 0.001), shorter mean (SD) hospital length of stay(days) (0.4 ± 4.3 vs 1.8 ± 4.6, p < 0.001) and operative time(min) (80.8 ± 36.1 vs 118.7 ± 63.7, p < 0.001). Mortality was similar between groups (0 vs 0.3%, p = 0.175). On multivariable analysis, MSA was independently associated with reduced postoperative complications (OR 0.23, CI 0.08 to 0.61, p = 0.002), readmissions (OR 0.53, CI 0.30 to 0.94, p = 0.02), operative time (RC − 36.56, CI − 41.62 to − 31.49. p < 0.001) and length of stay (RC − 1.22, CI − 1.61 to − 0.84 p < 0.001).ConclusionIn this national database study, compared to fundoplication MSA was associated with reduced postoperative complications, fewer readmissions, and shorter operative time and hospital length of stay. While randomized trials are lacking between MSA and fundoplication, both institutional and national database studies continue to support the use of MSA as a safe anti-reflux operation.

Diaphragmatic relaxing incisions for complex hiatal reconstruction: longer-term follow-up confirms safety, efficacy and rare complications.

Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up. A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both. Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%. A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate ofhiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.

5-Year Collis-Nissen Gastroplasty Outcomes for Type III-IV Hiatal Hernia with Short Esophagus: A Prospective Observational Study.

To assess the 5-year outcomes of patients undergoing Collis-Nissen gastroplasty for type III-IV hiatal hernia with short esophagus. From a prospective observational cohort of patients who underwent antireflux surgery for type III-IV hiatal hernia between 2009 and 2020, those with short esophagus (abdominal length <2.5 cm) in whom a Collis-Nissen procedure was performed and reached at least 5 years of follow-up were identified. Hernia recurrence, patients' symptoms, and quality of life were assessed annually by barium meal x-ray, upper endoscopy, and validated symptoms and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires. Of the 114 patients with Collis-Nissen gastroplasty, 80 patients who completed a 5-year follow-up were included (mean age 71 years). There were no postoperative leaks or deaths. Recurrent hiatal hernia (any size) was identified in 7 patients (8.8%). Heartburn, regurgitation, chest pain, and cough were significantly improved at each follow-up interval (p < 0.05). Preoperative dysphagia disappeared or improved in 26 of 30 patients, while new-onset dysphagia occurred in 6. Mean postoperative QOLRAD scores significantly improved at all dimensions (p < 0.05). Collis gastroplasty combined with Nissen fundoplication provides low hernia recurrence, good control of symptoms, and improved quality of life in patients with large hiatal hernia and short esophagus.

Endoscopy and Antireflux Surgery: A Technical Review of Pre- and Postoperative Evaluation and Recognizing Patterns of Failure

Endoscopic evaluation after antireflux surgery is a challenge, due to the complexity of anatomy, variations in anatomical repairs, and the various patterns of failure. Studies have demonstrated that endoscopy reports of postoperative examinations are often inaccurate and inconsistent. The key to consistent high quality endoscopic examinations of the integrity of an antireflux surgery is a sound foundation in the native anatomical gastroesophageal junction and an understanding of the anatomy of the various postoperative configurations. This review will clarify the critical details necessary to perform a detailed endoscopic evaluation of the patient with suspected gastroesophageal reflux, and highlight key features to distinguish the intact repair from the dysfunctional one. It first explores the anatomical components of the native gastroesophageal junction and the unique geometric architecture that manifests in the physiologic reflux barrier. Then details the essential structures to evaluate and techniques to perform in an endoscopic examination prior to an antireflux surgery. It then systematically examines the altered anatomy and postoperative changes in endoscopic appearance after Nissen, Toupet, and Dor fundoplication, Collis gastroplasty, magnetic sphincter augmentation, and transoral incisionless fundoplication. Finally, to aid in the endoscopic diagnosis of specific dysfunction, it discusses the various patterns of failure after antireflux surgery, their characteristic endoscopic appearances, and the most useful adjunct testing modalities to augment the endoscopic examination when diagnosis is unclear.

Current practice in antireflux and hiatal hernia surgery: exploration of the Belgian field

Background In Belgium, no publicly available information exists on the spread, quality, results nor follow-up of antireflux and hiatal hernia surgery, in contrast to the recently centralized esophageal cancer surgery. The aim of this study was to create a snap shot of the current practice in Belgium. Methods An online questionnaire was distributed among all members of the Royal Belgian Society for Surgery in autumn 2021. A total of 33 questions spread over four sections were asked, covering demographics, current practice (case load, case mix, indications, preoperative workup, patient information, average length of stay, follow up, quality of life (QOL)), operative techniques and future thoughts. Results Twenty-four surgeons completed the questionnaire. Surgical indications are discussed multidisciplinary and based on guidelines in 67%. Workup includes endoscopy, pH-monitoring and manometry in 100%. Barium swallow, impedance and gastric emptying tests were added in respectively 83%, 42% and 13%. Symptom or QOL scores were used in 17%. About 81% are performed as primary surgery, 18% redo surgery and 1% resections. Laparoscopic procedures are reported in 99%: Nissen(-Rosetti) 79%, Toupet/Lind 15%, partial gastrectomy 5% and Collis gastroplasty 1%. Discharge is planned on POD1 in 42% and on POD2 in 54%. 50% performs follow-up < 1 year. Interest in further clinical research collaboration was expressed in 92%. Conclusion Antireflux and hiatal hernia surgery is not standardized in Belgium. There is an evident variety in clinical practice, but this questionnaire shows similarity amongst respondents regarding workup and surgical approach. There is a willingness for future research collaborations.

Revision paraesophageal hernia repair outcomes in patients with typical and atypical reflux.

Revision laparoscopic anti-reflux surgery (RLARS) is effective in alleviating the typical symptoms of gastroesophageal reflux disease (GERD). RLARS outcomes in patients with atypical GERD symptoms has not been well established. A composite Reflux Symptom Index (RSI) score greater than 13 indicates extraesophageal manifestation of pathological reflux. In this study, we analyzed the differences in quality-of-life (QOL) and perioperative outcomes between patients with atypical versus typical GERD who underwent RLARS. A retrospective review was conducted of a prospectively maintained database of patients with pathologic reflux who underwent RLARS from February 2003 to October 2019. The cohort was divided into two groups, those with typical versus atypical manifestations of GERD, as defined by their RSI score. Patients with a RSI score of > 13 were assigned to the Atypical group and those ≤ 13 were assigned to the Typical group. Patient QOL outcomes were prospectively followed using the RSI survey. Significance was defined by p-value less than 0.05. A total of 133 patients (Typical 61, Atypical 72) were included in the final analysis. The two groups were similar (p > 0.05) in mean age (58.1 ± 13.3 vs. 55.3 ± 15.5years), body mass index (29.6 ± 5.0 vs. 30.3 ± 5.4), female sex distribution (60.7% vs. 59.7%) and age adjusted Charlson score (1.76 ± 1.58 vs. 1.98 ± 1.94). The Typical group had a higher frequency of type III hiatal hernia (62.3% vs. 29.2%) and Collis gastroplasty (29.5% vs. 5.6%). The groups had similar rates of partial and complete fundoplication with similar median length of stay (Typical: 3.0 ± 3.4days vs. Atypical: 2.4 ± 1.7days). After a mean follow-up of 30.2 ± 33.6months, both groups reported similar rates of improvement in RSI outcome from baseline (58.1% vs 43.3%, p = .149). However, the RSI outcome at the latest follow-up for the Typical group was significantly better than the Atypical group after RLARS (2.8 ± 5.3 vs. 15.9 ± 11.1, respectively). Patients who undergo revision paraesophageal hernia repair with objective findings of GERD and subjective complaints of atypical reflux symptoms may show long-term improvement in QOL outcomes. However, these results are contingent on proper patient selection and a thorough work-up for pathological reflux in this population. Further research is needed to determine universal diagnostic criteria to assist in the early detection and surgical treatment of patients with atypical GERD.

399. CURRENT PRACTICE IN ANTIREFLUX AND HIATAL HERNIA SURGERY: EXPLORATION OF THE BELGIAN FIELD

Abstract In Belgium no publicly available information exists on the spread, quality, results nor follow-up of antireflux and hiatal hernia surgery, in contrast to the recently centralized esophageal cancer surgery. However, in some countries a plea is rising to perform this benign esophageal surgery in high volume centers. The aim of this study was to create a snap shot of the current practice in Belgium. An online questionnaire was distributed among all members of the Royal Belgian Society for Surgery in autumn 2021. A total of 33 questions spread over four sections were asked, covering demographics, current practice (case load, case mix, indications for surgery, preoperative workup, patient information, average length of stay, follow up, quality of life (QOL)), operative techniques (approach, type of procedure, crural reinforcement) and future thoughts (opinion on the future of antireflux and hiatal hernia surgery in Belgium). Twenty-four surgeons completed the questionnaire. Surgical indications are discussed multidisciplinary and based on guidelines in 67%. Workup includes endoscopy, pH-monitoring and manometry in 100%. Barium swallow, impedance and gastric emptying tests were added in respectively 83%, 42% and 13%. Symptom or QOL scores were used in 17%. 81% are performed as primary surgery, 18% redo surgery and 1% resections. Laparoscopic procedures are reported in 99%: Nissen(−Rosetti) 79%, Toupet/Lind 15%, partial gastrectomy 5% and Collis gastroplasty 1%. Discharge is planned on POD1 in 42% and on POD2 in 54%. 50% performs follow-up &amp;lt;1 year. Interest in further clinical research collaboration was expressed in 92%. Antireflux and hiatal hernia surgery is not standardized in Belgium. There is an evident variety in clinical practice, but this questionnaire shows similarity amongst respondents regarding workup and surgical approach. Further research collaborations are possible in the future.

Quality of life and gastric acid-suppression medication post-laparoscopic fundoplication: a ten years retrospective study

Background: Although medical treatment is the best approach for treating gastroesophageal reflux disease (GERD), surgery has a significant role to play not only in cases of failure of medical treatment but also as in a long-term approach, specifically in young patient. On the other hand, alarming reports have been published concerning the outcomes and usefulness of antireflux surgery (ARS). The aim of this study was to evaluate medium and long-term functional outcomes following ARS performed in our institution over a 10 year period. Methods: This was a retrospective review of patients in our department who underwent primary or redo laparoscopic fundoplication between 2005 and 2015. Evaluation of the outcomes was made using a validated questionnaire specifically dedicated to GERD (the Gastroesophageal Reflux Disease – Health-Related Quality of Life (GERD-HRQL) questionnaire) and by investigation about the continued use of proton-pump inhibitors (PPIs). Exclusion criteria were patients treated for GERD with Roux-en-Y gastric bypass, emergency reduction of hiatal hernia, patients missing from follow-up and patients deceased from unrelated causes. Results: 296 patients out of 309 met the inclusion criteria. Primary procedures included 214 Nissen, 35 Toupet, and 23 Collis gastroplasty; there were additionally 62 redo operations. Neither postoperative mortality nor conversion was observed. The mean follow-up was 8 years post-surgery, and contact was made with 96% of the original group. 85% of the patients had stopped PPI use since their operation (86% after Nissen, 73% after Toupet, 94% after Collis and 82% after redos). 90% of the patients had good to excellent functional results as reported by their GERD-HRQL score, and independent of the type of previous procedure. 31 patients were dissatisfied due to dysphagia in 7 and GERD recurrence in 24. Again 75% were extremely satisfied and 15% satisfied. Our own incidence of redo procedures was 11% but the functional result and satisfaction index were comparable between redo and primary procedures. The addition of Collis gastroplasty in cases of real short oesophagus did not alter the final result. Conclusions: Laparoscopic ARS presents a superior alternative to lifetime medication use and can provide long-term control of GERD symptoms in the majority of patients if it is performed skillfully and in carefully evaluated patients. Based on the present study, we believed that significant improvement in GERD health-related quality of life can be attained following both primary and reoperative ARS.

Large hiatus hernia: time for a paradigm shift?

BackgroundLaparoscopic large hiatal hernia (LHH) repair remains a challenge despite three decades of ongoing attempts at improving surgical outcome. Its rarity and complexity, coupled with suboptimal initial approach that is usually best suited for small symptomatic herniae have contributed to unacceptable higher failure rates.ResultsWe have therefore undertaken a systematic appraisal of LHH with a view to clear out our misunderstandings of this entity and to address dogmatic practices that may have contributed to poor outcomes.ConclusionsFirst, we propose strict criteria to define nomenclature in LHH and discuss ways of subcategorising them. Next, we discuss preoperative workup strategies, paying particular attention to any relevant often atypical symptoms, indications for surgery, timing of surgery, role of surgery in the elderly and emphasizing the key role of a preoperative CT imaging in evaluating the mediastinum. Some key dissection methods are then discussed with respect to approach to the mediastinal sac, techniques to avoid/deal with pleural breach and rationale to avoid Collis gastroplasty. The issues pertaining to the repair phase are also discussed by evaluating the merits of the cruroplasty, fundoplication types and gastropexy. We end up debating the role of mesh reinforcement and assess the evidence with regards to recurrence, reoperation rate, complications, esophageal dilatation, delayed gastric emptying and mortality. Lastly, we propose a rationale for routine postoperative investigations.

Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data wereanalyzed using univariate analysis. One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7years, 29.7 ± 5.7kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

Surgical treatment of giant hiatal hernia in patient with type 2 diabetes mellitus. Clinical case

Introduction: Gastroesophageal reflux disease (GERD) is a common pathology today, especially in the population of patients with obesity and type 2 diabetes mellitus. Particular attention should be paid to the comorbid condition of patients, especially in the diagnosis of esophageal hernia, complicated by “short” esophagus, which can be reliably detected (intraoperatively) when it is impossible to surgically mobilize his/her abdomen, without tension, more than 2 — 3 cm in abdominal cavity, below the esophageal orifice of the diaphragm. “Short” esophagus occurs due to fibrosis, which progresses against the background of GERD and persistent chronic inflammation. Conservative long-term GERD treatment, especially against the background of decompensated diabetes, is ineffective and doesn’t provide satisfactory results and, and consequently leads to a complicated course of the disease. In the presence of a «short» esophagus against the background of hiatal, one of the effective surgical techniques is to perform gastroplasty according to Collis-Nissen, and compensation of type 2 diabetes in the prehospital stage is important for both favorable results and choice of adequate type of surgery (both antireflux and bariatric).&#x0D; Clinical case: A 63-year-old patient after type 2 diabetes mellitus compensation in outpatient settings, with hospitalized in the surgical department with complaint of chest pain and aching epigastric pain without irradiation that worsened after eating, belching air, periodic vomiting of food and shortness of breath. The anamnesis of the disease was followed for several decades of life. After correction of carbohydrate metabolism against the background of decompensated DM 2 and comprehensive follow-up, the patient was diagnosed with a giant hiatal hernia, complicated with a «short» esophagus. The patient underwent laparoscopic crurography and Nissen fundoplication supplemented by Collis gastroplasty in a Terry modification. The postoperative period was uncomplicated. The check-up after 1 month showed no complaints, no radiological signs of reflux (barium radioscopy in the Trendelenburg position), no data for recurrence of hiatal hernia (as per results of fibrogastroduodenoscopy and contrast-enhanced abdominal computed tomography).&#x0D;

How I Do It: Collis Gastroplasty

A key principle of hiatal hernia repair is mitigation of tension. While considerable emphasis is placed on the radial tension of the crural closure itself, of equal importance is assuring that axial tension on the esophagus is appropriately addressed. Because of this, esophageal lengthening procedures such as the transabdominal laparoscopic wedge Collis gastroplasty described here have been proposed. Such esophageal lengthening procedures allow for the creation of additional length of tubularized stomach to create a neo-esophagus that will allow for a tension free and appropriately sized fundoplication to be performed.

Modern aspects of diagnosis and surgical treatment of hiatal hernias: Literature Review

Laparoscopic correction is the main method of treating hiatal hernias. However, despite more than thirty years of experience, many issues remain controversial and require compilation and standardization. The authors have analyzed the latest scientific studies and recommendations on the treatment of hiatal hernias with a high level of evidence, which is presented in the form of a review with a comparison of their own experience in surgical treatment of 171 patients operated on for hiatal hernias. The risk of transition of an asymptomatic hiatal hernia to a clinically significant one is 1% per year, while observation, rather than active surgical tactics, is indicated. Only symptomatic hernias are subject to surgical treatment. Surgical intervention should include the following mandatory steps: dissection of the esophagealdiaphragmatic ligament with excision of the hernial sac while protecting the branches of the vagus nerve; dissection of both crura of diaphragm, transhiatal mobilization of the esophagus in the mediastinum to achieve the length of its intraabdominal segment of 2–3 cm; if a short esophagus is suspected, a mandatory step is to perform Collis gastroplasty; mobilization of the gastric fundus by dividing gastrointestinal ligament and short gastric arteries; creation of a fundoplication cuff on a calibration probe of at least 30–36 Fr. The choice of the fundoplication and cruroraphia methods did not significantly affect the long-term results of treatment. Laparoscopic interventions are the most effective way to treat patients with hiatal hernias, due to their safety, low trauma, low complication rate and the possibility of rapid rehabilitation of patients. The technique of surgical intervention needs a clarified standardization.

Collis gastroplasty in surgical treatment of hiatal hernia

To analyze the early and long-term postoperative outcomes after Collis gastroplasty in the treatment of patients with hiatal hernia complicated by gastroesophageal reflux disease and shortening of the esophagus. Postoperative outcomes after Collis gastroplasty were analyzed in 22 patients with hiatal hernia and shortening of the esophagus. The control group consisted of 166 patients after simple repair of hiatal hernia without Collis procedure. In case of Collis gastroplasty, surgery time was 185 (160-250) min. Intraoperative complications were observed in 3 (13.6%) patients, incidence of postoperative complications - 18.2%. There were no lethal outcomes in this group of patients. Mild functional dysphagia was observed in 2 (9.1%) patients. Length of hospital stay was 7.8±2.4 days. Mean follow-up was 34 (6-52) months. There were no anatomical recurrences. A relapse of gastroesophageal reflux was noted in 1 (4.6%) case. GERD-HRQL score was 4.8±2.2 points. Additional Collis gastroplasty did not affect the immediate and long-term results of surgical treatment in comparison with simple cruroraphy and fundoplication. Unreduced shortening of the esophagus may be followed by high incidence of recurrent hiatal hernia and GERD in long-term period. In case of shortening of the esophagus, surgery should include Collis gastroplasty. This effective and safe procedure does not impair treatment outcomes. Indications and optimal technique of Collis gastroplasty require clarification and further research.

Changes in esophageal physiology after paraesophageal hernia repair and Collis gastroplasty.

The surgical approach and technique for paraesophageal hernia (PEH) repair is much debated. The changes in the esophageal physiology after PEH repair with a concomitant Collis gastroplasty (PEH-CG) are not clearly known. The aim of this study was to determine the changes in high resolution esophageal manometry (HREM) and esophageal pH testing after PEH-CG. Retrospective analysis of all patients who underwent PEH-CG at our institution between 2006 and 2013 was performed. Patients had esophageal pH testing, HREM, barium swallow and an upper endoscopy before and after PEH-CG. A total of 182 patients underwent PEH-CG during the study period. Majority of patients had Nissen fundoplication (176, 96.7%) with Toupet in 6 (3.3%). Basal lower esophageal sphincter pressure (LESP) was lower after fundoplication (20.3mmHg ± 11.3 vs. 25.8mmHg ± 15.6, p < 0.001), whereas residual LESP was noted to be higher after fundoplication (7.7mmHg ± 4.9 vs. 6.1mmHg ± 6.7, p < 0.009). There were no significant changes in the esophageal motility patterns. There was an improvement in total pH and upright pH but not supine pH post PEH-CG. Normalization of total acid exposure after fundoplication was noted in 31 (59.6%) of the 52 patients who had abnormal total acid exposure prior to fundoplication. Objective clinical assessment in patients undergoing PEH-CG demonstrates an effective operation for this complex problem. There was an increase in residual LESP but interestingly, decrease in basal LESP. Additionally, there was an improvement in esophageal acid exposure afterwards. These findings will facilitate future management of PEH.

Patient Expectations After Collis Gastroplasty

This case series study examines short-term and long-terms outcomes in patients who have undergone Collis gastroplasty with fundoplication and hiatal hernia repair.