Lengthening Gastroplasties

In 1957, Collis,8 dissatisfied with the problems generated by the short esophagus, including the frequent periesophagitis present in these patients, introduced the concept of esophageal lengthening using the proximal lesser gastric curvature to create a neoesophagus. The lengthening gastroplasty was seen as an alternative to esophagectomy and reconstruction, a solution which was used more liberally at that time. The repositioning of the esophagogastric junction with the recreation of the angle of His was initially thought to be sufficient to prevent gastroesophageal reflux.8 No anti-reflux mechanism was then added to the gastroplasty, leading to poor reflux control. Subsequently, the initial Collis gastroplasty was combined to a Belsey-type of fundoplication by Pearson whereas Orringer and Henderson advocated the use of a total fundoplication to wrap the neoesopha-gus.43 The indications for using a lengthening gastroplasty with either a partial or a total antireflux fundoplication have been summarized by Pearson: chronic damage of reflux disease, reop-

erations for failed previous hiatal hernia repairs or anti-reflux operations, and massive hernias with an intrathoracic stomach. More controversial indications are its use in patients with gross obesity or with asthma and chronic obstructive pulmonary disease.45

Collis-Belsey gastroplasty. This repair involves the complete mobilization of the distal esophagus and proximal stomach. A no. 48 or 50 bougie is passed into the stomach by the anesthetist and held against the lesser curvature. A GIA stapler with 4.8-mm staples is applied to create a 4- to 5-cm gastroplasty. This is usually sufficient to obviate tension on the repair. The 270° fundoplication replicating the original Belsey repair is then completed, completely covering the transection margin of the gastroplasty while offering the anti-reflux protection of a partial fundoplication. Using this transthoracic repair, Pearson and Henderson46 reported satisfactory results in 93% of patients treated for a short esophagus associated with esophagitis or stricture. The success rate of the operation was 80% if the operation was offered to patients with unsuccessful previous repairs. If the operation was used in patients treated previously by esophageal myotomy for motor disorders, the overall results were poor. This operation shows excellent long-term results when used in patients with a massive hernia.30 The main cause for failure when a Collis-Belsey gastroplasty is used is persistent gastroesophageal reflux.47

Collis-Nissen repair. Henderson48 and Orringer and Sloan49 suggested the use of a combination of a lengthening gastroplasty with a total fundoplication. They proposed that this was a better anti-reflux operation for reflux disease with a reflux-damaged shortened esophagus. The gastroplasty tube is created just as described with the Collis-Belsey repair, resulting in a 4- to 5-cm gastroplasty (Figure 13.1). The transected fundus is then brought as a total fundoplication around the gastroplasty tube. The fundic wrap is sutured to itself, creating a 3- to 4-cm-long, 360° total fundoplication (Figure 13.2). Stirling and Orringer50 reported the results of this operation. Eighty-eight percent of the patients in their group had good control of symptoms and 8% required medication despite the operation. Ten years after the operation, 34% of patients assessed by 24-hour

MANAGEMENT OF THE SHORT ESOPHAGUS

Collis Nissen

Figure 13.1. The cut Collis-Nissen as described by Orringer requires full mobilization of the gastric fundus and placement of a large bougie along the lesser gastric curvature. A linear cutting stapler is then fired parallel to the bougie to elongate the esophageal tube and enlarge the fundus. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

Figure 13.1. The cut Collis-Nissen as described by Orringer requires full mobilization of the gastric fundus and placement of a large bougie along the lesser gastric curvature. A linear cutting stapler is then fired parallel to the bougie to elongate the esophageal tube and enlarge the fundus. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

pH testing revealed abnormal acid exposure, most of them asymptomatic. When a stricture was present, these authors reported the failure rate for this operation to be 23%.50

Uncut Collis-Nissen repair. The uncut gastroplasty was reported by Langer51 and described by Demos et al.52 and Bingham.53 The gastro-plasty tube is created from the proximal smaller curvature by the use of a 3-cm linear stapler with 4.8-mm staples, applied along an inlaying no. 48 or 50 bougie held against the small curvature (Figure 13.3). The gastroplasty is created by the apposition of the anterior and posterior wall of the stomach. The gastroplasty tube is not separated from the gastric fundus by transec-tion. The extensively mobilized remaining fundus is then brought around the entire length of the gastroplasty as a total fundoplication and the fundic wrap is sutured immediately anterior to the staple line (Figure 13.4). This repair provides excellent clinical and functional results.

Chen et al.54 and McDonald et al.55 reported reflux control in 95% of their patients. The repair remains competent over time, showing an excellent LES gradient but an incomplete relaxation of the sphincter area. A potential weakness of this operation is its obstructive character in patients with poor propulsive capacity. Bingham53 has also reported the tendency of staples to come out, leaving the mucosal apposition undone and the stomach wrapped around itself. The staple line, in our experience, is well protected by the total fundoplication.

Modified Collis-Nissen repair. When a reoperation becomes necessary after single or multiple previous repairs, the quality of the gastric fundic tissue may not be appropriate for a healthy gastroplasty wrap. In this situation, Jeyasingham's modified cut gastroplasty may be a useful technique as an esophageal-sparing operation. The gastroplasty is fashioned as for the uncut technique, using a 3-cm linear stapler with 4.8-mm staples apposing the anterior and the posterior walls of the proximal stomach

Collis Gastroplasty Hernia Repair

Figure 13.2. After completing the esophageal lengthening portion of the cut Collis-Nissen, a standard total fundoplication is performed with the bougie still in place to appropriately size the wrap. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

Figure 13.2. After completing the esophageal lengthening portion of the cut Collis-Nissen, a standard total fundoplication is performed with the bougie still in place to appropriately size the wrap. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

MANAGING FAILED ANTI-REFLUX THERAPY

Collis Belsey Gastroplasty

Figure 13.3. An uncut Collis-Nissen is initiated by complete mobilization of the proximal stomach and esophagus. A bougie is positioned along the lesser gastric curvature and a linear stapler (noncutting) is fired parallel to it. This elongates the esophageal tube, around which a fundoplication wrap can be created. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

Figure 13.3. An uncut Collis-Nissen is initiated by complete mobilization of the proximal stomach and esophagus. A bougie is positioned along the lesser gastric curvature and a linear stapler (noncutting) is fired parallel to it. This elongates the esophageal tube, around which a fundoplication wrap can be created. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

Esophagus Lengthen Procedure

Figure 13.4. After the staple line is created for the uncut CollisNissen, a fundoplication wrap is created around the extended esophageal tube. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

Figure 13.4. After the staple line is created for the uncut CollisNissen, a fundoplication wrap is created around the extended esophageal tube. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

parallel to a 48- or 50-French bougie held against the lesser gastric curvature (Figure 13.5). Once the staples are fired, the stomach on the fundus side is opened and the gastrotomy incision is elongated toward the apex of the fundus. The fundus is then closed transversely, as for a pyloroplasty (Figure 13.6). This closure provides a widened fundus with enough anterior and posterior gastric wall to create a 3-cm total fundoplication around the gastroplasty

Collis Nissen Fundoplication

Figure 13.5. A modified Collis-Nissen fundoplasty is initiated after complete mobilization of the fundus and distal esophagus by creating a staple line along the lesser gastric curvature in a manner similar to that used for an uncut Collis gastroplasty.The fundus is opened from the distal end of the staple line toward the tip of the fundus. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24—37, Copyright 2000, with permission from Elsevier.)

Figure 13.5. A modified Collis-Nissen fundoplasty is initiated after complete mobilization of the fundus and distal esophagus by creating a staple line along the lesser gastric curvature in a manner similar to that used for an uncut Collis gastroplasty.The fundus is opened from the distal end of the staple line toward the tip of the fundus. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24—37, Copyright 2000, with permission from Elsevier.)

MANAGEMENT OF THE SHORT ESOPHAGUS

MANAGEMENT OF THE SHORT ESOPHAGUS

Pierson Collis Belsey

Figure 13.6. After opening the stomach for the modified CollisNissen fundoplasty, the fundic incision is closed transversely to widen the fundus. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

to avoid functional obstruction or poor drainage of the supradiaphragmatic stomach.

Thal59 initially proposed to split the eso-phageal stricture caused by the reflux and widen the esophagus by pulling the fundus into the chest and applying a fundic patch to cover the opened esophagus. The healing pattern resulted in restricture and this was corrected by adding a skin graft to cover the fundus before the patch closure. But despite protection of the gastric serosa by the graft, free reflux and recurrent esophagitis persisted if an anti-reflux mechanism was not added. A total fundoplication covering the Thal patch was documented to result in satisfactory results in 84% of treated patients.60

Both these types of intrathoracic fundoplica-tions, although well known to correct reflux, are not used extensively because of the dangers that have been reported with supradiaphragmatic

Figure 13.6. After opening the stomach for the modified CollisNissen fundoplasty, the fundic incision is closed transversely to widen the fundus. (Reprinted from Ferraro P, Duranceau A. Elongation gastroplasty with total fundoplication. Operative Techniques in General Surgery 200;2:24-37, Copyright 2000, with permission from Elsevier.)

(Figure 13.7). A positive aspect of this repair is the usual better quality of the available tissue provided by the extensive mobilization of the lower gastric body. This "new" stomach wall provides a healthy wrap and a good protection around the gastroplasty tube.56

Virtual Gastric Banding

Virtual Gastric Banding

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