Difficult Decisions in Thoracic Surgery - part 7 pdf

305 38 Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture Sandro Mattioli and Maria Luisa Lugaresi laparothoracoscopic techniques for lengthening gastroplasty associated with a fundoplication have been designed in order to replace the open procedures. 6,9–11 Techniques of laparoscopic tubu- larization of the lesser gastric curvature by a wedge resection of the gastric fundus have also been published. 12–14 With the lack of tactile appreciation of the viscera, laparoscopic surgery has increased the need to identify the anatomy of the GE junction and more precisely its position with respect to the diaphragmatic hiatus. Minimally invasive surgery has revitalized the debate regarding the diagnosis and treatment of short esophagus and stricture; today, as in the past, even the very existence of the short esophagus is discussed. Many surgeons currently recognize cases of short esophagus that are managed with dedicated surgical techniques 9,10,12,13,15–26 ; others deny it is a clinical entity or state they have not seen one, even in large case series. 27–59 Traditionally, the short esophagus was coupled with pan mural esophagitis and stricture 4,14,60–64 in patients affected by severe GERD and mucosal esophagitis. Recent data indicate a decreasing frequency of peptic stenosis in the GERD population, 65–67 but also the not uncommon existence of true short esophagus in the absence of esophageal stricture. 12,13,26,68,69 Further knowledge has been acquired on the negative role of hiatus hernia, 70–72 and particu- larly regarding the effect of a permanent intrathoracic location of the lower esophageal sphincter (LES) 73–76 on the gastroesophageal anti-refl ux barrier. The conceptual differentiation between the intrathoracic position of the GE junction, A lengthening gastroplasty consists of the formation of a gastric tube by vertically stapling the proximal stomach from the angle of His parallel to the lesser gastric curvature. This procedure is designed to elongate the esophageal tube as part of surgical treatment of complicated cases of gastroesophageal refl ux disease (GERD) in which the esophagus is irreversibly shortened, thus the gastroesophageal (GE) junction cannot be re positioned into the abdomen without excessive tension. This technique was proposed in 1957 by J.L. Collis for the treatment of complicated cases of GERD as an alternative to esophageal resection. 1,2 A few years later, Collis, after following up the patients operated upon, reported 59% with GERD at barium swallow and 50% with specifi c symptoms. 3 In 1971, Pearson, Langer, and Henderson published the results of a series of 24 patients in whom a Collis gastroplasty had been performed in combination with a modifi ed Belsey anti-refl ux procedure. 4 The concept of the Pearson operation was to elongate the esophagus in order to perform an effective intra-abdominal anti-refl ux fundoplication, avoiding any tension on the sutures placed through the distal esophagus, the gastric fundus, and the diaphragmatic hiatus. Based on the same concept, the combination of a Collis gastroplasty with the Nissen fundusplication was proposed by Orringer and Sloan (transthoracic Collis–Nissen). 5 Details of the Collis–Nissen operation were successively modifi ed by Demos 6 and Cameron 7 (uncut Collis–Nissen; thoracic and abdominal approaches) and Steichen 8 (abdominal Collis–Nissen). Innovative laparoscopic and 306 S. Mattioli and M.L. Lugaresi generally diagnosed by barium swallow, and the true short esophagus unequivocally ascertained only in the operating room, 9,25,26,77–79 may be a signifi cant step of the clarifi cation of controversies. The consideration of factors predicting the ex is- tence of true esophageal shortening, 17,23–26,68,77,80 the precise intraoperative localization of the position of cardia with respect to diaphragmatic hiatus, 14,68,77,81 the knowledge of surgical physiol- ogy of anti-refl ux operations, the correct choice and performance of the surgical technique, and adequate experience in open and minimally invasive esophageal surgery are at the present time the key factors in the surgical therapy of complicated cases of GERD in whom the lengthening gastroplasty may be indicated. The above-mentioned issues are discussed in this chapter. 38.1. The Short Esophagus: Definition, Predictors, Diagnosis, Surgical Techniques, and Results 38.1.1. Definition The defi nition of short esophagus was fi rstly adopted by radiologists to describe the intrathoracic position of the GE junction and to classify this condition among the various types of hiatus hernia, taking into consideration the morphol- ogy of the thoracic esophagus (straight or redun- dant) and of the gastric fundus (axial displacement, funnel type, paraesophageal). 82–87 Surgeons generally base the diagnosis of short esophagus on the inability to reduce the GE junction below the diaphragm intraoperatively. Other surgeons deny the existence of short esophagus, stating they always are able to reposition the GE junction below the diaphragm. 88–91 Data related to the prevalence of short esophagus in open surgery case series, mainly expressed in terms of nonre- ducibility, range widely from 0% to 60% (Table 38.1). The scattering of data strongly suggests that the clinical research was biased by method- ological errors such as the subjective identifi cation of the GE junction and the equally subjective quantifi cation of the tension needed to be applied to the distal esophagus in order to reposition an adequate segment into the abdomen. 14,26,77,80,81,92 In the last decade, the widespread diffusion of minimally invasive surgery has again produced controversial effects on the perception of surgeons with respect to short esophagus: besides a generalized attitude to ignore the problem within the rush of new operative techniques, 80,93 an increasing interest has become evident among surgeons who pay specifi c attention to the issue (Table 38.2). The recent literature unequivocally tries to overcome the low grade of reliability of the historical data, instead referring to more objective methods aimed at localizing precisely the GE junction. 26,68,77,81 The current defi nition of short esophagus accepted by the majority of the groups interested in the argument, 9,10,14,17,26,92–96 includes several major concepts: (1) the short esophagus is diagnosed only intraoperatively; (2) only after extensive mobilization of the mediastinal esophagus 9–14,17,23–26,68,77,80,81,92,93,97,98 ; and (3) when the intra-abdominal portion of the esophagus is shorter than 2 to 3 cm with no downward tension applied. 9,11,13,14,17,23–26,68,77,80,81,92,98 Horwath and coworkers 77 subdivide short esophagus in: (1) true, nonreducible short esophagus; (2) true but reducible short esophagus; and (3) apparent short esophagus. Preoperative radiologic and endoscopic studies in the three groups placed the GE junction across or above the hiatus. In the fi rst category the GE junction cannot be reduced for at least 2.5 to 3 cm below the diaphragm, while in the second category this length of the intra- TABLE 38.1. Incidence of short esophagus in the surgical literature 1964–1995. No. Short Reference Year Patients Surgery Esophagus (%) Nygard 122 1964 102 Open 40.2% Collis 123 1968 420 Open 18% Hill 88 1970 36 Open 0 Gatzinsky 124 1979 140 Open 37% Maillet 125 1980 800 Open 10% Moghissi 126 1983 245 Open 39.2% Pearson 115 1987 430 Open 60% Kauer 97 1995 104 Open 9.6% Mattioli 26 2004 a 149 Open 29% Abbreviation: nr, not reported. a 1980–1991. 38. Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 307 abdominal esophagus is achieved. In the third category, the esophagus has a normal length but is accordioned into the distal mediastinum. 77 38.1.2. Predictive Factors Among patients undergoing surgery for GERD, up to 40% have developed complications such as macroscopic esophagitis, Barrett’s esophagus, peptic esophageal stricture, or acquired short esophagus. 14,60–62 Esophageal stricture is the clinical fi nding most commonly related with esophageal shortening 14,24,68,80 ; it may occur in 1% to 5% 14,63,64 of patients with longstanding severe esophagitis. Other abnormalities that should raise the suspicion of a short esophagus include the radiologic diagnosis of a large, nonreducible hiatal hernia in the upright position, a hiatal hernia larger than 5 cm, or an esophageal length of less than 35 cm from the incisors as determined by endoscopy. 13,17,77 The presence of a paraesophageal hiatal hernia is considered to be highly predictive of the presence of short esophagus. 24,78,80 Maziak and colleagues 99 reported that 80% (75/94) of patients with a large paraesophageal hernia required a lengthening procedure for short esophagus. Of lesser importance, but still thought to play a role, is a history of severe esophagitis or Barrett’s esophagus. 80 The incidence of reoperative surgery has been shown to be signifi - cantly increased in patients with esophageal stricture following standard Belsey and Nissen repairs. 100,101 The risk of gastroplasty was increased 3.8-fold [95% confi dence level (95% CI), 1.0–15.0) in the presence of esophageal stricture in the study of Urbach and colleagues, 24 and by a factor of 7.5 (95% CI, 3.3–16.7) according to Gastal. 17 Urbach observed that for paraesophageal hernia the risk of gastroplasty was increased 4.5-fold (95% CI, 1.4–14.6), 4.3-fold for Barrett’s esophagus (95% CI, 1.3–14.3), and 11.6-fold for reoperative surgery (95% CI, 2.8–48.4). 24 Mittal 68 found that, although the presence of Barrett’s esophagus or an esophageal stricture was associated with the need for esophageal lengthening, the presence of a large hiatal hernia on barium studies and the preoperative manometric length of the esophagus did not appear to be a statistically signifi cant factor. Preoperative esophagraphy, TABLE 38.2. Incidence of short esophagus in the surgical literature 1996–2004. Short No. Esophagus Reference Year Patients Surgery (%) Swanstrom 9 1996 238 Mini-invasive 14% Csendes 33 1998 152 Open 0 Anvari 27 1998 381 Mini-invasive 0 Dallemagne 35 1998 622 Mini-invasive 0 Eshraghi 37 1998 157 Mini-invasive 0 Kiviluoto 42 1998 200 Mini-invasive 0 Landreneau 44 1998 150 Mini-invasive 0 Lefebvre 45 1998 100 Mini-invasive 0 Patti 50 1998 201 Mini-invasive 0 Meyer 48 1998 224 Mini-invasive 0 Peters 52 1998 100 Mini-invasive 0 McKernan 15 1998 968 Mini-invasive 1.9% Johnson 10 1998 220 Mini-invasive 4% Jobe 16 1998 580 Mini-invasive 2.5% El-Serag 36 1999 1147 Open 0 Rydberg 53 1999 106 Open 0 Arnaud 28 1999 1470 Mini-invasive 0 Barrat 29 1999 150 Mini-invasive 0 Champault 32 1999 156 Mini-invasive 0 Coelho 34 1999 503 Mini-invasive 0 Johanet 40 1999 335 Mini-invasive 0 Klinger 43 1999 102 Mini-invasive 0 Loustarinen 47 1999 127 Mini-invasive 0 Soper 55 1999 292 Mini-invasive 0 Watson 56 1999 107 Mini-invasive 0 Gastal 17 1999 236 Mini-invasive 15.6% Bohmer 31 2000 106 Open 0 Basso 30 2000 135 Mini-invasive 0 Farrell 38 2000 669 Mini-invasive 0 Kamolz 41 2000 175 Mini-invasive 0 Leggett 46 2000 239 Mini-invasive 0 O’Boyle 49 2000 511 Mini-invasive 0 Pessaux 51 2000 1470 Mini-invasive 0 Ross 54 2000 200 Mini-invasive 0 Yau 58 2000 757 Mini-invasive 0 Eubanks 18 2000 228 Mini-invasive 0.8% Zaninotto 19 2000 621 Mini-invasive 0.9% Luketich 127 2000 100 Mini-invasive 27% Kleimann 21 2001 255 Mini-invasive 2% Terry 22 2001 1000 Mini-invasive 1.5% Awad 23 2001 260 Mini-invasive 5% Urbach 24 2001 153 Mini-invasive 13% O’Rourke 25 2003 487 Mini-invasive 19% Lin 13 2004 1579 Mini-invasive 4.3% Terry 12 2004 143 Mini-invasive 11.2% Mattioli 26 2004 a 170 Open, mini- 23% invasive a 1992–2003. 308 S. Mattioli and M.L. Lugaresi endoscopy, and esophageal manometric length assessment are useful, though not ideal, for iden- tifying patients in need of an esophageal lengthening procedure. 17,23,24,68 However, it has been shown that neither a single preoperative diagnos- tic test nor any combination of tests is completely accurate in making the diagnosis. 23 The combination of two or more tests resulted in a specifi c- ity ranging from 63% to 100% but a low sensitivity (28%–42%). 23 In a study on the outcomes of the surgical treatment of GERD in 319 patients, the preoperative factors predictive of the need for an esophageal lengthening procedure were evaluated. 26 The multivariate analysis showed the following preoperative factors as predicting the need of a Collis procedure: radiologic classifi cation [p = 0.005; odds ratio (OR) 20.53; 95% CI, 2.47–170.15), manometry in the upright position performed after the standard recording in the supine position (p = 0.038; OR 5.26; 95% CI, 1.09–25.41), and the presence of peptic stenosis (p = 0.015; OR 5.18; 95% CI, 1.38–19.44). The radiologic classifi cation adopted for the study was based on the assessment of the position of the GE junction with respect to the hiatus and not on the size of the hernia. Three grades of orad migration of the GE junction were considered: hiatal insuffi ciency, concentric hiatus hernia, and short esophagus. The classifi cation had been validated with a manometric–radiologic study, which demon- strated that the distance (in centimeters) from the LES inferior margin to the diaphragm was signifi cantly different in healthy volunteers versus the three grades of migration and between each contiguous grade. 75 Although the combination of endoscopy, radiology, and manometry has been shown to be associated with a high positive predictive value for short esophagus, the sensitivity and negative predictive value for the combination of these tests are low, and no single criterion has been shown to be associated with a high specifi city or predictive value. 23,25 38.1.3. Intraoperative Diagnosis In course of laparoscopic surgery for GERD, the surgeon may underestimate the presence of esophageal shortening because of a number of contributing factors. Complete dissection of the fat pad overlying the GE junction is necessary to identify the true GE junction, but this is not routinely described in laparoscopic reports. 92 The presence of pneumoperitoneum elevates the diaphragm signifi cantly and may give the false impression that an adequate length of intra- abdominal esophagus is achieved. 26,92,102 In some reports, a Penrose drain is placed around the distal esophagus and downward tension is applied during the dissection and wrap; this apparent intra-abdominal segment of esophagus may later retract back up into the thoracic cavity when the Penrose drain is removed. 92 Finally, many laparoscopic surgeons routinely place a weighted bougie into the esophagus, and the downward pressure from the bougie pushes the esophagus distally for a distance up to 2 to 3 cm. 92 During laparoscopy it is possible to miss the exact position of the GE junction because the proximal stomach, attracted upward, acquires a funnel like form after years of herniation, the serosa loses brightness, and the wall thins. 26 The tubularized proximal stomach is hardly distinguishable from the distal esophagus. 98,103 One or more of these factors can lead the surgeon to overestimate the length of intra-abdominal esophagus. Recently, intraoperative endoscopy has been proposed in order to identify the GE junction in relation to the hiatus. 26,68,81,103 The reference to the gastric folds as an anatomical–endoscopic land- mark of the GE junction 104,105,106 helps to eliminate the subjective component of the evaluation in the presence of short and long Barrett’s esophagus. 23,26,107 As the gastric folds are normally located at or few millimeters below the Z line, this anatomical reference also eliminates the risk of overdiagnosing the condition of short esophagus. 26,103 After the endoscopist has placed the tip of the fi berscope at the level of the gastric folds, the surgeon recognizes the point of passage between the tubular esophagus and the stomach by means of transillumination 68 or by localizing the tip of the scope with a grasping forceps. As the length of the open jaws of the forceps is known, the distance between the hiatus and the GE junction can be estimated. 81 The gold standard for determination of short esophagus is intraoperative esophageal mobilization followed by assessment of length. 68 As described by Collis, 1 there is a large subset of patients who have true but moderate esophageal shortening, which can be treated by an extended 38. Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 309 mediastinal dissection. Recently, O’Rourke and coworkers 25 proposed an extended laparoscopic transmediastinal dissection in patients with moderately short esophagus. These authors defi ned an esophageal dissection less than 5 cm into the mediastinum as type I, and an esophageal dissection greater than or equal to 5 cm into the mediastinum as type II. On average, a type II dissection was carried up between 7 and 10 cm into the mediastinum. In cases in which type II dissection failed to release intra-abdominally an adequate segment of tension-free esophagus, a thoracoscopic-assisted Collis gastroplasty was performed. 25 A concern associated with type II dissection is the potential for occult injury to the vagus nerves. 25 The decision to measure the length of the intra-abdominal esophagus after isolation without tension has the advantage of overcoming the totally subjective concepts of moderate or reasonable or adequate tension applied to pull downward the stomach. Any modality of objective measurement of the applied tension, although feasible with a dynamometer, would be unacceptably cumbersome. It is generally agreed that if a minimum of 2.5 to 3 centimeters of tension–free intra-abdominal esophagus are not obtained after adequate mobilization, a lengthening gastroplasty should be added to the fundoplication. 9,11,13,23,25,26,68,77,92,95,102 38.1.4. Surgical Techniques The techniques of transthoracic and transabdominal lengthening gastroplasty, associated with a total or partial fundoplication, are famil- iar to thoracic and esophageal surgeons who have an adequate training. These procedures remain the cornerstones of anti-refl ux surgery, especially for complicated cases and re-operative surgery. The minimally invasive Collis–Nissen has gained popularity, mainly in tertiary reference centers via laparoscopic or combined thoraco- laparoscopic approaches. In the mid 1990s, two techniques of thoracoscopic gastroplasty and laparoscopic fundoplication were published. 9,108 Swanstrom performed a lengthening gastroplasty by introducing an endostapler through the right chest [Figure 38.1(A)]. 9 In 1998, Johnson, AB CD FIGURE 38.1. Mini invasive esophageal lengthening gastroplasty: (A) right thoracoscopic approach, (B) laparoscopic approach, (C) left thoracoscopic approach, and (D) laparoscopic stapled wedge gastroplasty. 310 S. Mattioli and M.L. Lugaresi Oddostir, and Hunter 10 proposed a laparoscopic technique that reproduced the open one pro- moted by Steichen [Figure 38.1(B)]. The authors intended to avoid a “double cavity procedure” and its potential complications. Awad has preferred the left thoracoscopic approach for introducing the articulated endostapler [Figure 38.1(C)]. 11 The most recent modifi cation of the Collis gastroplasty is the stapled wedge gastroplasty published in 2004 by Tierry, Vernon, and Hunter, 12 Lin and associates, 13 and Hoang and coworkers. 14 This technique is performed laparoscopically, and requires the resection of a wedge of gastric fundus in order to staple the lesser curvature vertically [Figure 38.1(D)]. The wedge gas troplasty has been developed because, with the fully laparoscopic technique [Figure 38.1(B)], the apex of the tubularized fundus could become ischemic. 12 38.1.5. Results With regard to the transthoracic Collis–Belsey and Collis–Nissen operations, Pearson and Orringer reported an operative mortality of 0.5% to 1.1%. 109–111 Other authors achieved analogous results. 6,112–114 Complications related to the lengthening gastroplasty included leaks and fi stulas, which occurred in 10% or fewer patients. 77 Pearson reported good long-term results in 84.5% and fair/poor results in 15.5%, 115 and Orringer observed good results in 89%. 110,111 The long-term results of the open Collis procedure associated with anti-refl ux surgery are not uniform, and satisfactory results vary from 59% 107,116 to 80%. 26 With regard to the minimally invasive Collis– Nissen, the early results are satisfactory and compare favorably with previous open surgery series. Mean operative time for Hunter’s series was 294 min, 10 and for Swanstrom’s series, it was 257 min. 16 The average length of stay has been 2 to 3 days. 10,11,16,92 No operative mortalities were re ported. 10,11,12,14,16,92,117 Complications ranged from 0% to 50%. 10–12,14,16,92,117 Postoperative functional assessment at 12 months for Hunter’s series revealed that 11% of patients complained of refl ux symptoms and 11% had dysphagia. 10 Short-term follow-up in Swanstrom’s series revealed no evidence of recurrent refl ux. 9 However in medium- term follow up, 14% of patients complained of refl ux symptoms and 14% had dysphagia. 16 No wrap failures or mediastinal herniations were observed. 16 Awad and coworkers reported similar outcome data at a mean follow-up of 17 months: 9% of patients complained of refl ux symptoms and 9% had dysphagia. 23 They objectively docu- mented a 9% wrap failure rate and a 9% mediastinal herniation rate. 23 Pierre and colleagues 118 reported on a group of 112 patients with paraesophageal hernia who underwent a laparoscopic Collis–Nissen procedure. At a median of 18 months of follow-up, the patients satisfaction rate was 93%, 16% required, at least occasionally, anti-secretory medications, and 6% had dysphagia warranting dilation. Recurrent hiatal hernias. were observed in 2.7%. 118 The Collis gastroplasty is a suitable procedure also in case of re-operation after a failed anti- refl ux procedure, as performed in open surgery by Deschamps in 62.7% of cases 119 and recently in minimally invasive surgery by Luketich in 52.5%. 120 Two specifi c causes of malfunction of the lengthening gastroplasty have been identifi ed. The neo- esophagus’ lack of motility may predispose to dilation of the tube or contribute to postoperative dysphagia. 13,14,77 Of more potential concern is the production of acid within the neoesophagus pro- ducing localized esophagitis, as was observed in open Collis procedures. 13,14,77,107 Jobe and coworkers 16 performed an objective follow-up in 15 patients after laparoscopic lengthening gastroplasty and anti-refl ux fundoplication: in 7 of 15 patients the neoesophagus above the wrap was found to contain parietal cells that continued to secrete acid. This was indicated by an abnormal postoperative DeMeester score and it was confi rmed by positive Congo red testing of the suspected mucosa. In order to avoid leaving parietal cells above the fundoplication, Hunter suggests placing the highest stitch of the fundoplication on the native esophagus. 13 Although the Collis gastroplasty is conceptually appealing, these problems call into question the liberal ap plication of this technique during anti-refl ux surgery. 13 38.2. Recommendations All the data of the past and present literature originate from single center reports; no study was 38. Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 311 randomized; the criteria for inclusion of patients were not defi ned; the indications for surgical therapy of GERD were not specifi ed; and the methods for studying the patients were neither standardized nor uniform. The surgical techniques adopted in the last 10 years are substan- tially different and have been applied to relatively small numbers of patients. In consequence, the quality of data of the body of literature available regarding the arguments treated in the present chapter is unfortunately low (level of evidence 3 to 4). Nevertheless, every day patients affected by GERD undergo surgical therapy. It is imperative to draw empirical guidelines for the management of these patients. Authors who believe that the lengthening gastroplasty is still the only way to manage true short esophagus and other complex situations agree on the following concepts: (1) the preoperative evaluation offers the clinician positive ele- ments of suspicion on the eventual complexity of the case, but the diagnosis of short esophagus can be made only in the operating room with a combined surgical and endoscopic measurement of the distance between the GE junction and the diaphragm; (2) only after extensive mobilization of the mediastinal esophagus; and (3) when the intra-abdominal portion of the esophagus is shorter than 2 to 3 cm with no downward tension applied. With regard to the surgical techniques, many insist on the utility of perform- ing the fundoplication around the proximal neo-esophagus. 38.3. Our Approach The 25 years of clinical research of the Bologna group on anti-refl ux surgery, specifi cally on diagnosis, pathophysiology, and treatment of short esophagus, and the continuous attention paid to the work of others, has led us to progressively mature and share the above-mentioned principles according to our experience. We have adopted a series of technical details with the intention of eliminating the reasons for failure, still certainly not negligible, of the Collis procedure associated with anti-refl ux surgery. 26 At the present time, we believe that the only alternative to a lengthening gastroplasty for true short esophagus, with or without stricture or paraesophageal hernia, is long-term medical therapy, with the consequences already depicted. 76 The preoperative barium swallow and the radiologic classifi cation in three steps of cranial migration of the GE junction 75 provide enough information to adequately inform the patient and to plan the operative procedure. When a concentric hiatus hernia or short esophagus are diagnosed radiologically, we place the patient in the 45° left lateral position on the operating table [Figure 38.2(A)]. Rotating the bed on the left or on the right, the surgeon can com- fortably perform laparoscopy or laparoscopy-left thoracoscopy; the 10-mm optic port is placed at least 5 cm above the standard umbilicus position [Figure 38.2(A)]. The left thoracoscopic approach [Figure 38.2(B)] has been preferred because it permits effective control of the otherwise blind passage of the endostapler into the mediastinum and upper abdomen (if a second optic is not used). The tip of the stapler is clearly visible while walking the stapler tip along the left diaphragm. Moreover, with the left thoracic approach, the lower esophagus and hiatus are well displayed. The routine marking by clips of the GE junction with the help of the fi berscope is useful in placing the fundoplication in the correct position around the esophagus or the neo-esophagus. Intraopera- tive endoscopy requires a few technical details to precisely measure the length of the intraabdomi- nal esophagus: (1) defl ate the stomach to avoid distension of the fundus and the consequent shortening of the submerged esophageal segment; (2) mark the level of the gastric folds while The diagnosis of short esophagus can be made only in the operating room with a combined surgical and endoscopic measurement of the distance between the GE junction and the diaphragm, and only after extensive mobilization of the mediastinal esophagus. When these conditions are met and the intra-abdominal portion of the esophagus is shorter than 2 to 3 cm with no downward tension applied, it is appropriate to perform a Collis gastroplasty (level of evidence 3 to 4; recommendation grade C). 312 S. Mattioli and M.L. Lugaresi withdrawing the instrument [Figure 38.2(B,C)] measure the distance between the anterior apex of the hiatus (which is more cranial than the posterior aspect) and the clips. For measuring the distance between the clips and the apex of the diaphragm, we have created an L-shaped ruler which eliminates the perspective errors caused by the bidimensional video image [Figure 38.2(C)]. In order to avoid the formation of an amotile acid secreting pouch above the upper margin of the fundoplication, we consider it crucial that the neoesophagus is not longer than 3 cm [Figure 38.2(D)]. With the thoracoscopic approach, the lengthening achieved with one application of the roticulator endostapler cannot exceed 3 cm. It is therefore always possible to include the entire neo-esophagus in the 360° fundoplication. To date, the neo-esophagus and the fundoplication always have been placed below the diaphragm without tension. The importance of preserving a soft, balloon- shaped gastric fundus to wrap smoothly around the neo-esophagus has been clearly pointed out in the past. 121 With the EEA laparoscopic gastroplasty (same for the open Collis–Nissen), a long stiff fundus is frequently obtained that cannot softly cover the whole length of the neo-esophagus. We believe that this was the main reason for some of the poor long-term results we obtained with the abdominal Collis–Nissen with respect to the Pearson operation, in the absence of ischemia of the stapled gastric remnant and of anatomical relapse. 26 We extend this concern to the stapled wedge Collis gastroplasty techniques 12–14 which A B C DE FIGURE 38.2. Left thoracoscopic–laparoscopic Collis–Nissen procedure: (A) position of the patient on the operative bed, the chest is rotated 45° to the right side, the optic port is placed 5 cm above the ombilicus in the mid line, the thoracoscopic port (12 mm) is placed in the posterior axillary line 5th to 7th interspace according to the size of the chest; (B) the tip of the fiberscope is in correspondence of the gastric folds; (C) the L-shaped ruler; (D) the neoesophagus, and (E) the floppy Nissen is anchored to the esophagus at the level of the native GE junction. 38. Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 313 drastically reduce the volume of the gastric fundus. To prevent the formation of a gastric pouch above the fundoplication we fi x the wrap laterally to the native cardia with two stitches placed at the apex of the gastroplasty [Figure 38.2(E)]. To avoid the intraoperative splitting of the endosuture, 26 we currently use a 46 Maloney bougie to calibrate the gastroplasty. We have not yet registered any cases of troubling dysphagia. In summary, when treating complex cases of GERD, surgeons must optimize the pre- and intra-operative recognition of the anatomical and pathophysiological situation and must possess the experience and skill necessary to adequately perform very complex surgical procedures. References 1. Collis JL. An operation for hiatus hernia with short oesophagus. Thorax 1957;12:181–188. 2. Collis JL. An operation for hiatus hernia with short esophagus. J Thorac Surg 1957;34:768– 778. 3. Collis JL. Review of surgical results in hiatus hernia. Thorax 1961;16:114. 4. Pearson FG, Langer B, Henderson MB. Gastro- plasty and Belsey hiatal hernia repair: an operation for the management of peptic stricture with acquired short esophagus. J Thorac Cardiovasc Surg 1971;61:50–63. 5. Orringer MB, Sloan H. Complications and fail- ings of the combined Collis–Belsey operation. J Thoracic Cardiovasc Surg 1977;74:726–735. 6. Demos NJ. Stapled, uncut gastroplasty for hiatal hernia: 12-year follow-up. Ann Thorac Surg 1984;38:393–399. 7. Cameron BH, Cochran WJ, McGill CW. The uncut Collis–Nissen fundoplication: results for 79 consecutively treated high-risk children. J Pediatr Surg 1997;32:887–891. 8. Steichen FM. Abdominal approach to the Collis gastroplasty and Nissen fundoplication. Surg Gynecol Obstet 1986;162:272–274. 9. Swanstrom LL, Marcus DR, Galloway GQ. Lapa- roscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg 1996;171:477–481. 10. Johnson AB, Oddsdottir M, Hunter JG. Laparo- scopic Collis gastroplasty and Nissen fundoplication: a new technique for the management of esophageal foreshortening. Surg Endosc 19 98 ;12:105 5– 1060. 11. Awad ZT, Filipi CJ, Mittal SK, et al. 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[...]... reflux injuries Am J Med 2000; 108(suppl 4a):99S–103S 66 Sonnenberg A Esophageal diseases In: Everhart JE, ed Digestive Diseases in the United States: 67 68 69 70 71 72 73 74 75 76 77 78 315 Epidemiology and Impact US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease NIH publication no 94–14 47 Washington,... of a challenge using minimally invasive procedures, but excisions of diverticula up to 7 to 10 cm in size have been reported.18,21 In summary, the early experience with minimal access surgery for treating intrathoracic esophageal diverticula points to a potential benefit with no fallout on effectiveness and safety The indications for and principles of such surgery remain the same as in the case of the... precluding a tension-free repair In this chapter we will review the incidence, preoperative and intra-operative evaluation of esophageal shortening, and the role of lengthening gastro- 318 plasty in the management of giant paraesophageal hernias 39.1 Preoperative Evaluation The true incidence of the short esophagus in a giant paraesophageal hernia remains unknown This is mainly because there is no single... from Orringer is quoted in many articles addressing this issue: “A masterful inactivity in asymptomatic or mildly disturbing diverticula is a good practice even if, in this time of mini-invasive surgery and stapling device, an esophageal diverticulectomy may represent a tempting trophy for a hyperactive surgeon.”9 This is a wise attitude to take because the mere presence of a diverticulum in the thoracic. .. about the role of surgery, the approach (transthoracic or transabdominal), and the need for esophageal lengthening during repair Esophageal shortening is a result of longstanding gastroesophageal reflux disease wherein chronic irritation and injury leads to fibrosis and scarring of the esophagus.2 This results in a relative shortening of the esophagus that cannot be reduced intra-abdominally at the time... esophageal shortening in giant paraesophageal hernia is unknown There is no single preoperative investigation that can identify all patients with true esophageal shortening and the most defi nitive way of determining shortening is intraoperatively The data suggests that the recurrence rate following repair is higher if a lengthening gastroplasty is not used routinely in cases of esophageal shortening References... accurate way of determining esophageal shortening is in the operating room at the time of repair 39.2 Lengthening Gastroplasty: Is It Necessary? What Is the Ideal Technique? The role of esophageal lengthening gastroplasty remains a controversial point among clinicians as the true incidence of shortening is unknown While there are no prospective, randomized, controlled trials comparing the outcomes with... Luketich JD, Grondin SC, Pearson FG Minimally invasive approaches to acquired shortening of the esophagus: laparoscopic Collis-Nissen gastroplasty Semin Thorac Cardiovasc Surg 2000; 12: 173 – 178 39 Lengthening Gastroplasty for Managing Giant Paraesophageal Hernia Kalpaj R Parekh and Mark D Iannettoni The herniation of stomach into the thorax has been classified into four major types The sliding hiatus hernia... endoscopic surgery, dividing the cricopharyngeal bar between the sac and the esophagus, was first performed by Mosher in 19 17. 26 Dohlman, in 1935, introduced a specialized diverticuloscope and cautery into the endoscopic armamentarium and reported on a series of 100 patients so treated in 1960. 27 Overbeek further refined the endoscopic approach with the use of a 400-mm-lens operating microscope, allowing more... Complications including aspiration, bleeding, cervical emphysema, cervical spine irritation, dental injury, mediastinitis, myocardial infarction, pharyngeal perforation, pneumonia, postoperative fever, urinary tract infection, and vocal cord paralysis a Converted to an open procedure because of insufficient exposure (limited neck extension, retrognathia, etc.) or mucosal tear c Success defined as good-to-excellent . Mini-invasive 0 Johanet 40 1999 335 Mini-invasive 0 Klinger 43 1999 102 Mini-invasive 0 Loustarinen 47 1999 1 27 Mini-invasive 0 Soper 55 1999 292 Mini-invasive 0 Watson 56 1999 1 07 Mini-invasive. 239 Mini-invasive 0 O’Boyle 49 2000 511 Mini-invasive 0 Pessaux 51 2000 1 470 Mini-invasive 0 Ross 54 2000 200 Mini-invasive 0 Yau 58 2000 75 7 Mini-invasive 0 Eubanks 18 2000 228 Mini-invasive. 2001 153 Mini-invasive 13% O’Rourke 25 2003 4 87 Mini-invasive 19% Lin 13 2004 1 579 Mini-invasive 4.3% Terry 12 2004 143 Mini-invasive 11.2% Mattioli 26 2004 a 170 Open, mini- 23% invasive

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