Collis Gastroplasty Research Articles

Gastrectomy as a Remedial Operation for Failed Fundoplication

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997–2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients’ overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.

The Influence of Transabdominal Gastroplasty: Early Outcomes of Hiatal Hernia Repair

ObjectiveThe aim of our study was to review our experience with transabdominal gastroplasty to determine the safety and short-term efficacy of the procedure. MethodsRetrospective review of all patients that underwent transabdominal hiatal hernia repair with concurrent gastroplasty for shortened esophagus between October 1999 and May 2004. ResultsThere were 63 patients, 27 men and 36 women. Median age was 68 years. The hiatal hernia was classified as type-I in 6 patients, type-II in 10, type-III in 43, and type-IV in 4. The operative approach was laparoscopic in 44 patients and laparotomy in 19. A Nissen fundoplication was performed in 62 patients and a Toupet fundoplication in 1. Wedge gastroplasty was performed in 47 patients and modified Collis gastroplasty in 16. Median hospitalization was 3 days (range, 2–10). Intraoperative complications occurred in 11 patients (17%). One laparoscopic approach (2%) was converted to laparotomy. Postoperative complications occurred in 12 patients (19%), there were no operative deaths. Median follow-up was 12 months (range, 0 to 64). One patient (2%) was found to have a recurrent hiatal hernia diagnosed 14 months, postoperatively. Functional results were excellent in 41 (68%), good in 6 (10%), fair in 12 (20%), and poor in 1 (2%). ConclusionTransabdominal gastroplasty can be performed safely, with good functional results and a low incidence of recurrent herniation during the short-term follow-up period.

Laparoscopic Collis Gastroplasty and Nissen Fundoplication for Reflux Esophagitis With Shortened Esophagus in Japanese Patients

There is an extremely small number of surgical cases of laparoscopic Collis gastroplasty and Nissen fundoplication (LCN procedure) in Japan, and it is a fact that the surgical results are not thoroughly examined. To investigate the results of LCN procedure for shortened esophagus. The subjects consisted of 11 patients who underwent LCN procedure for shortened esophagus and followed for at least 2 years after surgery. The group of subjects consisted of 3 men and 8 women with an average age of 65.0+/-11.6 years, and an average follow-up period of 40.7+/-14.4 months. Esophagography, pH monitoring, and endoscopy were performed to assess preoperative conditions. Symptoms were clarified into 5 grades between 0 and 4 points, whereas patient satisfaction was assessed in 4 grades. The use of postoperative acid-reducing medication and the recurrence of esophagitis were also investigated. None of the patients experienced intraoperative complications, received transfusions, required conversion to open surgery, or died postoperatively. The average preoperative heartburn, regurgitation, and dysphagia scores were 2.36+/-1.29, 2.27+/-1.19, and 1.82+/-1.78 points, respectively. These scores improved after surgery to 0.55+/-1.21 (P=0.0063), 0.55+/-1.21 (P=0.0094), and 1.0+/-1.18 (P=0.1236) points, respectively. All patients had esophagitis preoperatively, which recurred in 3 patients (27%). In these 3 patients, acid-secreting mucosa was confirmed on the oral side of the wrap, by positive Congo-red staining. Hiatal hernia recurred in one patient, who also experienced recurrent esophagitis. Five patients received acid-reducing medication postoperatively. The degree of satisfaction was excellent in 2, good in 6 patients, fair in 2, and poor in 1 patient(s). Although the LCN procedure can be performed safely, the outcome was not necessarily satisfactory. The LCN procedure requires avoidance of residual acid-secreting mucosa on the oral side of the wrapped neoesophagus. If acid-secreting mucosa remains, continuous acid suppression therapy should be employed postoperatively.

Long-term evaluation of patient satisfaction and reflux symptoms after laparoscopic fundoplication with Collis gastroplasty

Esophageal shortening is a complication of advanced gastroesophageal reflux disease (GERD). For patients with short esophagus, Collis gastroplasty combined with fundoplication provides excellent symptomatic relief from GERD disease. The literature lacks studies comparing satisfaction and reflux symptoms between patients who underwent Nissen fundoplication with Collis gastroplasty and those who had primary fundoplication alone. This study aimed to assess long-term satisfaction and GERD-related quality of life after laparoscopic Collis-Nissen fundoplication, and to compare them with those for Nissen fundoplication alone. A nested case-control study was conducted. In this study, 14 cases of laparoscopic Collis-Nissen fundoplications were matched for age, gender, and length of the follow-up period to a cohort of 120 control subjects who underwent laparoscopic Nissen fundoplication. All the patients were mailed a follow-up survey which included a Short Form-12 (SF-12) health status (quality-of-life) questionnaire (a validated quality-of-life instrument), a Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire (a GERD-specific quality-of-life instrument), and queries regarding long-term satisfaction and medication use. Both groups showed a significant postoperative increase in QOLRAD mean scores (p = 0.01). However, the difference in the delta (postoperative-preoperative) score between the two groups was not significant (Fig. 1). There were no differences in mental (MCS) or physical (PCS) SF-12 scores between the two groups. The rate of satisfaction with the surgery was similar in the Nissen-Collis fundoplication (87.5%) and Nissen fundoplication (87%) groups. Collis gastroplasty combined with Nissen fundoplication is an effective procedure for patients with a shortened esophagus diagnosed intraoperatively during antireflux surgery. Patient satisfaction, postoperative quality of life, and QOLRAD score improvement after this procedure are comparable with those observed in patients treated with Nissen fundoplication alone.

Repair of 104 failed anti-reflux operations.

To assess whether reoperative surgery for failed Nissen fundoplication is beneficial and to classify all mechanisms of failure recognized. Antireflux surgery is often necessary, but a 10% failure rate is commonplace. We report results for patients undergoing reoperative surgery and present a nomenclature of mechanisms of failure. A total of 104 patients, who had a previous fundoplication for gastroesophageal reflux disease (GERD), underwent reoperative surgery. Manometry (n = 86), endoscopy (n = 101), pH monitoring (n = 27), upright esophagram (n = 90), gastric emptying (n = 26), and symptom assessment (n = 104) were performed prior to reoperative surgery. Patients were also assessed before and during reoperation for mechanism of failure using a newly proposed classification. The operative approach was laparoscopic in 58 patients, via open laparotomy in 12, and a thoracotomy in 34 patients. Follow-up was conducted by phone interview and was completed in 97 patients (97%; 3 were deceased) with a mean follow-up of 32 months (range, 1-146 months). The conversion rate to laparotomy for laparoscopic patients was 8%. The perioperative complication rate was 32%. One patient died of respiratory insufficiency after a laparotomy. Seven patients required additional surgery for correction of persistent or recurrent symptoms. The short and long-term complication rate was similar for the different operative approachs. Symptom resolution (rare or absent) occurred in 74% of patients with dysphagia, 75% with heartburn, 85% with regurgitation, and 94% with chest pain. The overall post-reoperative patient satisfaction was 7 on a scale of 1 to 10 and 3 on a scale of 1 to 4 when patients were asked to grade the operative result. There was no difference in the symptom resolution for patients operated upon by the laparoscopic approach as compared with laparotomy, but those patients undergoing a Collis gastroplasty had poorer results. The preoperative accuracy of assessment for mechanism of failure was 78%. A nomenclature of mechanisms of failure is included to aide reoperative assessment and new mechanisms of failure are described. Reoperative surgery results for GERD are satisfactory. A variety of operative approaches proved equally effective. Poorer results were observed in patients with more advanced disease.

Value of Endoscopic Marking of the Z-Line for Detecting Short Esophagus Before Repeat Surgery for Recurrent Paraesophageal Hernias

With the increasing use of antireflux surgery in the treatment of gastroesophageal reflux disease, the need has arisen for an accurate method of assessing the length of the esophagus. The enigmatic finding of short esophagus is a continuing matter of controversy with regard to prevalence, cause, and management. Short esophagus precludes a tension-free intra-abdominal antireflux procedure. The most effective treatment for the condition is an esophagus-lengthening procedure using a Collis gastroplasty. Alternative procedures, such as intrathoracic fundoplication or esophageal resection, are not widely accepted. The risk of encountering a short esophagus requiring a Collis gastroplasty is significantly greater in the presence of paraesophageal hernia, Barrett’s esophagus, an esophageal stricture, and repeat surgery [1]. Esophagography has been reported to have a sensitivity of 66 % and a positive predictive value of 27 % for diagnosing short esophagus, whereas the length as measured by manometry had a sensitivity of 43 % and a positive predictive value of 25 % [2]. Intraoperative techniques have also been described that combine laparoscopic with endoscopic methods to determine the position of the gastroesophageal junction. The length of the intra-abdominal esophagus is determined by using a probe to measure the distance between the esophagogastric junction and the crura of the diaphragm [3]. Recurrent paraesophageal hernia is the most challenging scenario for repeat laparoscopic surgery, and the one most likely to require conversion to an open procedure. Some 30 - 80 % of patients with paraesophageal hernias 5 cm or larger require gastroplasty [4] [5].

Surgical treatment of reflux stricture of the oesophagus.

The choice of surgery in patients with reflux-induced oesophageal stricture remains controversial. From 1976 to 1990, a total of 65 patients underwent fundoplication (36 patients), Collis gastroplasty plus fundoplication (ten), total duodenal diversion (four) and oesophageal resection (15). The postoperative mortality rate was 5 per cent (three patients): necrosis of the colon transplant in two patients and acute pancreatitis in one. The median follow-up was 25 (range 6-120) months. After conservative surgery, the median number of dilatations per patient per year significantly decreased (P < 0.001). Nine patients (25 per cent) complained of persistent or recurrent symptoms after standard fundoplication and six required reoperation. Clinical results were satisfactory in patients who underwent Collis fundoplication, total duodenal diversion and oesophageal resection. It is concluded that the causes of failed fundoplication are irreversible stricture or persistent gastro-oesophageal reflux; the latter may be caused by inefficacy or deterioration of the partial fundoplication wrap. A subtle degree of oesophageal shortening is probably underestimated in such patients and this may explain the better results obtained with the Collis fundoplication. Total duodenal diversion is a good therapeutic option in patients who have undergone previous oesophagogastric surgery. Oesophageal resection should be reserved for patients with tight strictures unresponsive to dilatation or those with scleroderma, multiple previous operations or severe dysplasia in Barrett's oesophagus.

DIFFUSE ESOPHAGEAL SPASM IN CHILDREN

Diffuse esophageal spasm (DES) causes chest pain and/or dysphagia in adults but is rarely reported in children. We defined DES as simultaneous contractions associated with >10% of swallows and mean simultaneous contraction amplitude >30 mmHg (Castell, 2004). We reviewed charts of 278 subjects 0-18 years of age after esophageal manometry. Results included normal motility 61%, nonspecific esophageal motility disorder 20%, DES 13% (n = 36), and achalasia 4%. Of 24 subjects <5 years, chief complaints were food refusal (14), vomiting (3), choking (3), retching (1), and no symptoms (3). Of 12 subjects >5 years, chief complaints were chest pain (4), dysphagia (3), vomiting (2), food refusal (2), and retching (1). Food refusal was more common in infants and toddlers than in children and teens (p < 0.05). Esophageal manometry was the only motility test in 14 subjects; 22 subjects were evaluated with antroduodenal (15) or colonic manometry (3) or both (4). Of these 22 subjects, 9 were diagnosed with DES only, and 13 were diagnosed with generalized motility disorders. Prior to manometry, 25 subjects (69%) had surgery for symptoms: 20 gastrostomies, 13 fundoplications, 3 pyloroplasties, 1 Collis gastroplasty, and 1 gastrojejunostomy. Comorbid medical conditions, often multiple, were found in 33 subjects: idiopathic developmental delay (7), heart malformation (7), Down's Syndrome (6), cerebral palsy (4), seizures (2), and neuropathic pseudoobstruction (2). Mitochondrial myopathy, chromosome 3p25 deletion, chromosome X q26-28 duplication, mixed connective tissue disease, holoprosencephaly, Rett Syndrome, Charcot-Marie-Tooth disease, Ehlers-Danlos Syndrome, Hirschsprung's disease, and celiac disease were each found in one subject. Follow up treatment modalities and effects were variable. We conclude that DES in infants and children is not rare. DES should be considered when children present with food refusal, dysphagia, chest pain, or unexplained vomiting. DES in infants and children rarely presents without comorbidity. We speculate that early diagnosis and treatment may prevent unnecessary surgery in some cases.

Objective outcomes after laparoscopic giant hiatal hernia repair: Minimization of hernia recurrence

Abstract Introduction: Laparoscopic giant hiatal hernia (GHH) (> 50% of stomach above the diaphragm) repair is associated with a 12–40% early recurrence rate. We applied specialized laparoscopic maneuvers to address this potential technical compromise. Methods: 43 patients underwent GHH laparoscopic repair (34 virgin, 9 reoperative) with esophageal lengthening. Specific emphasis was placed on meticulous preservation of crural integrity, complete sac excision, routine gastroesophageal fat-pad dissection, and Collis gastroplasty. A totally intraabdominal wedge Collis gastroplasty (using simplified EndoGIA stapler techniques) combined with Nissen fundoplication was performed. A validated questionnaire assessed functional outcomes at a 7.8 month median (range, 2–42). Postoperative esophagram objectively evaluated for possible hiatal hernia recurrence at a 7.5 month median (range, 1–26). Results: Operating time averaged 299 ± 108 minutes; wedge gastroplasty added only 10 minutes (mean). Median hospital stay was 4 days (range, 1–43). Perioperative complications occurred in 9% (4/43) of patients: 1 esophageal leak, 1 respiratory failure, 1 gastric-bloat readmission, and 1 pneumothorax. Complete postoperative data were available for 74% (32/43). There was 1 (3%) miniscule, asymptomatic radiographic recurrence. Most patients reported on questionnaire, excellent results in each of 9 symptoms (e.g., heartburn resolved in 94% [30/32]). GERD-related medications were discontinued in 78% (25/32). The mean postoperative GERD Quality-of-Life score was 1.2 ± 3.2 (scale 0–45; 0=asymptomatic). Overall, 97% (31/32) were satisfied with their surgical outcome. Conclusions: Consistent application of specialized techniques in minimally-invasive GHH repair yields a very low rate of early recurrence. Functional results are excellent in most patients, translating to high levels of satisfaction with the procedure.

Stapled-wedge Collis gastroplasty for the shortened esophagus

Background Minimally invasive Collis gastroplasty is an established technique for managing the shortened esophagus. The purpose of this report is to describe our new technique, the wedge gastroplasty, and report the short-term outcomes. Methods All patients (n = 143) undergoing laparoscopic fundoplication from May 2000 to March 2001 were assessed intraoperatively for shortened esophagus. After mediastinal dissection, 15 patients with inadequate intraabdominal esophageal length underwent wedge gastroplasty. Preoperative symptoms, operative times, and short-term outcomes were evaluated. Results Mean operative time was 184 ± 36 minutes (range 138 to 258). There was 1 cervical esophageal tear from bougie passage and no other minor or major complications. At 6 weeks, there was more improvement in esophageal symptoms compared with extraesophageal symptoms. Conclusions Wedge gastroplasty is effective in decreasing symptoms in patients with shortened esophagus and takes less time to perform than other gastroplasty techniques. Further study is needed to assess long-term outcomes.

The surgical treatment of the intrathoracic migration of the gastro-oesophageal junction and of short oesophagus in gastro-oesophageal reflux disease.

In the rush to implement laparoscopic surgery for gastro-oesophageal reflux disease (GORD), the necessity to treat a short oesophagus with dedicated techniques was not always adequately considered. The aim of this study was to define the frequency, patterns and surgical treatment of the intrathoracic migration of the g-o junction and short oesophagus in GORD. Between 1980 and 2003 our group indicated surgery only for severe and complicated GORD and for drawbacks of medical therapy. Preoperatively patients underwent clinical-instrumental work up. The various degrees of the intrathoracic migration of the g-o junction were classified according to the barium swallow. A total of 319 patients operated upon were grouped according to the periods 1980-1991 and 1992-2003 with 149 and 170 patients, respectively. In the first period only 'open' procedures were performed; the Collis gastroplasty in addition to the antireflux procedure was performed when reduction of the g-o junction in the abdomen required excessive tension. In the second period mini-invasive techniques were progressively introduced. During laparoscopy, the relationship between the g-o junction and the hiatus, and the need to elongate the oesophagus, was assessed by intraoperative oesophagoscopy. The Collis gastroplasty was performed in 29% in the first period and in 23% in the second period. Radiology was a strong predictor of the necessity to elongate the oesophagus. In the second period, global long-term results improved with respect to the first period; P = 0.047 (first period satisfactory 82%, poor 18%, median FU 84, 12-252 months; second period satisfactory 93%, poor 7%, median FU 34, 6-126 months). In the second period, Collis-Nissen and Collis-Belsey procedures had satisfactory results in 80% and poor in 20%. In surgery for severe GORD, the Collis procedure is required in 23% of operations; radiology helps to plan surgery; intraoperative endoscopy avoids unnecessary oesophageal lengthening.

A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia

Objective The optimal surgical treatment of paraesophageal hiatal hernia is in debate. Our experience with a traditional transthoracic approach was reviewed to provide “benchmark” data against which newer surgical techniques can be measured. Methods Between 1977 and 2001, 240 patients had primary transthoracic repair of paraesophageal hiatal hernia. Presenting complaints included reflux (69%), pain (67%), dysphagia (36%), and bleeding or anemia (33%). Preoperative esophageal function testing showed abnormal reflux in 86%. Hernia types were combined (type III) in 92% and type IV in 8%. All patients had reduction of the hernia and a concomitant antireflux procedure. An esophageal lengthening Collis gastroplasty was performed in 96%. Results There were 3 perioperative deaths (1.7%). The median length of hospital stay was 7 days. Early complications requiring reoperation occurred in 12 patients (5%) and included recurrent hernia in 4, leak in 3, and a tight hiatal closure in 3. Mean follow-up in 226 patients was 42 months (median 27.8 months). Satisfactory results were obtained in 86% of patients. Follow-up complaints (moderate or persistent symptoms) included dysphagia (4), reflux (1), dumping (3), and post-thoracotomy pain (1). Routine postoperative barium radiographs showed intact repair in 71% (108/153). Of 19 patients with an anatomic recurrence, 4 (2%) had more than a partial asymptomatic migration of the fundoplication and required reoperation. Postoperative esophageal function testing, obtained in 28% of the patients, showed abnormal gastroesophageal reflux in 2. Conclusion Open transthoracic repair of paraesophageal hiatal hernia provides good to excellent long-term control of both the hernia and gastroesophageal reflux with relatively low early morbidity.

Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery.

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during follow-up to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett's esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.

Extended transmediastinal dissection: an alternative to gastroplasty for short esophagus.

The significance of short esophagus and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although patients with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of patients undergoing fundoplication, we hypothesize that patients with moderate esophageal shortening requiring extended mediastinal dissection make up a larger subgroup and that extended laparoscopic mediastinal dissection is a good treatment strategy for such patients. Retrospective comparative analysis in an academic and private practice-based tertiary referral center. A total of 205 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernias over 4 years. Outcomes in patients requiring either a type I (<5 cm) or type II (>5 cm) mediastinal dissection were compared. Laparoscopic Nissen fundoplication with or without extended mediastinal dissection and esophageal physiology testing. Symptom assessments, operative reports, and outcomes were prospectively recorded on standardized data sheets. Postoperative symptom assessment and esophageal physiology testing were performed. A total of 133 (65%) of the 205 patients underwent type I dissection, and 72 (35%) of the 205 patients underwent type II dissection. Failure occurred in 15 (11%) of 133 patients and 6 (10%) of 72 patients, respectively. The presence of a large hiatal or paraesophageal hernia predicted the need for type II dissection. No difference was seen in failure rates between patients who required a type II dissection and those who did not. This finding suggests that aggressive application of laparoscopic transmediastinal dissection to obtain adequate esophageal length may reduce fundoplication failure in patients with esophageal shortening and provide a success rate similar to that of patients with normal esophageal length. More liberal application of Collis gastroplasty in these patients is not warranted.

Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during followup to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett’s esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.

Laparoscopic mesh cruroplasty for large paraesophageal hernias.

Previous studies have shown that surgical repair of paraesophageal hernias is associated with a high recurrence rate, especially when a laparoscopic approach is used. Anatomic recurrence due to crura breakdown is a primary etiology, which has led us to employ prosthetic mesh reinforcement of large hiatal defects (> 5 cm) since 1996. We discuss the evolution of this approach and describe our current technique with limited outcomes in 52 consecutive patients during a 5-year period. There were 31 males and 21 females, with a mean age of 57 years (range, 32-77 years) with symptomatic reflux and endoscopic or radiologic evidence of a large paraesophageal hernia. Utilizing a laparoscopic approach, the contents of the sac were reduced and the crura approximated with permanent interrupted sutures and a prosthetic mesh was secured over the repair as an on-lay reinforcement buttress. A Nissen (42) or Tilley (9) fundoplication was performed in all but 1 patient, and 18 patients (34%) required a wedge collis gastroplasty. Fifteen patients (28%) had a previous unsuccessful antireflux operation. There was no perioperative morbidity or mortality. Follow-up averaged 25 months (range, 7-60 months). Postoperative gastroscopy or barium swallow have been performed in 27 patients to date, with 11 experiencing foregut symptoms. There has been 1 recurrence (1.9%) and no prosthetic erosion. Early results suggest that prosthetic mesh cruroplasty may be effective in reducing recurrence after laparoscopic repair of large paraesophageal hernias, but long-term follow-up is required in all patients to determine the true incidence of anatomic recurrence and prosthetic erosion.

10 OC Laparoscopic collis gastroplasty and fundoplicatio sec Nissen in the treatment of the gastroesophageal reflux desease(GERD)with short esophagus problem

10 OC Laparoscopic collis gastroplasty and fundoplicatio sec Nissen in the treatment of the gastroesophageal reflux desease(GERD)with short esophagus problem

Results of Collis gastroplasty and selective fundoplication, using a left thoracoabdominal approach, for failed antireflux surgery.

To study patterns of failure following primary antireflux surgery and to evaluate efficacy of reoperation using a left thoracoabdominal Collis gastroplasty and selective fundoplication. Thirty-one patients who underwent reoperative antireflux surgery between 1991 and 2000 were studied. Transabdominal fundoplication had been performed in 21 patients, and ten patients had a partial fundoplication by left thoracotomy, 1-33 years (mean, 15 years) previously. All patients presented with clinically disabling symptoms. Objective studies documented for all patients, a disrupted fundoplication, a short esophagus, and an associated hiatus hernia (Type I: 21 patients, 68%; Type III: ten patients, 32%), esophagitis (nine patients, 29%), and Barrett's mucosa (five patients, 16%). Abnormal esophageal motility was found in nine of 26 (36%) patients studied. All patients were reoperated using a left thoracoabdominal approach, with epidural analgesia. A Collis gastroplasty was used to lengthen the esophagus, incorporating a complete (24 patients, 77%) or partial (seven patients, 23%) fundoplication based of preoperative esophageal function studies. There was no perioperative mortality. Median length of hospitalization was 8 days, and was uncomplicated for 18 (58%) patients. Postoperative morbidity was considered minimal, and comprised left lower lobe infiltrates (six patients, 19%), atrial fibrillation (three patients, 10%), urinary tract infection (one patient, 3%), superficial wound infection (one patient, 3%), aspiration (one patient, 3%), and nausea (one patient, 3%). Median follow-up was 42 months (6-105 months), and was complete for 29 patients. Six patients (21%) had moderate-severe post-thoracotomy pain, for up to 18 months postoperatively, and five patients (17%) required esophageal dilation, ranging from two to six dilations within the first 6 months after surgery. Overall, 93% (27/29) of patients were satisfied with the results of surgery, in terms of quality of swallowing and control of preoperative symptoms. In this series, failure of primary antireflux surgery was related to short esophagus. Intermediate-term subjective results of reoperative antireflux surgery were good for selected patients who undergo esophageal lengthening and fundoplication. The left thoracoabdominal approach was safe, generally well tolerated, and provided excellent exposure of the esophagogastric junction for complex reoperative antireflux surgery.

The short esophagus—recognition and management

Esophageal shortening is a real and clinically important issue for surgeons performing antireflux surgery. The ability to identify these patients preoperatively is based predominantly on experience; however, particular awareness and appropriate preparations should be made for patients demonstrating esophageal strictures and large fixed hiatal hernias. Management should include extensive mobilization of the esophagus to facilitate a tension-free reduction of the esophagogastric junction into the abdominal cavity with subsequent meticulous closure of the esophageal hiatus and anchoring of the repair within the abdomen. If tension-free reduction cannot be achieved, surgeons should be prepared to proceed with a procedure involving Collis gastroplasty or an operation such as the Hill procedure, which involves reliable anchoring within the abdominal cavity. It is currently estimated that approximately 1.5% of patients presenting for antireflux surgery will have some degree of esophageal shortening, and various estimates indicate that 20% to 70% of this population will require specialized surgery because of the inability to establish a tension-free reduction of esophagogastric junction. Based on projections that 20,000 to 40,000 antireflux procedures will be performed in the United States in the year 2000, calculations would show that between 1200 and 2500 patients will require specialized operations for esophageal shortening. Surgeons should be making every attempt to identify these patients preoperatively and have the flexibility to manage them appropriately at the time of antireflux repair.

Esophageal shortening during the era of laparoscopic surgery.

An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia > or = 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n = 11) or open transthoracic Collis gastroplasty (n = 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63-100%) without a corresponding increase in sensitivity (28-42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.