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Elongation gastroplasty with total fundoplication (Collis-Nissen operation)
Elongation Gastroplasty With Total Fundoplication (Collis-Nissen Operation) Pasquale Ferraro, MD and Andre Duranceau, MD
The elongation gastroplasty initially described by Collis provides a tube created from the lesser curvature of the stomach, adding to the length of the original esophagus. The total fundoplication creates a new antireflux barrier. This operation aims to provide 9 an appropriate intra-abdominal length by adding a neoesophagus
SURGICAL
1
9 an antireflux mechanism that is not an impediment to the passage of the alimentary bolus but acts as a good defense against gastric or duodenogastric refluxates 9 a tension-free antireflux repair, reduced and fixed below the diaphragm, where it is exposed to intraabdominal pressures.
TECHNIQUE
A double-lumen tube is positioned in the trachea, and the patient
is placed in a right lateral decubitus position. The left arm is supported by an arm rest, and the incision follows the upper border of the eighth rib. The posterior arc of the rib is divided, and 1 cm of the rib is removed to avoid postoperative e n d - t o - e n d rib contact. (Modified with permission from the Mayo F o u n d a t i o n . )
From the Thoracic Surgery Division, Department of Surge~ Universityof Montreal, Montreal,Quebec,Canada. Address reprint requests to Andr~ D~.~ranceau,MD, Universityof Montreal MedicalCenter, 3840 St. Urbain,Montreal,Quebec, Canada,H2W 1T8. Copyright 9 2000 by "vVB.SaundersCompany 1524-153X/00/0201-0003510.00/0 doi:10.1053/gs.2000.5735
24
Operative Techniques in General Surgery, Vol 2, No 1 (March), 2000: pp 24-37
25
Collis-Nissen Operation
Pericardium
Penrose ~//drain
Pericardium
I k',,
C
Ao~a
Esophagus
2 (A) Adhesions between the lung and the chest wall are freed if necessary. The mediastinum is opened as an inverted T, and the vertical incision is made 1 cm anterior to the descending aorta and along the pericardium. Both incisions meet behind the inferior pulmonary vein. (B) The horizontal part of the T is made along the left crus of the diaphragm and extended anteriorly, where the pericardium is freed from "the fibrous portion of the diaphragm. The inferior pulmonary ligament is divided using electrocautery. The collapsed left inferior lobe is retracted anteriorly and kept in place by large intrathoracic pads. The mediastinum is opened widely, and vessels from the aorta to the esophagus are clamped and divided. (C) After being freed from the aorta and pericardium, the esophagus is encircled by blunt dissection, protecting both the anterior and posterior vagi. Doing so exposes the contralateral pleura. The esophagus is dissected completely free between the hiatus and the area between the inferior pulmonary vein and the aortic arch. (Modified with permission from the Mayo Foundation.)
26
Ferraro and Duranceau
3 (A) The diaphragmatic hiatus is freed with easy identification of the left crus. Anterior to the esophagus or herniated stomach, the incision follows the circular limits of the hiatus. (B) The right crus is exposed posterior to the esophagus. Complete dissection of the hiatus is easier when the peritoneal cavity is opened. The peritoneum is protected on the undersurface of the hiatus, and the pleura covers the upper surface of the hiatus. Identification of the pleura where it covers the right crus is obtained by opening the right chest pleura. Division of the pleura then follows the inferior surface of the right lung and the right inferior pulmonary ligament. At this point, the entire diaphragmatic hiatus is well identified. The left and right crura are ready for reapproximation. (Modified with permission from the Mayo Foundation.)
27
Collis-Nissen Operation
4 (A) If a massive hernia is presen t (types II, III, or IV), the hiatus is usually very wide; and the peritoneum is easily opened anteriorly. In this situation, the fundus and greater curvature are easily identified, and the short gastric vessels are dissected free and ligated. More than 50% of patients with severe complications of idiopathic reflux disease (ie, esophageal stricture or Barrett's esophagus) actually reveal no evidence of a hiatal hernia. In such a situation, two techniques allow access to dissection of the greater curvature. The first technique opens the retrogastric cavity behind the esophagogastric junction and left crus. Progressive freeing of the stomach is then accomplished by ligation of the short gastric vessels. The second approach creates a lateral opening in the diaphragm, approximately 2 to 3 cm from the muscular insertion on the chest wall. A GIA stapler is used to create a 6to 8-cm-long diaphragmatic division. Thus exposed, the short gastric vessels are ligated under direct vision , and the entire greater curvature is freed. With 2 or 3 fingers positioned through the abdominal hiatus, the phrenoesophageal ligament is put under tension and divided around the limits of the hiatus. The anterior and posterior aspects of the lesser curvature are easily identified and dissected using this approach. When completely free, the esophagus and proximal stomach are delivered into the chest through the hiatus. (Modified with permission from the Mayo Foundation.)
28
Ferraro and Duranceau
4
(continued) (B) The anterior and posterior portions of the proximal lesser curvature are dissected as for a highly selective vagotomy. The fat pad of the esophagogastric junction is resected, the anterior and posterior vagi are dissected free from the stomach wall and pushed away to allow the creation of the gastroplasty, and 6 to 7 cm of smaller curvature is denuded from the surrounding tissue. Closure of the hiatus behind the esophagus is accomplished at this point. These sutures cannot be easily placed once the esophagogastric junction repair is completed. The right crus is taken with a small Duval clamp, holding the crus with the peritoneum under and the pleura above. The left crus is seized in the same way with a second clamp. 1-0 silk sutures are initially passed posteriorly with bites taking all tissue layers, including the transversal fascia and the fibrous portion of the crus. A distance of 0.5 to 1 cm is left between each suture, and when the last suture is installed, easy passage should remain for the index finger between the esophageal wall containing the #50 bougie and the last suture reapproximating the crura (refer to Fig 9). (Modified with permission from the Mayo Foundation.)
Collis-Nissen Operation
29
Creation of the Elongation Gastroplasty The entire esophagogastric junction lies within the chest. A #50 tapered bougie is positioned in the esophagus and stomach. The bougie is held snug against the wall of the
lesser curvature, and the gastroplasty is created using a linear stapler. Three techniques are available to create elongation of the gastroplasty in association with total fundoplication.
J
I
Fundus
/,
i
%
J It
Anterior and posterior vagi are dissected free of lesser curvature
.,a ,, \ f
Dissected vagi (anterior and posterior) freed and pushed away from gastroplasty/ .
B
/
'-
,
/
5 Uncut elongation gastroplasty. (A) The uncut elongation gastroplasty is made by applying a 3 cm linear stapler with 4.8 mm staples to appose the anterior and posterior walls of the fundus around the bougie held against the lesser curvature. Pushing through the pin of the stapling device results in small anterior and posterior gastric perforations, which are closed with separate monofilament resorbable sutures. (B) The fundus, extensively mobilized, is pushed to bring the anterior and posterior walls together to surround the entire length of the uncut gastroplasty while t h e intraesophageal bougie remains in place. The fundoplication is completed with the vagi safely retracted away from the gastroplasty.
30
Ferraro and Duranceau
/
C
/
~J"An h rin ii / / ~ / i~aSsCd~ --~
t]/./~
us,
top of fundoplicat[on,
? '1 , ' . 5 [ ~ ~ ' ~ Suture/~~/// D
t r
neoesophagus
Staple-"
5 (continued) (C) 2-0 silk sutures are used to tie the free fundus to a line immediately anterior to the staple line2 Fixation of the sutures on the neoesophagus is optional. The entire length of the gastr0P!asty is then covered by the wrapped fundus. The bougie is removed, and a nasogastric tube is positioned under direct guidance. (D) A second row of silk sutures buries the first series of ligatures, and the repair is reduced under th~ diaphragm. Using a double needle, 3 2-0 prolene sutures are positioned On the apex of the gastroplasty tube, passed through the apex of the fundoplication, and tied. Both needles are then passed separately through the diaphragm from below to above, and the sutures are tied on the pleural side of the diaphragm. The repair is reduced and fixed under the diaphragm (see Fig 8).
Collis-Nissen Operation
31
+,
A
9.....
/ tlG.~_~d '
-~=-~~--"~e-'~
//
-
B 6 Cut gastrop!asty (Orringer). (A) The anterior and posterior proximal lesser curvatures are free, Both vagi have been dissected away from the gastroplasty tube, With the endo!uminal bougie held against the lesser curvature, the GIA stapling device is applied, creating a 5-cm gastroplasty around the bougie, (B) The gastric tissue has been transected between the staple lines. Both suture lines are scrutinized for hemostasis and suture integrity The fundns remains attached by its base to the gastric body,
32
Ferraro and Duranceau
C
~ Gastroplasly p
~J'~"Fundoplication
6 (continued) (C) The tip of the fundus is brought around the elongation gastroplasty to create a total fundoplication. The fundic wrap is sutured anterior to the gastroplasty suture line and to the wrap itself, completing a 360 ~ fundoplication that covers both suture lines. (D) The elongation gastroplasty covered by the fundoplication is reduced under the diaphragm. The anchoring sutures are passed from the apex of the gastroplasty through the apex of the fundoplication and through the diaphragm to be tied above the diaphragm. The crural sutures ate then tied behind the esophagus, leaving enough space to pass an index finger between the last suture and the esophageal wall (see Fig 8).
Collis-Nissen Operation
33
Fundus
,,Y ,, / !
K
A
/
/
Anterior and posterior vagi are dissected free of lesser curvature
ri
7 Cut gastroplasty with transverse fundoplasty 0eyasingham). (A) A second type of cut gastroplasty may be useful to repair a shortened esophagus. The 3-cm linear stapler with 4.8-ram staples is applied to appose the anterior and posterior stomach walls around the #50 bougie held against the lesser curvature of the stomach. (B) The fundic side of the stapler is transected open. This results in a hermetically closed 3-cm elongation gastroplasty and a wide-open gastrostomy. The fundus is positioned for transverse closure to provide a widened fundus for the subsequent fundoplication.
34
Ferraro and Duranceau
Bougie I
/
tr
E,
\
/
D 7 (continued) (C) The fundoplasty line is made symmetrical, and a "u" stitch apposes the middle of the [undic tissue to the distal extremity of the staple line. Separate inverting resorbabie sutures are used to close the [undoplasty line on both sides of the middle suture. (D) The remaining fundus and the extensively mobilized greater curvature are then brought up to completely cover the gastroplasty suture line. The new fundus is applied symmetrically to cover the gastroplasty and is held in place by two sutures positioned on each side of the proximal gastroplast~
d
Collis-Nissen Operation
35
I
F
,!
....
Transected A ~ . . / / staple line /
7 (continued) (E) A standard total fundoplication is created, with the sutures anchored on the lesser curvature side, away from the gastroplasty line. Doing this makes the transverse fundoplasty part of the total fundoplication wrapping the gastroplasty. (F) The 3-cm total fundoplication is reduced under the diaphragm, and three or four anchoring sutures are passed from the apex of the gastroplasty to the apex of the fundoplication and then through the diaphragm.
36
Ferraro and Duranceau
8 All 3 elongation gastroplasties with their fundoplication are reduced in the same way using anchoring sutures. The heavy silk sutures reapproximating the left and right crura are then tied. (Modified with permission from the Mayo Foundation.)
=ericardium
Esophagus Johnsrud ~uture
9 With the repair reduced and anchoring completed, an index finger should pass easily between the esophageal wall and the ~ast crural suture. (Modified wRh permission ~rom the Mayo ~ ou~dat'lo~t.)
37
Collis-Nissen Operation
,~
~:
:{? /, I , , //,
' ~//,,"
~s _=.~ :~
9
l 0 The final result should be a tension-free repair and a closed hiatus. (Modified with permission from the Mayo Foundation.)
Surgical Closure T h e p e r i p h e r a l d i a p h r a g m , w h e n o p e n e d , is closed w i t h 2-0 i n t e r r u p t e d silk sutures. A #28 chest tu_be is installed in a posterolateral p o s i t i o n to allow p r o p e r r e e x p a n s i o n and drainage. The chest wall is closed in the u s u a l m a n n e r .
REFERENCES 1. Trastek VF, Deschamps C, Allen MS, et al: Uncut Collis-Nissen fundoplication: Learning curve and long-term results. Ann Thorac Surg 66:1739-1744, 1998
2. CollisJL: Gastroplasty. Thorax 16:197-206, 1961 3. Demos NJ: Stapled, uncut gastroplasty for hiatal hernia: 12 year follow-up. Ann Thorac Surg 38:393-399, 1984 4. PiehlerJM, Payne WS, CameronAJ, etal: The uncut Collis-Nissen procedure for esophageal hiatal hernia and its complications. Probl Gen Surg 1:1-14, 1984 5. Pera M, Deschamps C, Taillefer R, et al: The uncut Collis-Nissen gastroplasty: Early functional results. Ann Thorac Surg 60:915921, 1995 6. Bingham JAW: Hiatus hernia repair combined with the construction of an anti-reflux valve in the stomach. Br J Surg 64:460-465, 1977
The elongation gastroplasty initially described by Collis provides a tube created from the lesser curvature of the stomach, adding to the length of the original esophagus. The total fundoplication creates a new antireflux barrier. This operation aims to provide 9 an appropriate intra-abdominal length by adding a neoesophagus
SURGICAL
1
9 an antireflux mechanism that is not an impediment to the passage of the alimentary bolus but acts as a good defense against gastric or duodenogastric refluxates 9 a tension-free antireflux repair, reduced and fixed below the diaphragm, where it is exposed to intraabdominal pressures.
TECHNIQUE
A double-lumen tube is positioned in the trachea, and the patient
is placed in a right lateral decubitus position. The left arm is supported by an arm rest, and the incision follows the upper border of the eighth rib. The posterior arc of the rib is divided, and 1 cm of the rib is removed to avoid postoperative e n d - t o - e n d rib contact. (Modified with permission from the Mayo F o u n d a t i o n . )
From the Thoracic Surgery Division, Department of Surge~ Universityof Montreal, Montreal,Quebec,Canada. Address reprint requests to Andr~ D~.~ranceau,MD, Universityof Montreal MedicalCenter, 3840 St. Urbain,Montreal,Quebec, Canada,H2W 1T8. Copyright 9 2000 by "vVB.SaundersCompany 1524-153X/00/0201-0003510.00/0 doi:10.1053/gs.2000.5735
24
Operative Techniques in General Surgery, Vol 2, No 1 (March), 2000: pp 24-37
25
Collis-Nissen Operation
Pericardium
Penrose ~//drain
Pericardium
I k',,
C
Ao~a
Esophagus
2 (A) Adhesions between the lung and the chest wall are freed if necessary. The mediastinum is opened as an inverted T, and the vertical incision is made 1 cm anterior to the descending aorta and along the pericardium. Both incisions meet behind the inferior pulmonary vein. (B) The horizontal part of the T is made along the left crus of the diaphragm and extended anteriorly, where the pericardium is freed from "the fibrous portion of the diaphragm. The inferior pulmonary ligament is divided using electrocautery. The collapsed left inferior lobe is retracted anteriorly and kept in place by large intrathoracic pads. The mediastinum is opened widely, and vessels from the aorta to the esophagus are clamped and divided. (C) After being freed from the aorta and pericardium, the esophagus is encircled by blunt dissection, protecting both the anterior and posterior vagi. Doing so exposes the contralateral pleura. The esophagus is dissected completely free between the hiatus and the area between the inferior pulmonary vein and the aortic arch. (Modified with permission from the Mayo Foundation.)
26
Ferraro and Duranceau
3 (A) The diaphragmatic hiatus is freed with easy identification of the left crus. Anterior to the esophagus or herniated stomach, the incision follows the circular limits of the hiatus. (B) The right crus is exposed posterior to the esophagus. Complete dissection of the hiatus is easier when the peritoneal cavity is opened. The peritoneum is protected on the undersurface of the hiatus, and the pleura covers the upper surface of the hiatus. Identification of the pleura where it covers the right crus is obtained by opening the right chest pleura. Division of the pleura then follows the inferior surface of the right lung and the right inferior pulmonary ligament. At this point, the entire diaphragmatic hiatus is well identified. The left and right crura are ready for reapproximation. (Modified with permission from the Mayo Foundation.)
27
Collis-Nissen Operation
4 (A) If a massive hernia is presen t (types II, III, or IV), the hiatus is usually very wide; and the peritoneum is easily opened anteriorly. In this situation, the fundus and greater curvature are easily identified, and the short gastric vessels are dissected free and ligated. More than 50% of patients with severe complications of idiopathic reflux disease (ie, esophageal stricture or Barrett's esophagus) actually reveal no evidence of a hiatal hernia. In such a situation, two techniques allow access to dissection of the greater curvature. The first technique opens the retrogastric cavity behind the esophagogastric junction and left crus. Progressive freeing of the stomach is then accomplished by ligation of the short gastric vessels. The second approach creates a lateral opening in the diaphragm, approximately 2 to 3 cm from the muscular insertion on the chest wall. A GIA stapler is used to create a 6to 8-cm-long diaphragmatic division. Thus exposed, the short gastric vessels are ligated under direct vision , and the entire greater curvature is freed. With 2 or 3 fingers positioned through the abdominal hiatus, the phrenoesophageal ligament is put under tension and divided around the limits of the hiatus. The anterior and posterior aspects of the lesser curvature are easily identified and dissected using this approach. When completely free, the esophagus and proximal stomach are delivered into the chest through the hiatus. (Modified with permission from the Mayo Foundation.)
28
Ferraro and Duranceau
4
(continued) (B) The anterior and posterior portions of the proximal lesser curvature are dissected as for a highly selective vagotomy. The fat pad of the esophagogastric junction is resected, the anterior and posterior vagi are dissected free from the stomach wall and pushed away to allow the creation of the gastroplasty, and 6 to 7 cm of smaller curvature is denuded from the surrounding tissue. Closure of the hiatus behind the esophagus is accomplished at this point. These sutures cannot be easily placed once the esophagogastric junction repair is completed. The right crus is taken with a small Duval clamp, holding the crus with the peritoneum under and the pleura above. The left crus is seized in the same way with a second clamp. 1-0 silk sutures are initially passed posteriorly with bites taking all tissue layers, including the transversal fascia and the fibrous portion of the crus. A distance of 0.5 to 1 cm is left between each suture, and when the last suture is installed, easy passage should remain for the index finger between the esophageal wall containing the #50 bougie and the last suture reapproximating the crura (refer to Fig 9). (Modified with permission from the Mayo Foundation.)
Collis-Nissen Operation
29
Creation of the Elongation Gastroplasty The entire esophagogastric junction lies within the chest. A #50 tapered bougie is positioned in the esophagus and stomach. The bougie is held snug against the wall of the
lesser curvature, and the gastroplasty is created using a linear stapler. Three techniques are available to create elongation of the gastroplasty in association with total fundoplication.
J
I
Fundus
/,
i
%
J It
Anterior and posterior vagi are dissected free of lesser curvature
.,a ,, \ f
Dissected vagi (anterior and posterior) freed and pushed away from gastroplasty/ .
B
/
'-
,
/
5 Uncut elongation gastroplasty. (A) The uncut elongation gastroplasty is made by applying a 3 cm linear stapler with 4.8 mm staples to appose the anterior and posterior walls of the fundus around the bougie held against the lesser curvature. Pushing through the pin of the stapling device results in small anterior and posterior gastric perforations, which are closed with separate monofilament resorbable sutures. (B) The fundus, extensively mobilized, is pushed to bring the anterior and posterior walls together to surround the entire length of the uncut gastroplasty while t h e intraesophageal bougie remains in place. The fundoplication is completed with the vagi safely retracted away from the gastroplasty.
30
Ferraro and Duranceau
/
C
/
~J"An h rin ii / / ~ / i~aSsCd~ --~
t]/./~
us,
top of fundoplicat[on,
? '1 , ' . 5 [ ~ ~ ' ~ Suture/~~/// D
t r
neoesophagus
Staple-"
5 (continued) (C) 2-0 silk sutures are used to tie the free fundus to a line immediately anterior to the staple line2 Fixation of the sutures on the neoesophagus is optional. The entire length of the gastr0P!asty is then covered by the wrapped fundus. The bougie is removed, and a nasogastric tube is positioned under direct guidance. (D) A second row of silk sutures buries the first series of ligatures, and the repair is reduced under th~ diaphragm. Using a double needle, 3 2-0 prolene sutures are positioned On the apex of the gastroplasty tube, passed through the apex of the fundoplication, and tied. Both needles are then passed separately through the diaphragm from below to above, and the sutures are tied on the pleural side of the diaphragm. The repair is reduced and fixed under the diaphragm (see Fig 8).
Collis-Nissen Operation
31
+,
A
9.....
/ tlG.~_~d '
-~=-~~--"~e-'~
//
-
B 6 Cut gastrop!asty (Orringer). (A) The anterior and posterior proximal lesser curvatures are free, Both vagi have been dissected away from the gastroplasty tube, With the endo!uminal bougie held against the lesser curvature, the GIA stapling device is applied, creating a 5-cm gastroplasty around the bougie, (B) The gastric tissue has been transected between the staple lines. Both suture lines are scrutinized for hemostasis and suture integrity The fundns remains attached by its base to the gastric body,
32
Ferraro and Duranceau
C
~ Gastroplasly p
~J'~"Fundoplication
6 (continued) (C) The tip of the fundus is brought around the elongation gastroplasty to create a total fundoplication. The fundic wrap is sutured anterior to the gastroplasty suture line and to the wrap itself, completing a 360 ~ fundoplication that covers both suture lines. (D) The elongation gastroplasty covered by the fundoplication is reduced under the diaphragm. The anchoring sutures are passed from the apex of the gastroplasty through the apex of the fundoplication and through the diaphragm to be tied above the diaphragm. The crural sutures ate then tied behind the esophagus, leaving enough space to pass an index finger between the last suture and the esophageal wall (see Fig 8).
Collis-Nissen Operation
33
Fundus
,,Y ,, / !
K
A
/
/
Anterior and posterior vagi are dissected free of lesser curvature
ri
7 Cut gastroplasty with transverse fundoplasty 0eyasingham). (A) A second type of cut gastroplasty may be useful to repair a shortened esophagus. The 3-cm linear stapler with 4.8-ram staples is applied to appose the anterior and posterior stomach walls around the #50 bougie held against the lesser curvature of the stomach. (B) The fundic side of the stapler is transected open. This results in a hermetically closed 3-cm elongation gastroplasty and a wide-open gastrostomy. The fundus is positioned for transverse closure to provide a widened fundus for the subsequent fundoplication.
34
Ferraro and Duranceau
Bougie I
/
tr
E,
\
/
D 7 (continued) (C) The fundoplasty line is made symmetrical, and a "u" stitch apposes the middle of the [undic tissue to the distal extremity of the staple line. Separate inverting resorbabie sutures are used to close the [undoplasty line on both sides of the middle suture. (D) The remaining fundus and the extensively mobilized greater curvature are then brought up to completely cover the gastroplasty suture line. The new fundus is applied symmetrically to cover the gastroplasty and is held in place by two sutures positioned on each side of the proximal gastroplast~
d
Collis-Nissen Operation
35
I
F
,!
....
Transected A ~ . . / / staple line /
7 (continued) (E) A standard total fundoplication is created, with the sutures anchored on the lesser curvature side, away from the gastroplasty line. Doing this makes the transverse fundoplasty part of the total fundoplication wrapping the gastroplasty. (F) The 3-cm total fundoplication is reduced under the diaphragm, and three or four anchoring sutures are passed from the apex of the gastroplasty to the apex of the fundoplication and then through the diaphragm.
36
Ferraro and Duranceau
8 All 3 elongation gastroplasties with their fundoplication are reduced in the same way using anchoring sutures. The heavy silk sutures reapproximating the left and right crura are then tied. (Modified with permission from the Mayo Foundation.)
=ericardium
Esophagus Johnsrud ~uture
9 With the repair reduced and anchoring completed, an index finger should pass easily between the esophageal wall and the ~ast crural suture. (Modified wRh permission ~rom the Mayo ~ ou~dat'lo~t.)
37
Collis-Nissen Operation
,~
~:
:{? /, I , , //,
' ~//,,"
~s _=.~ :~
9
l 0 The final result should be a tension-free repair and a closed hiatus. (Modified with permission from the Mayo Foundation.)
Surgical Closure T h e p e r i p h e r a l d i a p h r a g m , w h e n o p e n e d , is closed w i t h 2-0 i n t e r r u p t e d silk sutures. A #28 chest tu_be is installed in a posterolateral p o s i t i o n to allow p r o p e r r e e x p a n s i o n and drainage. The chest wall is closed in the u s u a l m a n n e r .
REFERENCES 1. Trastek VF, Deschamps C, Allen MS, et al: Uncut Collis-Nissen fundoplication: Learning curve and long-term results. Ann Thorac Surg 66:1739-1744, 1998
2. CollisJL: Gastroplasty. Thorax 16:197-206, 1961 3. Demos NJ: Stapled, uncut gastroplasty for hiatal hernia: 12 year follow-up. Ann Thorac Surg 38:393-399, 1984 4. PiehlerJM, Payne WS, CameronAJ, etal: The uncut Collis-Nissen procedure for esophageal hiatal hernia and its complications. Probl Gen Surg 1:1-14, 1984 5. Pera M, Deschamps C, Taillefer R, et al: The uncut Collis-Nissen gastroplasty: Early functional results. Ann Thorac Surg 60:915921, 1995 6. Bingham JAW: Hiatus hernia repair combined with the construction of an anti-reflux valve in the stomach. Br J Surg 64:460-465, 1977