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Thoracoscopic collis gastroplasty and laparoscopic Nissen fundoplication for shortened esophagus
Thoracoscopic Collis Gastroplasty and Laparoscopic Nissen Fundoplication for Shortened Esophagus Richard J. Finley, MD, FACS, FRCSC
Laparoscopic hiatial hernia repair with fundoplication is rapidly becoming the treatment of choice for the complications of gastroesophageal reflux disease (GERD). Careful patient selection after preoperative testing and proper operative technique, including crural closure and fundoplication performed without tension, have contributed to the good results reported in most series. 1,2 All of the commonly used standard repairs (Nissen, Belsey, and Hill) restore a segment of the distal esophagus to an intra-abdominal position. Extensive dissection of the esophagogastric junction and the mediastinal esophagus up to the level of the carina allows the mobilization of 3 cm of tubular esophagus into the abdomen in most cases. A small minority of patients experience an acquired shortening of the esophagus caused by mural scarring, with vertical scar contractures secondary to peptic esophagitis. This complication occurs as a result of the most advanced stages of reflux esophagitis, which include confluent ulceration, peptic stricture, and acquired columnar-lined esophagus. In this situation, an esophageal lengthening procedure or gastroplasty is indicated as an addition to any antireflux operation if the repair is anticipated to result in an unacceptable level of tension on the esophagogastric junction anchored in the abdomen. A gastroplasty is fashioned from the lesser curvature side of the stomach in continuity with the distal esophagus, so that at completion the distal end of the gastroplasty serves as the new esophagogastric junction. The esophagus thus has been lengthened, reducing the likelihood of tension on and migration of the new esophagogastric junction into the chest. The technique of gastroplasty should not be confused with the various operations for the management of morbid obesity.
HISTORICAL N O T E In 1957, Collis 3 described the use of gastroplasty tO help patients with hiataI hernia repair associated with a short Fromthe Departmentof Surgery,Universityof BritishColumbiaand VancouverHospitaland HealthSciencesCentre,Vancouver,BritishColumbia,Canada. Address reprint requeststo R. J. Finley,MD, UBC Departmentof Surgery, LSP/VGH,#3100-910West10thAvenue,Vancouver,BCCanadaV5Z4E3. Copyright9 2000byWB.SaundersCompany 1524-153X/00/0201-0002510.00/0 doi:10.1053/gs.2000.5733
esophagus. In 1971, Pearson et al 4 reported the use of Collis gastroplasty in combination with a Belsey partial fundoplication through a left thoracotomy. Subsequent modifications by other surgeons included an uncut gastroplasty 5 and the use of Nissen-type fundoplication rather than a Belsey Mark IV procedure. 6,7 Using the experience derived from laparoscopic cholecystectomy, Weerts et al 8 described the first use of laparoscopic techniques for hiatal hernia repair. In 1996, Swanstrom et al 9 described the use of combination laparoscopic and thorascopic approach for Collis gastroplasty in conjunction with laparoscopic fundoplication.
INDICATIONS Gastroplasty is indicated if it is not possible to deliver the gastroesophagealjunction at least 3 cm below the front of the hiatus after extensive mediastinal esophageal mobilization. The primary indication for the addition of gastroplasty is acquired esophageal shortening caused by esophagitis. Pearson 1~ adds a gastroplasty to the hiatus hernia repair for patients with failed previous antireflux surger3z. This decision is based on the observation that the first operation failed because of esophagitis and esophageal shortening or because the patient had esophageal tissues that were damaged secondary to the first operation. Therefore, the addition of gastroplast~' reduces tension on the repair, decreasing the chances of recurrence. Patients with massive hiatus hernias and intrathoracic stomach have some vertical shortening of the esophagus during evolution of the hernia. Pearson et a111 have stressed the importance of lengthening of the esophagus in patients with massive hiatial hernia, because their initial experience with the Belsey repair alone resulted in a high recurrence rate. Gastroplasty is also suggested for patients with chronic cough or asthma, who put increased strain on the repair and thus have a greater risk of recurrence. Gastroplasty should not be done in patients taking high doses of oral steroids.
D I A G N O S I S OF A C Q U I R E D S H O R T ESOPHAGUS Diagnosis of a short esophagus is made using contrast radiographs, esophagogastroscopy, special measurements
Operative Techniquesin General Surgery,Vol 2, No 1 (March), 2000: pp 15-23
15
16 during esophageal manometry, and intraoperative findings at the time of surgery. The accepted criterion for describing a shortened esophagus is identification of the esophagogastric junction 5 cm or more above the diaphragmatic hiatus. As the esophagus shortens, the angle of His is lost, and the esophagogastric junction slides into the chest. During a barium swallow, the patient is examined in the supine and upright positions. If the esophagogastric junction is 5 cm above the hiatus and does not reduce into the abdomen in the upright position, then a shortened esophagus should be suspected. The distance from the esophagogastric junction up to the level of the diaphragmatic hiatus can also be determined during flexible endoscopy. An esophagogastric junction that lies 5 cm above the diaphragmatic hiatus and does not reduce with tilting of the endoscopy table also points to esophageal shortening. An esophagoscopic finding of severe, gross peptic esophagitis with confluent ulceration, peptic stricture, or acquired columnar-lined esophagus should alert the surgeon to the possibility of acquired shortening. The distance between the cricopharyngeal sphincter
Richard J. Finley and the lower esophageal sphincter can be determined during esophageal manometry. This is probably the most accurate means of determining a true shortened esophagus. In most normal adults, the distance between the lower border of cricopharyngeal sphincter and the upper border of the esophageal sphincter is 18 cm or more. At the time of operation, the presence of panmural esophagitis, including edema and thickening of the esophageal wall, chronic periesophageal lymphadenopathy, and scarred periesophageal areolar tissues that embed the esophagus in the posterior mediastinum, suggests a shortened esophagus. After circumferential mobilization of the distal esophagus up to the level of the carina, a shortened esophagus is diagnosed if at least 3 cm of esophagus cannot be mobilized into the abdomen without tension. With massive hiatal hernia, the mediastinal hiatal hernia sac should be mobilized into the abdomen to deliver the esophagus into the abdomen. If the esophagus remains shortened after this maneuver, then the sac must be excised to expose the esophagogastric junction for formation of the gastroplasty.
Gastroplasty With Fundoplication
17
SURGICAL TECHNIQUE All patients with suspected shortened esophagus requiring a gastroplasty should be ventilated through a double-lumen endotracheal tube placed under general anesthesia.
Site for optional 5-mm port
12-mm Trocar for endostapler
.%*
?i
5-mm Trc with liver retractor 9. / /
./
': 7:)
/
.:
-., %.,
.
5-mm Trocar with Babcock
.
. ..,,.
"--..
_.
10-mm Trocar with camera and insuflation
1 The patient is positioned in the low lithotomy position in a steep reverse Trendelenburg position. A small roll is placed under the scapula, then the right arm is placed on an arm board. The abdomen and the right side of the chest are prepared and draped. Two 10-mm ports and 3 5-mm ports are placed in the upper abdomen after induction of a safe pneumoperitoneum. If a gastroplasty is indicated, a 12-mm port is placed in the right anterior axillary line at the level of the fourth intercostal space. The liver retractor is inserted through port E to expose the hiatus, a 5-mm Babcock clamp is placed through port D, and the esophagogastric junction is retracted toward the left lower quadrant. Laparoscopic scissors are placed through port B, and blunt forceps are placed through port C. The laparoscope is placed through port A.
18
Richard J. Finley
:ric ]ted led
with scissors
onfundus
2 The upper part of the gastrohepatic omentum and the phrenoesophageal ligament are divided, exposing the lower esophagus. The right and left limbs of the right diaphragmatic crus are carefully exposed, and care should be taken not to injure the anterior and posterior vagus nerves. The mediastinal hernia sac is dissected out of the mediastinum and reduced into the abdomen by gentle retraction. The division of the short gastric vessels and posterior fundal attachments mobilizes the gastric fundus. The fundus of the stomach, the esophagogastric junction, and the esophagus should be free from all diaphragmatic attachments. After the establishment of a large retroesophageal window, a tape is placed around the~esophagogastric junction to keep the anterior and posterior vagus nerves in continuity with the esophagus. Extensive transhiatal mediastinal dissection is carried up to the level of the carina. If the gastroesophageal junction cannot be mobilized at least 3 cm below the anterior part of the hiatus without undue tension, then endoscopic gastroplasty is performed.
19
Gastroplasty With Fundoplication
Linear endost~ introduced thoracos via esophageal
50 French bougie
3 If a double-lumen tube has been inserted, the right lung is collapsed and a 12-mm thoracic port is placed in the fourth intercostal space at the level of the right anterior axillary line. If a double-lumen tube is not in place, a 12-mm closed thoracic port is inserted in the right fourth intercostal space, and a pneumothorax is produced using carbon dioxide up to a pressure of 10 mm Hg. A 30 ~ telescope is inserted and advanced to the mediastinal pleura at the posteroinferior pulmonary sulcus. This allows for transillumination and visualization of the right posterior pleura from the abdominal cavity. Once the proper trajectory has been selected, the thoracic port is stabilized, the telescope withdrawn, and a 45-mm endoscopic linear stapler inserted. If visualization is not adequate, then an additional 5-mm trocar site is introduced in the posterolateral lateral intercostal space to aid insertion of the endoscopic stapler: The stapler is pushed into the mediastinal pleura, which is divided laparoscopically to allow passage of the stapling device into the abdominal cavity. The fundus is then grasped along the greater curvature and rotated into the anterior position, allowing placement of the stapler parallel to the distal esophagus beg,inning at the angle of His. A 50 French bougie is inserted orally into the stomach along its lesser curvature. The stapler is held tightly along the lateral aspect of the bougie and closed and fixed, which creates a 4.5-cm neoesophagus or gastroplasty. It is important that the bougie be removed before the endoscopic stapler is removed, to prevent any dehiscence of the staple line.
20
Richard J. Finley
" ~i' : / ~ '\,,
Right and left crura approximated with 0 silk sutures
Superior end of staple line on fundus reinforced with Lembert ..... / sutures
s
:';~
.:."
I
;
.
.
.
.
.
'
Crotch of gastroplasty reinforced with interrupted sutures
4 After the stapler is removed, the tip of the fundoplication is reinforced with 2-0 silk sutures. The crotch of the gastroplasty is also reinforced with a horizontal mattress suture to prevent dehiscence. After the stapler is removed, the thoracic port is vented as the patient is given positive pressure ventilation. The diaphragmatic crura are approximated with 0 silk sutures.
Gastroplasty With Fundoplication
21
Fundus wrapped behind esophagus and sewn
5 The fundoplication is sewn to the diaphragmatic crura to avoid any migration of the fundoplication into the chest.
f ,,i i!!i
J!iil
Loose 2.5-cm d
6 A ,loose 2.5-cm fundoplication is created around the neoesophagus with 0 silk sutures. All sutures are tied intracorporally to minimize tissue trauma. The pneumoperitoneum is released, and the laparoscopic port sites are closed with 0 polyglycolic sutures in the fascia and subcuticular skin sutures. A chest tube is inserted into the thoracic port site, attached to underwater drainage, and removed after 24 hours.
22
Postoperative Management The patient undergoes a diatrizoate meglumine (gastrograffin) swallow on the first postoperative day. If this swallow is normal, the patient is started on clear fluids and discharged from the hospital approximately 48 hours after the operation The patient is placed on full fluid diet, proton pump inhibitor, and prokinetic agents for 3 weeks after the operation. The patient should be assessed at 3-month intervals for i year and twice yearly thereafter.
Results In 1987, Pearson et a112 reported results obtained in a consecutive series of 430 patients with complex reflux problems who underwent modified Collis gastroplasty and partial fundoplication through a left thoracotomy. Follow-up was complete in 90% of patients and extended from 1 year to 28 years. In the 215 cases with shortened esophagus due to stricture of the esophagus, 93% of the patients reported good results. Of the patients with 1 or more previous unsuccessful antireflux operations, 80% described a good result. Only 54% of the patients with a peptic stricture or esophagitis associated with a primary motor disorder had a good result. In 54 patients with an intrathoracic stomach, 91% had a good result. In 1989, Stifling and Orringer 13 reported excellent results when they performed modified Collis gastroplasty and Nissen fundoplication through a left thoracotomy on patients with shortened esophagus. They found that patients with bad reflux disease had a better result with the addition of a Nissen fundoplication than with the .Belsey partial fundoplication added to the gastroplasty. Functional results using both techniques are very good. Anatomic recurrence of the hernia is exceedingly rare in patients with gastroplasty because of the absence of tension on the reconstruction. In 1996, Swanstrom et al 9 described the use of thoracoscopic Collis gastroplasty in combination with Nissen fundoplication in a small groups of patients with paraesophageal hiatial hernias where ~ the esophagogastric junction is in the chest. He was unable to reduce the esophagus into the abdomen despite extensive mediastinal dissection. In a more detailed follow-up of this operation, Jobe et a114 described thoracoscopic Collis gastroplasty and Nissen fundoplication in 4.3% of 580 patients undergoing laparoscopic hiatal hernia repair. The mean operative time was 4.2 hours, and no intraoperative complications, deaths, or conversion to a laparotomy were reported. One patient had a postoperative ileus that resolved spontaneously. Two patients returned to the emergency department soon after discharge with pleuritic chest pain that resolved with anti-inflammatory agents. The length of hospital stay averaged 2 days. Two of the 14 patients available for long-term follow-up had heartburn, and 2 patients had dysphagia. Biopsy of the neoesophagus directly under the fundoplication revealed
Richard J. Finley oxyntic mucosa with parietal and G cell tissue in all 11 of the patients undergoing endoscopy. Lower esophageal sphincter pressure increased from 7 m m Hg to 16 m m Hg. A 93% increase in resting pressure and a 196% increase in lower esophageal length were seen after Collis gastroplasty and fundoplication. Seven patients had abnormal postoperative 24-hour pH studies; two were symptomatic and were treated with proton pump inhibitors. All 7 of these patients exhibited positive Congo red staining, indicating actively secreting gastric mucosa in the gastroplasty. Of these 7 patients, 5 had persistent esophagitis. There has been no anatomical recurrence of the hiatal hernias. Results suggest an effective antireflux mechanism; however, gastroplasty patients require close objective follow-up and, if necessary, maintenance acid suppression because of the acid-secreting gastric mucosa proximal to the intact fundoplication. Over the past 5 years, the aggressive use of proton pump inhibitors and prokinetic agents before antireflux procedures has reduced the incidence of panesophagitis, esophagitis, and peptic strictures. Patients with severe esophagitis despite m a x i m u m proton pump inhibitor therapy should be investigated for the use of nonsteroidal anti-inflammatory agents, presence of viral or fungal infections, or the presence of Zollinger-Ellison syndrome. If these known causes of esophagitis have been ruled out, then the patient may require an esophageallengthening procedure in association with laparoscopic hiatal hernia repair. Patients with massive hernias may also require an esophageal-lengthening procedure, and the surgeon should obtain consent for gastroplasty before proceeding with laparoscopic repair of these large hernias.
REFERENCES 1. Hinder RA, Filipi CJ, Wescher G, et al: Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220:472-481, 1994 2. Peters JH, Heimbucher J, Kauer WKH, et al: Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Coil Surg 180:385-393, 1995 3. CollisJL: An operation for hiatus hernia with short esophagus.J Thorac CardiovascSurg34:768-773, 1957 4. Pearson RG, Langer R, Henderson RD: Gastroplasty and Belsey hiatus hernia repair.J Thorac CardiovascSurg 61:50-63, 1971 5. Langer B: Modified gastroplasty: A simple operation for reflux esophagitis with moderate degrees of shortening. Can J Surg 16:84-91, 1973 6. Henderson RD: Refluxcontrol followinggastroplasty.Ann Thorac Surg 24:206-214, 1977 7. Orringer MB, Sloan H: Complications and failings of combined Collis-Belsey operation. J Thorac Cardiovasc Surg 74:726-35, 1977 8. WeertsJM, DallemagneB, Hamoir E, et al: LaparoscopicNissen fundoplication: Detailed analysis of 132 patients. Surg Endosc 3:359-364, 1993
Gastroplasty With Fundoplication 9. Swanstrom LL, Marcus DM, Galloway GQ: Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. AmJ Surg 171:477-481, 1996 10. Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty, and Belsey hiatus hernia repair. Surgery 80:396-404, 1976 11. Pearson FG, Cooper JD, Ilves R, et al: Massive hiatal hernia with incarceration: A report of 53 cases. Ann Thorac Surg 35:45-51, 1983
23 12. Pearson FG, Cooper J, Patterson G, et ah Gastroplasty and fundoplication for complex reflux problems. Ann Surg 206:473481, 1987 13. Stifling MC, Orringer MB: Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989;47:224230 14. Jobe BA, Horvath K, Swanstrom LL: Postoperative function following laparoscopic Collis gastroplasty for shortened esophagus. Arch Surg 133:867-874, 1998
Laparoscopic hiatial hernia repair with fundoplication is rapidly becoming the treatment of choice for the complications of gastroesophageal reflux disease (GERD). Careful patient selection after preoperative testing and proper operative technique, including crural closure and fundoplication performed without tension, have contributed to the good results reported in most series. 1,2 All of the commonly used standard repairs (Nissen, Belsey, and Hill) restore a segment of the distal esophagus to an intra-abdominal position. Extensive dissection of the esophagogastric junction and the mediastinal esophagus up to the level of the carina allows the mobilization of 3 cm of tubular esophagus into the abdomen in most cases. A small minority of patients experience an acquired shortening of the esophagus caused by mural scarring, with vertical scar contractures secondary to peptic esophagitis. This complication occurs as a result of the most advanced stages of reflux esophagitis, which include confluent ulceration, peptic stricture, and acquired columnar-lined esophagus. In this situation, an esophageal lengthening procedure or gastroplasty is indicated as an addition to any antireflux operation if the repair is anticipated to result in an unacceptable level of tension on the esophagogastric junction anchored in the abdomen. A gastroplasty is fashioned from the lesser curvature side of the stomach in continuity with the distal esophagus, so that at completion the distal end of the gastroplasty serves as the new esophagogastric junction. The esophagus thus has been lengthened, reducing the likelihood of tension on and migration of the new esophagogastric junction into the chest. The technique of gastroplasty should not be confused with the various operations for the management of morbid obesity.
HISTORICAL N O T E In 1957, Collis 3 described the use of gastroplasty tO help patients with hiataI hernia repair associated with a short Fromthe Departmentof Surgery,Universityof BritishColumbiaand VancouverHospitaland HealthSciencesCentre,Vancouver,BritishColumbia,Canada. Address reprint requeststo R. J. Finley,MD, UBC Departmentof Surgery, LSP/VGH,#3100-910West10thAvenue,Vancouver,BCCanadaV5Z4E3. Copyright9 2000byWB.SaundersCompany 1524-153X/00/0201-0002510.00/0 doi:10.1053/gs.2000.5733
esophagus. In 1971, Pearson et al 4 reported the use of Collis gastroplasty in combination with a Belsey partial fundoplication through a left thoracotomy. Subsequent modifications by other surgeons included an uncut gastroplasty 5 and the use of Nissen-type fundoplication rather than a Belsey Mark IV procedure. 6,7 Using the experience derived from laparoscopic cholecystectomy, Weerts et al 8 described the first use of laparoscopic techniques for hiatal hernia repair. In 1996, Swanstrom et al 9 described the use of combination laparoscopic and thorascopic approach for Collis gastroplasty in conjunction with laparoscopic fundoplication.
INDICATIONS Gastroplasty is indicated if it is not possible to deliver the gastroesophagealjunction at least 3 cm below the front of the hiatus after extensive mediastinal esophageal mobilization. The primary indication for the addition of gastroplasty is acquired esophageal shortening caused by esophagitis. Pearson 1~ adds a gastroplasty to the hiatus hernia repair for patients with failed previous antireflux surger3z. This decision is based on the observation that the first operation failed because of esophagitis and esophageal shortening or because the patient had esophageal tissues that were damaged secondary to the first operation. Therefore, the addition of gastroplast~' reduces tension on the repair, decreasing the chances of recurrence. Patients with massive hiatus hernias and intrathoracic stomach have some vertical shortening of the esophagus during evolution of the hernia. Pearson et a111 have stressed the importance of lengthening of the esophagus in patients with massive hiatial hernia, because their initial experience with the Belsey repair alone resulted in a high recurrence rate. Gastroplasty is also suggested for patients with chronic cough or asthma, who put increased strain on the repair and thus have a greater risk of recurrence. Gastroplasty should not be done in patients taking high doses of oral steroids.
D I A G N O S I S OF A C Q U I R E D S H O R T ESOPHAGUS Diagnosis of a short esophagus is made using contrast radiographs, esophagogastroscopy, special measurements
Operative Techniquesin General Surgery,Vol 2, No 1 (March), 2000: pp 15-23
15
16 during esophageal manometry, and intraoperative findings at the time of surgery. The accepted criterion for describing a shortened esophagus is identification of the esophagogastric junction 5 cm or more above the diaphragmatic hiatus. As the esophagus shortens, the angle of His is lost, and the esophagogastric junction slides into the chest. During a barium swallow, the patient is examined in the supine and upright positions. If the esophagogastric junction is 5 cm above the hiatus and does not reduce into the abdomen in the upright position, then a shortened esophagus should be suspected. The distance from the esophagogastric junction up to the level of the diaphragmatic hiatus can also be determined during flexible endoscopy. An esophagogastric junction that lies 5 cm above the diaphragmatic hiatus and does not reduce with tilting of the endoscopy table also points to esophageal shortening. An esophagoscopic finding of severe, gross peptic esophagitis with confluent ulceration, peptic stricture, or acquired columnar-lined esophagus should alert the surgeon to the possibility of acquired shortening. The distance between the cricopharyngeal sphincter
Richard J. Finley and the lower esophageal sphincter can be determined during esophageal manometry. This is probably the most accurate means of determining a true shortened esophagus. In most normal adults, the distance between the lower border of cricopharyngeal sphincter and the upper border of the esophageal sphincter is 18 cm or more. At the time of operation, the presence of panmural esophagitis, including edema and thickening of the esophageal wall, chronic periesophageal lymphadenopathy, and scarred periesophageal areolar tissues that embed the esophagus in the posterior mediastinum, suggests a shortened esophagus. After circumferential mobilization of the distal esophagus up to the level of the carina, a shortened esophagus is diagnosed if at least 3 cm of esophagus cannot be mobilized into the abdomen without tension. With massive hiatal hernia, the mediastinal hiatal hernia sac should be mobilized into the abdomen to deliver the esophagus into the abdomen. If the esophagus remains shortened after this maneuver, then the sac must be excised to expose the esophagogastric junction for formation of the gastroplasty.
Gastroplasty With Fundoplication
17
SURGICAL TECHNIQUE All patients with suspected shortened esophagus requiring a gastroplasty should be ventilated through a double-lumen endotracheal tube placed under general anesthesia.
Site for optional 5-mm port
12-mm Trocar for endostapler
.%*
?i
5-mm Trc with liver retractor 9. / /
./
': 7:)
/
.:
-., %.,
.
5-mm Trocar with Babcock
.
. ..,,.
"--..
_.
10-mm Trocar with camera and insuflation
1 The patient is positioned in the low lithotomy position in a steep reverse Trendelenburg position. A small roll is placed under the scapula, then the right arm is placed on an arm board. The abdomen and the right side of the chest are prepared and draped. Two 10-mm ports and 3 5-mm ports are placed in the upper abdomen after induction of a safe pneumoperitoneum. If a gastroplasty is indicated, a 12-mm port is placed in the right anterior axillary line at the level of the fourth intercostal space. The liver retractor is inserted through port E to expose the hiatus, a 5-mm Babcock clamp is placed through port D, and the esophagogastric junction is retracted toward the left lower quadrant. Laparoscopic scissors are placed through port B, and blunt forceps are placed through port C. The laparoscope is placed through port A.
18
Richard J. Finley
:ric ]ted led
with scissors
onfundus
2 The upper part of the gastrohepatic omentum and the phrenoesophageal ligament are divided, exposing the lower esophagus. The right and left limbs of the right diaphragmatic crus are carefully exposed, and care should be taken not to injure the anterior and posterior vagus nerves. The mediastinal hernia sac is dissected out of the mediastinum and reduced into the abdomen by gentle retraction. The division of the short gastric vessels and posterior fundal attachments mobilizes the gastric fundus. The fundus of the stomach, the esophagogastric junction, and the esophagus should be free from all diaphragmatic attachments. After the establishment of a large retroesophageal window, a tape is placed around the~esophagogastric junction to keep the anterior and posterior vagus nerves in continuity with the esophagus. Extensive transhiatal mediastinal dissection is carried up to the level of the carina. If the gastroesophageal junction cannot be mobilized at least 3 cm below the anterior part of the hiatus without undue tension, then endoscopic gastroplasty is performed.
19
Gastroplasty With Fundoplication
Linear endost~ introduced thoracos via esophageal
50 French bougie
3 If a double-lumen tube has been inserted, the right lung is collapsed and a 12-mm thoracic port is placed in the fourth intercostal space at the level of the right anterior axillary line. If a double-lumen tube is not in place, a 12-mm closed thoracic port is inserted in the right fourth intercostal space, and a pneumothorax is produced using carbon dioxide up to a pressure of 10 mm Hg. A 30 ~ telescope is inserted and advanced to the mediastinal pleura at the posteroinferior pulmonary sulcus. This allows for transillumination and visualization of the right posterior pleura from the abdominal cavity. Once the proper trajectory has been selected, the thoracic port is stabilized, the telescope withdrawn, and a 45-mm endoscopic linear stapler inserted. If visualization is not adequate, then an additional 5-mm trocar site is introduced in the posterolateral lateral intercostal space to aid insertion of the endoscopic stapler: The stapler is pushed into the mediastinal pleura, which is divided laparoscopically to allow passage of the stapling device into the abdominal cavity. The fundus is then grasped along the greater curvature and rotated into the anterior position, allowing placement of the stapler parallel to the distal esophagus beg,inning at the angle of His. A 50 French bougie is inserted orally into the stomach along its lesser curvature. The stapler is held tightly along the lateral aspect of the bougie and closed and fixed, which creates a 4.5-cm neoesophagus or gastroplasty. It is important that the bougie be removed before the endoscopic stapler is removed, to prevent any dehiscence of the staple line.
20
Richard J. Finley
" ~i' : / ~ '\,,
Right and left crura approximated with 0 silk sutures
Superior end of staple line on fundus reinforced with Lembert ..... / sutures
s
:';~
.:."
I
;
.
.
.
.
.
'
Crotch of gastroplasty reinforced with interrupted sutures
4 After the stapler is removed, the tip of the fundoplication is reinforced with 2-0 silk sutures. The crotch of the gastroplasty is also reinforced with a horizontal mattress suture to prevent dehiscence. After the stapler is removed, the thoracic port is vented as the patient is given positive pressure ventilation. The diaphragmatic crura are approximated with 0 silk sutures.
Gastroplasty With Fundoplication
21
Fundus wrapped behind esophagus and sewn
5 The fundoplication is sewn to the diaphragmatic crura to avoid any migration of the fundoplication into the chest.
f ,,i i!!i
J!iil
Loose 2.5-cm d
6 A ,loose 2.5-cm fundoplication is created around the neoesophagus with 0 silk sutures. All sutures are tied intracorporally to minimize tissue trauma. The pneumoperitoneum is released, and the laparoscopic port sites are closed with 0 polyglycolic sutures in the fascia and subcuticular skin sutures. A chest tube is inserted into the thoracic port site, attached to underwater drainage, and removed after 24 hours.
22
Postoperative Management The patient undergoes a diatrizoate meglumine (gastrograffin) swallow on the first postoperative day. If this swallow is normal, the patient is started on clear fluids and discharged from the hospital approximately 48 hours after the operation The patient is placed on full fluid diet, proton pump inhibitor, and prokinetic agents for 3 weeks after the operation. The patient should be assessed at 3-month intervals for i year and twice yearly thereafter.
Results In 1987, Pearson et a112 reported results obtained in a consecutive series of 430 patients with complex reflux problems who underwent modified Collis gastroplasty and partial fundoplication through a left thoracotomy. Follow-up was complete in 90% of patients and extended from 1 year to 28 years. In the 215 cases with shortened esophagus due to stricture of the esophagus, 93% of the patients reported good results. Of the patients with 1 or more previous unsuccessful antireflux operations, 80% described a good result. Only 54% of the patients with a peptic stricture or esophagitis associated with a primary motor disorder had a good result. In 54 patients with an intrathoracic stomach, 91% had a good result. In 1989, Stifling and Orringer 13 reported excellent results when they performed modified Collis gastroplasty and Nissen fundoplication through a left thoracotomy on patients with shortened esophagus. They found that patients with bad reflux disease had a better result with the addition of a Nissen fundoplication than with the .Belsey partial fundoplication added to the gastroplasty. Functional results using both techniques are very good. Anatomic recurrence of the hernia is exceedingly rare in patients with gastroplasty because of the absence of tension on the reconstruction. In 1996, Swanstrom et al 9 described the use of thoracoscopic Collis gastroplasty in combination with Nissen fundoplication in a small groups of patients with paraesophageal hiatial hernias where ~ the esophagogastric junction is in the chest. He was unable to reduce the esophagus into the abdomen despite extensive mediastinal dissection. In a more detailed follow-up of this operation, Jobe et a114 described thoracoscopic Collis gastroplasty and Nissen fundoplication in 4.3% of 580 patients undergoing laparoscopic hiatal hernia repair. The mean operative time was 4.2 hours, and no intraoperative complications, deaths, or conversion to a laparotomy were reported. One patient had a postoperative ileus that resolved spontaneously. Two patients returned to the emergency department soon after discharge with pleuritic chest pain that resolved with anti-inflammatory agents. The length of hospital stay averaged 2 days. Two of the 14 patients available for long-term follow-up had heartburn, and 2 patients had dysphagia. Biopsy of the neoesophagus directly under the fundoplication revealed
Richard J. Finley oxyntic mucosa with parietal and G cell tissue in all 11 of the patients undergoing endoscopy. Lower esophageal sphincter pressure increased from 7 m m Hg to 16 m m Hg. A 93% increase in resting pressure and a 196% increase in lower esophageal length were seen after Collis gastroplasty and fundoplication. Seven patients had abnormal postoperative 24-hour pH studies; two were symptomatic and were treated with proton pump inhibitors. All 7 of these patients exhibited positive Congo red staining, indicating actively secreting gastric mucosa in the gastroplasty. Of these 7 patients, 5 had persistent esophagitis. There has been no anatomical recurrence of the hiatal hernias. Results suggest an effective antireflux mechanism; however, gastroplasty patients require close objective follow-up and, if necessary, maintenance acid suppression because of the acid-secreting gastric mucosa proximal to the intact fundoplication. Over the past 5 years, the aggressive use of proton pump inhibitors and prokinetic agents before antireflux procedures has reduced the incidence of panesophagitis, esophagitis, and peptic strictures. Patients with severe esophagitis despite m a x i m u m proton pump inhibitor therapy should be investigated for the use of nonsteroidal anti-inflammatory agents, presence of viral or fungal infections, or the presence of Zollinger-Ellison syndrome. If these known causes of esophagitis have been ruled out, then the patient may require an esophageallengthening procedure in association with laparoscopic hiatal hernia repair. Patients with massive hernias may also require an esophageal-lengthening procedure, and the surgeon should obtain consent for gastroplasty before proceeding with laparoscopic repair of these large hernias.
REFERENCES 1. Hinder RA, Filipi CJ, Wescher G, et al: Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220:472-481, 1994 2. Peters JH, Heimbucher J, Kauer WKH, et al: Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Coil Surg 180:385-393, 1995 3. CollisJL: An operation for hiatus hernia with short esophagus.J Thorac CardiovascSurg34:768-773, 1957 4. Pearson RG, Langer R, Henderson RD: Gastroplasty and Belsey hiatus hernia repair.J Thorac CardiovascSurg 61:50-63, 1971 5. Langer B: Modified gastroplasty: A simple operation for reflux esophagitis with moderate degrees of shortening. Can J Surg 16:84-91, 1973 6. Henderson RD: Refluxcontrol followinggastroplasty.Ann Thorac Surg 24:206-214, 1977 7. Orringer MB, Sloan H: Complications and failings of combined Collis-Belsey operation. J Thorac Cardiovasc Surg 74:726-35, 1977 8. WeertsJM, DallemagneB, Hamoir E, et al: LaparoscopicNissen fundoplication: Detailed analysis of 132 patients. Surg Endosc 3:359-364, 1993
Gastroplasty With Fundoplication 9. Swanstrom LL, Marcus DM, Galloway GQ: Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. AmJ Surg 171:477-481, 1996 10. Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty, and Belsey hiatus hernia repair. Surgery 80:396-404, 1976 11. Pearson FG, Cooper JD, Ilves R, et al: Massive hiatal hernia with incarceration: A report of 53 cases. Ann Thorac Surg 35:45-51, 1983
23 12. Pearson FG, Cooper J, Patterson G, et ah Gastroplasty and fundoplication for complex reflux problems. Ann Surg 206:473481, 1987 13. Stifling MC, Orringer MB: Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989;47:224230 14. Jobe BA, Horvath K, Swanstrom LL: Postoperative function following laparoscopic Collis gastroplasty for shortened esophagus. Arch Surg 133:867-874, 1998