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Laparoscopic collis gastroplasty is the treatment of choice for the shortened esophagus
Laparoscopic Collis Gastroplasty Is the Treatment of Choice for the Shortened Esophagus Lee L. Swanstrom,
MD, Daniel R. Marcus,
BACKGROUND:Theshottenedesophagushas long been recognized as a potential complicating factor for reflux surgery or the repair of paraesophageal hernias. We discuss the incidence of shortened esophagus encountered in a prospective series of laparoscopic hiatal hernia repairs and present our current operative strategies for dealing with this problem, including a new technique for preforming a cut Collis gastroplasty for severe cases. METHODS: A prospectively gathered database on laparoscopic fundoplications (n = 213) and giant paraesophageal hernia repairs (n = 25) revealed 34 (14%) patients who had shortened esophagus as defined by the gastroesphageal (GE) junction being >5 cm above the hiatus. Presentation preoperative diagnosis, operative times, techniques, and outcomes were evaluated. RESULTS: Three categories of dissection were determined from review of the operative data of these 34 patients. Category I (a normal esophagus easily brought into the abdominal cavity with minimal dissection) occurred in 30% of patients. Category II occurred in 50% of patients and was defined as shortened esophagus requiring extensive mediastinal dissection to allow the GE junction to be brought 2 cm below the diaphram. Category Ill patients (20%) were unable, in spite of extensive dissection, to have their GE junction sufficiently reduced to permit fundoplication. Four of these patients had a simple cural closure and gastropexy. Three patients underwent an endoscopic Collis gastroplasty to lengthen the esophagus and allow a tension-free fundoplication. Patients who had a type I or type Ill dissection with Collis gastroplasty did uniformly well. Patients having type II dissections or no fundoplication had a higher rate of postoperative hernia recurrences and reflux disease.
From the Department of Minimally Invasive Surgery, Legacy Portland Hospital, and the Department of Surgery, Oregon Health Sciences University, Portland, Oregon. Requests for reprints should be addressed to Lee L. Swanstrom, MD, Associate Clinical Professor of Surgery, OHSU, Director, Deptartment of Minimally Invasive Surgery, Legacy Portland Hospital, 501 North Graham Street, Suite 120, Portland, Oregon 97227. Presented at the Annual Meeting of the North Pacific Surgical Association, Victoria, British Columbia, November 9-11, 1995.
0 1996 by Excerpta All rights reserved.
Medica,
Inc.
MD, Gil Q. Galloway,
MD, Portland, Oregon
CONCLUSION: Approximately 14% of patients presenting for surgical treatment of gastrolesophageal reflux disease or paraesophageal hernias demonstrate a shortened esophagus. While 30% of these patients are easily treated laparoscopically, 20% to 70% may benefit from an esophageal lengthening procedure. Proper utiliization of the Collis gastroplasty should minimize the incidence of postoperative dysphagia, postoperative acid reflux, and hiatal hernia recurrence. Am J Surg. 1996;171:477-461.
L
aparoscopic fundoplication is rapidly becoming the treatment of choice for gastroesophageal reflux disease (GERD). This is due to data supporting the effectiveness of surgical treatments when compared to chronic medical therapy.’ Well-studied and reported series of laparoscopic fundoplications have also contributed to this dramatic treatment paradigm shift.‘m5 These early reports describe extremely good results. In most cases, the results for the laparoscopic cases are better than those reported in the literature for open fundoplications.h.7 This is due in part to the relatively controlled teaching and dissemination of this new approach by a small nurnber of “experts.” This teaching has relied heavily on the best techniques and philosophies gleaned from decades of experience with open procedures. Such factors as thorough preoperative testing, meticulous atraumatic technique, crural closure, and repairs performed without tension, have contributed to the good results reported in the majority of series.s,” In particular, much attention has been paid to the need to divide the short gastric vessels to achieve a tension-free, short wrap. ” Another aspect of tension-free laparoscopic hiatal hernia repair which has, to some degree, been minimized is the treatment of the shortened esophagus. In the open literature, this phenomenon and its treatments were often discussed.” While this problem may have been over emphasized in the past, it certainly exists and is a finding that needs to be addressed by laparoscopic gastrointestinal surgeons who deal increasingly with patients who have reflux disease or paraesophageal hernias. In the open literature, there are several surgical options described for treating the shortened esophagus. These include performing an intrathoracic fundoplication, an esophagectomy, or a lengthening procedure.12mm14 Of these choices, the Collis gastroplasty, which was first described in 1963, seems to have “gold standard” status. In the laparostopic literature to date, the Collis procedure has been previously reported only as a cadaver study.15 We present our experience with the shortened esophagus in laparoscopic 0002-961 O/916/$1 5.00 PII SOOO2-9610(96)00008-6
477
Figure 1. The endoscopic Collis procedure involves mobilization of the gastric fundus and transthoracic a liner endoscopic stapling device.
laparoscopic placement of
patients which we feel is a much more common finding than has been previously described. We also describe the indications, technique, and results of the laparoscopic Collis gastroplasty.
METHODS A retrospective study was performed of prospectively gathered data on 238 laparoscopic fundoplications done between October 1991 and June 1995. Preoperative objective tests including barium swallows (97% of patients), esophageal motility (99% of patients), and upper endoscopy (99% of patients) were examined to identify patients who had a shortened esophagus. Our criteria for describing a shortened esophagus is the identification of the gastroesphageal (GE) junction junction 5 cm or greater above the diaphragmatic hiatus. A total of 34 patients (14%) were identified as having a shortened esophagus by UGI (30)) EGD (3 ) , or esophageal motility study ( 1) . Operative and follow-up data sheets were examined for all 34 patients to determine their treatment and outcomes. All cases were associated with significant hiatal hernias; 25 with giant type III paraesophageal hernias and 9 with large type I hiatal hernias. The endoscopic grade of esophagitis was assessed according to the Savory-Miller classification system (grade 0 is no inflammation; grade I is erythema; grade II is superficial ulcerations; grade III is severe ulcerations; grade IV is severe, confluent esophagitis including peptic complications; and grade V is esophagitis associated with Barrett’s 478
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Figure 2. Following the firing of the stapling device a gastric is created which effectively lengthens the esophagus.
tube
disease) .16 Operative outcomes, including operative time, complications, and procedure performed, were assessed by reviewing the operating room data collection forms and operative dictations. Postoperative outcomes were derived from standardized data collection forms which were completed at discharge (length of stay and in house complications), 1 week, 6 weeks (readmission and early complications), 6 months, and every 3 years (clinical assessment, EGD, 24-hour PH testing, and esophageal motility). Numbers were too small for definitive statistical analysis.
SURGICAL
TECHNIQUE
All patients underwent general endotracheal anesthesia. Two patients with a suspected short esophagus had double lumen endotracheal tubes placed at induction. The patients were positioned in low lithotomy position and in steep reversed Trendelenburg. Five ports (three 5mm and two lomm) were placed in the upper abdomen as has been described elsewhere.“17 Mediastinal hernia sacs were excised in all cases using bipolar scissors for dissection. In all cases, a 45degree angled laparoscope was used to perform the dissection. Care was used to preserve the vagus nerves while carefully mobilizing the GE junction into the abdomen. In 5 cases, the esophageal dissection was described as extending to the tracheal bifurcation in an attempt to achieve adequate esophageal length. Once adequate intra-abdominal length (>2 cm) of the esophagus was achieved, posterior crural repair was accomplished using pledgited “U” MAY
1996
1 LAPAROSCOPIC
stitches of 0 Ethibond (Ethicon, Inc., Sommerville, New Jersey). The short gastric vessels were mobilized using either a clip and division technique or ultrasonic coagulating shears (Ultracision, Smithfield, Rhode Island). In cases in which a fundoplication was performed, a loose, floppy, 360. degree (N&en) or a 270-degree posterior (Toupet) fundoplication was done after placement of a 56Fr esophageal dilator. The wraps were further fixed in place by suturing them to the right and left crus and, in several cases, posterior sutures were used as well. Nissen repairs were usually completed with two or three interrupted, intracorporally tied sutures which incorporated both sides of the wrap and the anterior esophageal wall. Toupet repairs were completed with two fundus-to-esophagus interrupted suture rows at the 10 and 2 o’clock positions. When used, gastrostomy tubes were placed by inserting an 18-Fr Malencort catheter through an intracorporally sewn purse string suture with additional sutures placed to the anterior abdominal wall as needed. In patients who had an anterior gastropexy, interrupted intracorporally tied sutures were placed along the greater gastric curvature to the anterior-lateral abdominal wall. In patients with massive mediastinal hernias, a closed suction drain was left in the resulting mediastinal cavity. The patients who had an esophageal lengthening procedure (Collis gastroplasty) had the right chest prepped to the table surface; a small roll was placed under the right scapula and the right arm was left extended on an arm board. A second camera system was set up at the head of the bed and a 12smm trocar was placed in the anterior axillary line in the third or fourth intercostal space. A Odegree laparoscope was introduced through this trocar and the pleural cavity inspected to insure the absence of adhesions. In 2 cases, an additional 5-mm trocar site was introduced under direct vision in the sixth lateral intercostal space. In these cases, the lo-mm scope was withdrawn and a 5-mm scope introduced. A 3-cm endoscopic linear stapling device is introduced through the 12-mm trocar site and advanced caudally to the posterior mediastinal pleura where transillumination from the abdominal laparoscope is easily visible. The stapler is advanced either under direct visuahzarion using the 5-mm thoracoscope or, more recently, by gentle blind advancement of the stapler along the anterior thoracic wall and down to the posterior medial sulcus. The stapler can then be identified laparoscopically as it indents the mediastinal pleura. An incision is made to allow passage of the stapler into the abdomen, where it is positioned parallel to and above the esophagus. The previously mobilized gastric fundus is grasped along the greater curvature and rotated into an anterior-posterior orientation. A 46Fr dilator is advanced carefully into the stomach. The gastric fundus is then fed into the opened stapler, making sure that the anterior vagus is not included in the staple line (Figure 1) The stapler is placed flush against the esophageal dilator and fired. The result is a 3-cm lengthening of the distal esophagus which, in all cases to date, has been sufficient to provide adequate intra-abdominal length to permit a fundoplication (Figure 2). The stapler can then be withdrawn leaving the mediastinal pleura open. The intrathoracic trocarb are closed and left in place to prevent leakage of the pneumoperitoneum. Posterior crural closure THE
AMERICAN
Figure around
COiLIS
GASTROPLASlYfSWANSTROM
3. The fundus is brought the neo-esophagus.
posteriorly
ET AL
to create
a wrap
is performed and a total or partial fundoplication created around the neo-esophagus in the usual fashion (Figure 3 ) . All patients have a gastrogtaffin swallow on postoperative day 1 and are started on a liquid diet if there are no leaks or delays in esophageal clearance. Patients are advanced to a soft diet as tolerated and are discharged home when atnbulatory. RESULTS Three categories of shortened section (Table I).
esophagi were found at dis-
Ten patients (30%) had an easy reduction of the GE junction requiring only minimal mediastinal dissection. These were typically patients with an “accordioned” esophagus. All 10 patients had paraesophageal hernias, Eshad no esophagitis, and 2 had only mild, grade I esophagitis. Type II Seventeen patients (50%) required extensiv’e mediastinal dissection to reduce the GE junction the minimum 2.0 cm below the tepaired hiatus. This included 12 lpatients with type III pamesophageal hernias, and 5 with large type I hiatal hernias. Nine of these patients had severe, grade III, IV, or V esophagitis. Type III Seven patients (20%) were unable to be reduced far enough below the diaphragm to perform a standard funJOURNAL
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TABLE
I
Dissection Categories
Dissection Minimal
dissection
Extensive
dissection
Impossible
Characteristics
to reduce needed
to reduce
No. of Patients
Hiatal
Hernia
the GE junction
10 (30%)
to reduce
17 (5%)
type type type type
III = 10 I= 0 Ill = 12 I= 5
type type
Ill = 5 I= 2
the GE junction
the GE junction
7 (20%)
Esophagi& grade grade grade grade grade grade grade grade
Grade 0 = 8 I= 2 I= 1 II = 7 Ill = 4 IV = 5 Ill = 1 IV = 6
GE = gastroesophageai.
TABLE
II Category
Mean operative time (min) lntraoperative complications Postoperative reflux (by pH testing, roentgenogram endoscopy) Recurrent hiatal hernia Postoperative dysphagia
I
Categow 3 hr. 30 (0%)
(0%) 1 (10%) (0%)
1 (6%) 4 (20%) 1 (6%)
duplication in spite of extensive mediastinal dissections. Five of these patients had type III giant paraesophageal hernias and 2 had large type I hiatal hernias. Six of these pa, tients had grade IV or V esophagi+ 4 with Barrett’s esophagus and 2 with strictures. In 4 patients with paraesophageal hernias, simple crural closure and an anterior gastropexy alone were performed. In 3 patients, a Collis procedure was done using the technique described above. Following the lengthening procedure a short, loose Nissen fundoplication was performed. Mean operative time for all patients was 3 hours and 49 minutes. Mean operating time in the Collis patients was 4 hours and 17 minutes. Intraoperative complications included 1 anterior perforation of the GE junction during dilator insertion in a type I patient with mild esophagitis. This was repaired laparoscopically with no subsequent complications. Postoperative complications included 1 ischemic gastric perforation (7 days), 2 instances of severe gastroparesis ( 1 requiring a subsequent gastric resection and the other the placement of a PEG tube), and 2 incidences of severe postoperative dysphagia, including 1 patient who required reoperation via laparotomy for release of the esophageal hiatus. There was no dysphagia or complications in any of the Collis patients. Mean discharge time for all patients was 3.8 days (range 1 to 18)) the average for the Collis patients was 2.0 days. Mean follow-up is 19 months (range 6 to 46). The current follow up protocol involves data collection at 1 week, 6 weeks, 6 months, and every 3 years. All of the described patients have completed their 6-month evaluation which includes completion of a data assessment form (loo%), upper endoscopy (97%), 24-hour pH study, and esophageal motility testing (94%). Twelve patients have completed their 3-year follow up evaluation. Mean followup for the Collis patients is 8 months. Recurrent hiatal her-
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Category 4 hr. 3 (0%) 2 (29%) 1 (14%) 1 (14%)
Ill
Collis
Total
4 hr. 17 (0%)
3 hr. 49 1 (3%)
(0%) (0%) (0%)
1 (3%) 6 (18%) 2 (6%)
nias (type I) were found at follow-up examinations in 6 patients; all category III or IV dissections. Follow up of the Collis patients reveals no evidence of recurrent hiatal hernias or recurrent reflux. Thirty-one (91%) patients report good to excellent subjective results at latest follow-up. Three patients have reflux symptoms and are currently taking omeprazole. Two of these patients had a gastropexy alone (type III dissection) and 1 had a type II dissection with a fundoplication (Toupet). There have been no patients with a type I dissection or a Collis gastroplasty who have had objective evidence of recurrent reflux (Table II).
COMMENTS In our experience, 14% of patients who present for elective surgical treatment of their gastroesophageal reflux disease or paraesophageal hernias will have a significantly shortened esophagus on preoperative studies. Thirty percent of these patient actually have a normal length esophagus that is ‘raccordioned7’ into the mediastinum. This is particularly true in patients with type III paraesophageal hernias and mild or no esophagitis (Savory-Miller grade 0 or I). These patients are easily repaired laparoscopically with a reduction, crural repair, and fundoplication. On the other hand, 70% of patients with a shortened esophagus will require much more extensive surgery; either an extensive esophageal mobilization or a laparosco-pit Collis procedure . There are few alternatives for treating the irreducibly short esophagus. One can elect to reduce the stomach as much as possible and repair the hiatus, usually adding a gastropexy as well. This is fairly easy and we, in fact, used this approach in 4 patients. Unfortunately the end results are poor, with 50% of our patients having severe reflux postoperatively and 25% having their hernia recurr. Consistent MAY
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with the prefered open approach we try to add a fundoplication to all repairs of hiatal hemias.14 For those with a short esophagus, this fundoplication could be performed and simply left in the chest. This option, however, has been shown to have an unacceptible rate of associated complications and probably should be avoided.” Esophagectomy and reconstruction is an option best left for those patients who fail less aggressive treatments. We feel that the best option for this group of patients is a laparoscopic Collis gastroplasty which we have demonstrated to be safe and easily performed and which allows a tension-free fundoplication to be added. In addition to the 3 cases described in this series, 5 additional cases have subsequently been performed with equally favorable results. We currently use the endoscopic Collis procedure for all patients who have unreducible GE junctions (type III dissections) and for select patients who require extensive esophageal mobilization (type II dissections). More liberal use of the Collis procedure for these difficult cases may lead to lower rates of “slippage” or transhiatal herniation; postoperative complications which have created concern about laparoscopic repairs in some reports.‘8,‘9
REFERENCES 1. Spechler S], the Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. Comparison of medical and surgical therapy for complicated gastro-esophageal reflux disease in veterans. NE/M. 1992;326:786-792. 2. Cuschieri A, Hunter J, Wolfe B, et al. Multicenter prospective evaluation of laparoscopic antireflux surgery. Surg En&c. 1993;7:505-510. 3. Weerts JM, Dallemagne B, Hamoir E, et al. Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Surg E&SC. 1993;3:359-364. 4. Hallerback B, Glise H, Johansson B, Radmark T. Laparoscopic Rosetti fundoplication. Surg E&SC. 1994;8:1417-1422. 5. Pitcher DE, Curet MJ, Martin DT, et al. Successful management of severe gastroesophageal reflux disease with laparoscopic Nissen fundoplication. AmJ Surg. 1994;168:547-554.
THE
6. DeMeester
COLLIS TR, Bonavina
GASTROPLASTY/SWAN’STROM L, Albertucci
ET AL
l-----II
M. Nissen fundoplicaof primary repair 1986;204:9-20. for reflux esophagitis. Ann
tion for gdstroesophageal reflux disease. Evaluation in 100 consecutive patients. Ann Surg. 7. Luostarinen M. Nissen fundoplication Surg. 1993;217:329-337.
8. Hinder RA, Filipi CJ, Wescher G, et al. Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg. 1994;220:472-481. 9. Cadiere GB, Houben JJ, et al. Laparoscopic Nissen fundoplication: technique and preliminary results. BrJ Surg. 1994;81:400-403. 10. Peters JH, Heimbucher J, Kauer WKH, et al. Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Cal Surg. 1995;4:385-393. 11. DeMeester TR, Hubert S. Surgical treatment of gastroesophageal reflux disease. In: Castell, Don, eds. The Esop/urgus. Boston: Little Brown & Co.; 1992579-626. 12. Richardson JD, Larson GM, Polk HC Jr. Intrathoracic fundoplication for shortened esophagus. Treacherous solution to a challenging problem. Am J Surg. 1982;143:29-35. 13. Stirling MC, Orringer MB. Surgical treatment after the failed antireflux operation. J Thorax Cardiovusc Surg. 1986;92:667-672. 14. Pearson FG, Cooper JD, Ilves R, et al. Massive hiatal hernia with incarceration: a report of 53 cases. Ann Thorax Surg. 1983;35:45-51. 15. Oddsdottir M, Laycock W, Champion K, Hunter J. Laparostopic esophageal lengthening procedure. Surg Endosc. 1995;9:621 (Abstr). 16. Savary M, Miller G. The esophagus. In: Savary M, Miller G, eds. Hanbook and Atlas of Endoscopy. Solthurm, Switzerland: Glossman; 1978:160-167. 17. Swanstrom L, Hunter J. Laparoscopic partial fundoplication. In: Peter J, Demeester T, eds. Minimally Invasive Surgery of the Foregut.
AMERICAN
St. Louis, Missouri: Quality Medical Publishing, Inc.; 1994:159176. 18. Watson Dl, Jamieson GG, Devitt PG, et al. Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication. Br J Surg. 1995;82:521-523. 19. Collard JM, de Gheldere CA, De Kock M, et al. Laparoscopic antireflux surgery: what is real progress? Ann Surg. 1994;220:146154.
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MD, Daniel R. Marcus,
BACKGROUND:Theshottenedesophagushas long been recognized as a potential complicating factor for reflux surgery or the repair of paraesophageal hernias. We discuss the incidence of shortened esophagus encountered in a prospective series of laparoscopic hiatal hernia repairs and present our current operative strategies for dealing with this problem, including a new technique for preforming a cut Collis gastroplasty for severe cases. METHODS: A prospectively gathered database on laparoscopic fundoplications (n = 213) and giant paraesophageal hernia repairs (n = 25) revealed 34 (14%) patients who had shortened esophagus as defined by the gastroesphageal (GE) junction being >5 cm above the hiatus. Presentation preoperative diagnosis, operative times, techniques, and outcomes were evaluated. RESULTS: Three categories of dissection were determined from review of the operative data of these 34 patients. Category I (a normal esophagus easily brought into the abdominal cavity with minimal dissection) occurred in 30% of patients. Category II occurred in 50% of patients and was defined as shortened esophagus requiring extensive mediastinal dissection to allow the GE junction to be brought 2 cm below the diaphram. Category Ill patients (20%) were unable, in spite of extensive dissection, to have their GE junction sufficiently reduced to permit fundoplication. Four of these patients had a simple cural closure and gastropexy. Three patients underwent an endoscopic Collis gastroplasty to lengthen the esophagus and allow a tension-free fundoplication. Patients who had a type I or type Ill dissection with Collis gastroplasty did uniformly well. Patients having type II dissections or no fundoplication had a higher rate of postoperative hernia recurrences and reflux disease.
From the Department of Minimally Invasive Surgery, Legacy Portland Hospital, and the Department of Surgery, Oregon Health Sciences University, Portland, Oregon. Requests for reprints should be addressed to Lee L. Swanstrom, MD, Associate Clinical Professor of Surgery, OHSU, Director, Deptartment of Minimally Invasive Surgery, Legacy Portland Hospital, 501 North Graham Street, Suite 120, Portland, Oregon 97227. Presented at the Annual Meeting of the North Pacific Surgical Association, Victoria, British Columbia, November 9-11, 1995.
0 1996 by Excerpta All rights reserved.
Medica,
Inc.
MD, Gil Q. Galloway,
MD, Portland, Oregon
CONCLUSION: Approximately 14% of patients presenting for surgical treatment of gastrolesophageal reflux disease or paraesophageal hernias demonstrate a shortened esophagus. While 30% of these patients are easily treated laparoscopically, 20% to 70% may benefit from an esophageal lengthening procedure. Proper utiliization of the Collis gastroplasty should minimize the incidence of postoperative dysphagia, postoperative acid reflux, and hiatal hernia recurrence. Am J Surg. 1996;171:477-461.
L
aparoscopic fundoplication is rapidly becoming the treatment of choice for gastroesophageal reflux disease (GERD). This is due to data supporting the effectiveness of surgical treatments when compared to chronic medical therapy.’ Well-studied and reported series of laparoscopic fundoplications have also contributed to this dramatic treatment paradigm shift.‘m5 These early reports describe extremely good results. In most cases, the results for the laparoscopic cases are better than those reported in the literature for open fundoplications.h.7 This is due in part to the relatively controlled teaching and dissemination of this new approach by a small nurnber of “experts.” This teaching has relied heavily on the best techniques and philosophies gleaned from decades of experience with open procedures. Such factors as thorough preoperative testing, meticulous atraumatic technique, crural closure, and repairs performed without tension, have contributed to the good results reported in the majority of series.s,” In particular, much attention has been paid to the need to divide the short gastric vessels to achieve a tension-free, short wrap. ” Another aspect of tension-free laparoscopic hiatal hernia repair which has, to some degree, been minimized is the treatment of the shortened esophagus. In the open literature, this phenomenon and its treatments were often discussed.” While this problem may have been over emphasized in the past, it certainly exists and is a finding that needs to be addressed by laparoscopic gastrointestinal surgeons who deal increasingly with patients who have reflux disease or paraesophageal hernias. In the open literature, there are several surgical options described for treating the shortened esophagus. These include performing an intrathoracic fundoplication, an esophagectomy, or a lengthening procedure.12mm14 Of these choices, the Collis gastroplasty, which was first described in 1963, seems to have “gold standard” status. In the laparostopic literature to date, the Collis procedure has been previously reported only as a cadaver study.15 We present our experience with the shortened esophagus in laparoscopic 0002-961 O/916/$1 5.00 PII SOOO2-9610(96)00008-6
477
Figure 1. The endoscopic Collis procedure involves mobilization of the gastric fundus and transthoracic a liner endoscopic stapling device.
laparoscopic placement of
patients which we feel is a much more common finding than has been previously described. We also describe the indications, technique, and results of the laparoscopic Collis gastroplasty.
METHODS A retrospective study was performed of prospectively gathered data on 238 laparoscopic fundoplications done between October 1991 and June 1995. Preoperative objective tests including barium swallows (97% of patients), esophageal motility (99% of patients), and upper endoscopy (99% of patients) were examined to identify patients who had a shortened esophagus. Our criteria for describing a shortened esophagus is the identification of the gastroesphageal (GE) junction junction 5 cm or greater above the diaphragmatic hiatus. A total of 34 patients (14%) were identified as having a shortened esophagus by UGI (30)) EGD (3 ) , or esophageal motility study ( 1) . Operative and follow-up data sheets were examined for all 34 patients to determine their treatment and outcomes. All cases were associated with significant hiatal hernias; 25 with giant type III paraesophageal hernias and 9 with large type I hiatal hernias. The endoscopic grade of esophagitis was assessed according to the Savory-Miller classification system (grade 0 is no inflammation; grade I is erythema; grade II is superficial ulcerations; grade III is severe ulcerations; grade IV is severe, confluent esophagitis including peptic complications; and grade V is esophagitis associated with Barrett’s 478
THE
AMERICAN
JOURNAL
OF SURGERY@
VOLUME
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Figure 2. Following the firing of the stapling device a gastric is created which effectively lengthens the esophagus.
tube
disease) .16 Operative outcomes, including operative time, complications, and procedure performed, were assessed by reviewing the operating room data collection forms and operative dictations. Postoperative outcomes were derived from standardized data collection forms which were completed at discharge (length of stay and in house complications), 1 week, 6 weeks (readmission and early complications), 6 months, and every 3 years (clinical assessment, EGD, 24-hour PH testing, and esophageal motility). Numbers were too small for definitive statistical analysis.
SURGICAL
TECHNIQUE
All patients underwent general endotracheal anesthesia. Two patients with a suspected short esophagus had double lumen endotracheal tubes placed at induction. The patients were positioned in low lithotomy position and in steep reversed Trendelenburg. Five ports (three 5mm and two lomm) were placed in the upper abdomen as has been described elsewhere.“17 Mediastinal hernia sacs were excised in all cases using bipolar scissors for dissection. In all cases, a 45degree angled laparoscope was used to perform the dissection. Care was used to preserve the vagus nerves while carefully mobilizing the GE junction into the abdomen. In 5 cases, the esophageal dissection was described as extending to the tracheal bifurcation in an attempt to achieve adequate esophageal length. Once adequate intra-abdominal length (>2 cm) of the esophagus was achieved, posterior crural repair was accomplished using pledgited “U” MAY
1996
1 LAPAROSCOPIC
stitches of 0 Ethibond (Ethicon, Inc., Sommerville, New Jersey). The short gastric vessels were mobilized using either a clip and division technique or ultrasonic coagulating shears (Ultracision, Smithfield, Rhode Island). In cases in which a fundoplication was performed, a loose, floppy, 360. degree (N&en) or a 270-degree posterior (Toupet) fundoplication was done after placement of a 56Fr esophageal dilator. The wraps were further fixed in place by suturing them to the right and left crus and, in several cases, posterior sutures were used as well. Nissen repairs were usually completed with two or three interrupted, intracorporally tied sutures which incorporated both sides of the wrap and the anterior esophageal wall. Toupet repairs were completed with two fundus-to-esophagus interrupted suture rows at the 10 and 2 o’clock positions. When used, gastrostomy tubes were placed by inserting an 18-Fr Malencort catheter through an intracorporally sewn purse string suture with additional sutures placed to the anterior abdominal wall as needed. In patients who had an anterior gastropexy, interrupted intracorporally tied sutures were placed along the greater gastric curvature to the anterior-lateral abdominal wall. In patients with massive mediastinal hernias, a closed suction drain was left in the resulting mediastinal cavity. The patients who had an esophageal lengthening procedure (Collis gastroplasty) had the right chest prepped to the table surface; a small roll was placed under the right scapula and the right arm was left extended on an arm board. A second camera system was set up at the head of the bed and a 12smm trocar was placed in the anterior axillary line in the third or fourth intercostal space. A Odegree laparoscope was introduced through this trocar and the pleural cavity inspected to insure the absence of adhesions. In 2 cases, an additional 5-mm trocar site was introduced under direct vision in the sixth lateral intercostal space. In these cases, the lo-mm scope was withdrawn and a 5-mm scope introduced. A 3-cm endoscopic linear stapling device is introduced through the 12-mm trocar site and advanced caudally to the posterior mediastinal pleura where transillumination from the abdominal laparoscope is easily visible. The stapler is advanced either under direct visuahzarion using the 5-mm thoracoscope or, more recently, by gentle blind advancement of the stapler along the anterior thoracic wall and down to the posterior medial sulcus. The stapler can then be identified laparoscopically as it indents the mediastinal pleura. An incision is made to allow passage of the stapler into the abdomen, where it is positioned parallel to and above the esophagus. The previously mobilized gastric fundus is grasped along the greater curvature and rotated into an anterior-posterior orientation. A 46Fr dilator is advanced carefully into the stomach. The gastric fundus is then fed into the opened stapler, making sure that the anterior vagus is not included in the staple line (Figure 1) The stapler is placed flush against the esophageal dilator and fired. The result is a 3-cm lengthening of the distal esophagus which, in all cases to date, has been sufficient to provide adequate intra-abdominal length to permit a fundoplication (Figure 2). The stapler can then be withdrawn leaving the mediastinal pleura open. The intrathoracic trocarb are closed and left in place to prevent leakage of the pneumoperitoneum. Posterior crural closure THE
AMERICAN
Figure around
COiLIS
GASTROPLASlYfSWANSTROM
3. The fundus is brought the neo-esophagus.
posteriorly
ET AL
to create
a wrap
is performed and a total or partial fundoplication created around the neo-esophagus in the usual fashion (Figure 3 ) . All patients have a gastrogtaffin swallow on postoperative day 1 and are started on a liquid diet if there are no leaks or delays in esophageal clearance. Patients are advanced to a soft diet as tolerated and are discharged home when atnbulatory. RESULTS Three categories of shortened section (Table I).
esophagi were found at dis-
Ten patients (30%) had an easy reduction of the GE junction requiring only minimal mediastinal dissection. These were typically patients with an “accordioned” esophagus. All 10 patients had paraesophageal hernias, Eshad no esophagitis, and 2 had only mild, grade I esophagitis. Type II Seventeen patients (50%) required extensiv’e mediastinal dissection to reduce the GE junction the minimum 2.0 cm below the tepaired hiatus. This included 12 lpatients with type III pamesophageal hernias, and 5 with large type I hiatal hernias. Nine of these patients had severe, grade III, IV, or V esophagitis. Type III Seven patients (20%) were unable to be reduced far enough below the diaphragm to perform a standard funJOURNAL
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TABLE
I
Dissection Categories
Dissection Minimal
dissection
Extensive
dissection
Impossible
Characteristics
to reduce needed
to reduce
No. of Patients
Hiatal
Hernia
the GE junction
10 (30%)
to reduce
17 (5%)
type type type type
III = 10 I= 0 Ill = 12 I= 5
type type
Ill = 5 I= 2
the GE junction
the GE junction
7 (20%)
Esophagi& grade grade grade grade grade grade grade grade
Grade 0 = 8 I= 2 I= 1 II = 7 Ill = 4 IV = 5 Ill = 1 IV = 6
GE = gastroesophageai.
TABLE
II Category
Mean operative time (min) lntraoperative complications Postoperative reflux (by pH testing, roentgenogram endoscopy) Recurrent hiatal hernia Postoperative dysphagia
I
Categow 3 hr. 30 (0%)
(0%) 1 (10%) (0%)
1 (6%) 4 (20%) 1 (6%)
duplication in spite of extensive mediastinal dissections. Five of these patients had type III giant paraesophageal hernias and 2 had large type I hiatal hernias. Six of these pa, tients had grade IV or V esophagi+ 4 with Barrett’s esophagus and 2 with strictures. In 4 patients with paraesophageal hernias, simple crural closure and an anterior gastropexy alone were performed. In 3 patients, a Collis procedure was done using the technique described above. Following the lengthening procedure a short, loose Nissen fundoplication was performed. Mean operative time for all patients was 3 hours and 49 minutes. Mean operating time in the Collis patients was 4 hours and 17 minutes. Intraoperative complications included 1 anterior perforation of the GE junction during dilator insertion in a type I patient with mild esophagitis. This was repaired laparoscopically with no subsequent complications. Postoperative complications included 1 ischemic gastric perforation (7 days), 2 instances of severe gastroparesis ( 1 requiring a subsequent gastric resection and the other the placement of a PEG tube), and 2 incidences of severe postoperative dysphagia, including 1 patient who required reoperation via laparotomy for release of the esophageal hiatus. There was no dysphagia or complications in any of the Collis patients. Mean discharge time for all patients was 3.8 days (range 1 to 18)) the average for the Collis patients was 2.0 days. Mean follow-up is 19 months (range 6 to 46). The current follow up protocol involves data collection at 1 week, 6 weeks, 6 months, and every 3 years. All of the described patients have completed their 6-month evaluation which includes completion of a data assessment form (loo%), upper endoscopy (97%), 24-hour pH study, and esophageal motility testing (94%). Twelve patients have completed their 3-year follow up evaluation. Mean followup for the Collis patients is 8 months. Recurrent hiatal her-
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Category 4 hr. 3 (0%) 2 (29%) 1 (14%) 1 (14%)
Ill
Collis
Total
4 hr. 17 (0%)
3 hr. 49 1 (3%)
(0%) (0%) (0%)
1 (3%) 6 (18%) 2 (6%)
nias (type I) were found at follow-up examinations in 6 patients; all category III or IV dissections. Follow up of the Collis patients reveals no evidence of recurrent hiatal hernias or recurrent reflux. Thirty-one (91%) patients report good to excellent subjective results at latest follow-up. Three patients have reflux symptoms and are currently taking omeprazole. Two of these patients had a gastropexy alone (type III dissection) and 1 had a type II dissection with a fundoplication (Toupet). There have been no patients with a type I dissection or a Collis gastroplasty who have had objective evidence of recurrent reflux (Table II).
COMMENTS In our experience, 14% of patients who present for elective surgical treatment of their gastroesophageal reflux disease or paraesophageal hernias will have a significantly shortened esophagus on preoperative studies. Thirty percent of these patient actually have a normal length esophagus that is ‘raccordioned7’ into the mediastinum. This is particularly true in patients with type III paraesophageal hernias and mild or no esophagitis (Savory-Miller grade 0 or I). These patients are easily repaired laparoscopically with a reduction, crural repair, and fundoplication. On the other hand, 70% of patients with a shortened esophagus will require much more extensive surgery; either an extensive esophageal mobilization or a laparosco-pit Collis procedure . There are few alternatives for treating the irreducibly short esophagus. One can elect to reduce the stomach as much as possible and repair the hiatus, usually adding a gastropexy as well. This is fairly easy and we, in fact, used this approach in 4 patients. Unfortunately the end results are poor, with 50% of our patients having severe reflux postoperatively and 25% having their hernia recurr. Consistent MAY
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with the prefered open approach we try to add a fundoplication to all repairs of hiatal hemias.14 For those with a short esophagus, this fundoplication could be performed and simply left in the chest. This option, however, has been shown to have an unacceptible rate of associated complications and probably should be avoided.” Esophagectomy and reconstruction is an option best left for those patients who fail less aggressive treatments. We feel that the best option for this group of patients is a laparoscopic Collis gastroplasty which we have demonstrated to be safe and easily performed and which allows a tension-free fundoplication to be added. In addition to the 3 cases described in this series, 5 additional cases have subsequently been performed with equally favorable results. We currently use the endoscopic Collis procedure for all patients who have unreducible GE junctions (type III dissections) and for select patients who require extensive esophageal mobilization (type II dissections). More liberal use of the Collis procedure for these difficult cases may lead to lower rates of “slippage” or transhiatal herniation; postoperative complications which have created concern about laparoscopic repairs in some reports.‘8,‘9
REFERENCES 1. Spechler S], the Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. Comparison of medical and surgical therapy for complicated gastro-esophageal reflux disease in veterans. NE/M. 1992;326:786-792. 2. Cuschieri A, Hunter J, Wolfe B, et al. Multicenter prospective evaluation of laparoscopic antireflux surgery. Surg En&c. 1993;7:505-510. 3. Weerts JM, Dallemagne B, Hamoir E, et al. Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Surg E&SC. 1993;3:359-364. 4. Hallerback B, Glise H, Johansson B, Radmark T. Laparoscopic Rosetti fundoplication. Surg E&SC. 1994;8:1417-1422. 5. Pitcher DE, Curet MJ, Martin DT, et al. Successful management of severe gastroesophageal reflux disease with laparoscopic Nissen fundoplication. AmJ Surg. 1994;168:547-554.
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8. Hinder RA, Filipi CJ, Wescher G, et al. Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg. 1994;220:472-481. 9. Cadiere GB, Houben JJ, et al. Laparoscopic Nissen fundoplication: technique and preliminary results. BrJ Surg. 1994;81:400-403. 10. Peters JH, Heimbucher J, Kauer WKH, et al. Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Cal Surg. 1995;4:385-393. 11. DeMeester TR, Hubert S. Surgical treatment of gastroesophageal reflux disease. In: Castell, Don, eds. The Esop/urgus. Boston: Little Brown & Co.; 1992579-626. 12. Richardson JD, Larson GM, Polk HC Jr. Intrathoracic fundoplication for shortened esophagus. Treacherous solution to a challenging problem. Am J Surg. 1982;143:29-35. 13. Stirling MC, Orringer MB. Surgical treatment after the failed antireflux operation. J Thorax Cardiovusc Surg. 1986;92:667-672. 14. Pearson FG, Cooper JD, Ilves R, et al. Massive hiatal hernia with incarceration: a report of 53 cases. Ann Thorax Surg. 1983;35:45-51. 15. Oddsdottir M, Laycock W, Champion K, Hunter J. Laparostopic esophageal lengthening procedure. Surg Endosc. 1995;9:621 (Abstr). 16. Savary M, Miller G. The esophagus. In: Savary M, Miller G, eds. Hanbook and Atlas of Endoscopy. Solthurm, Switzerland: Glossman; 1978:160-167. 17. Swanstrom L, Hunter J. Laparoscopic partial fundoplication. In: Peter J, Demeester T, eds. Minimally Invasive Surgery of the Foregut.
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St. Louis, Missouri: Quality Medical Publishing, Inc.; 1994:159176. 18. Watson Dl, Jamieson GG, Devitt PG, et al. Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication. Br J Surg. 1995;82:521-523. 19. Collard JM, de Gheldere CA, De Kock M, et al. Laparoscopic antireflux surgery: what is real progress? Ann Surg. 1994;220:146154.
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