Stapled, Uncut Gastroplasty for Hiatal Hernia: 12-Year Follow-up

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1 Stapled, Uncut Gastroplasty for Hiatal Hernia: 12-Year Follow-up Nicholas J. Demos, M.S.(Path), M.D. ABSTRACT A total of 82 patients with gastroesophageal reflux were consecutively treated with stapled, uncut gastroplasty and complete fundoplication over a 12-year period. The conditions treated included symptomatic reflux; esophageal stricture; massive hernia; collagen esophagus; short esophagus; Barrett s esophagus; recurrent, massive bleeding or anemia; small gastric remnant after gastrectomy; and acute volvulus. The transthoracic approach of stapled, uncut gastroplasty gives superb exposure. Outstanding features of the procedure are (1) the safety and versatility resulting from the small amount of fundus required, (2) no need either to ligate short gastric vessels or to suture the esophagus itself, and (3) preservation of anatomical continuity between the wrapping fundus and the wrapped gastric tubular segment. There have been no deaths and no cases of anatomical or symptomatic recurrence in the series. Complications included some nondebilitating and mainly self-limiting symptoms. Since 1971 my colleagues and I have used stapled, uncut gastroplasty to correct the symptoms and complications of gastroesophageal reflux. A preliminary report of our experimental work and clinical application was presented at the annual meeting of the New York Society for Thoracic Surgery in 1974 [l]. Two reasons led to the development of our new approach: simplification of the operative procedure and reduction of recurrence, splenic injury, and fistula formation. We perform uncut gastroplasty by stapling the anterior gastric fundus in addition to complete fundoplication of the anterior gastric wall. Our technique represents one step further in the evolution of surgical treatment proposed by notable pioneers [2-4]. We have applied the technique to nearly all cases of gastroesophageal reflux that necessitated surgical correction. Material and Methods A detailed history was taken, and flexible upper endoscopic and barium studies were performed before and after operation in 82 patients, 50 of whom were women From the Department of Surgery, Christ Hospital, Jersey City, NJ Presented at the Nineteenth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 17-19, Address reprint requests to Dr. Demos, 4 Cambridge Dr, Short Hills, NJ and 32, men. A Honeywell system was used for esophageal function studies employing the photosensitive tracing paper technique. Acid esophageal perfusion was done with 1% normal hydrochloric acid. In addition to intractable symptomatology of reflux, indications for operation were stricture (19 patients), respiratory symptoms (18), massive hernia (ll), collagen disease (lo), short esophagus (9), Barrett s esophagus (6), recurrent disease (5), anemia or massive bleeding (5), small gastric remnant after gastrectomy (3), and acute volvulus (1). The operation was performed through the left sixth intercostal space in 81 patients. A left upper lobectomy for adenocarcinoma was done concomitantly in 1 patient. One repair was performed transabdominally after a concomitant aortic aneurysmectomy. I conducted all of the preoperative and postoperative interviews. I saw the patients three weeks and 3, 5, 9, and 15 months after operation, and then yearly or at 6-month intervals thereafter. I performed all of the operative procedures as well as the majority of endoscopic examinations. Operative Technique The strictured esophagus is dilated during anesthesia just before the thoracotomy using graded, tapered, mercury-filled Maloney bougies. When adequate transoral dilation is impossible, retrograde transgastric dilation is accomplished with Hegar dilators. Through the left sixth intercostal space, a 1.5-cm segment of the seventh rib is excised posteriorly as a controlled fracture. The lowermost few centimeters of thoracic esophagus are sharply and bluntly dissected out. Care is taken to avoid injury to the vagi, which are left attached onto the esophagus. The peritoneum is entered through the hiatus, and circumferential blunt and sharp dissection is performed. The anterior fundic wall is pulled into the chest, and 3 to 5 cm of stapling is done. Large (4.8 mm) staples are used to avoid crushing the gastric wall. The double-row stapling line is parallel to the posterior gastric wall and fits as a linear continuation of the anterior esophageal wall. This ensures against too narrow or large a lumen (Figs 1, 2). I have found it unnecessary and somewhat awkward to have a Maloney bougie inserted into the esophageal lumen during stapling and subsequent fundoplication. However, the surgeon may occasionally find it beneficial to use the bougie. At this point, three to four size 0 silk sutures are inserted posterior to the esophagus on the right and left sides of the esophageal hiatus but left untied. While the surgeon s left hand folds the fundus around the cardia 393

2 394 The Annals of Thoracic Surgery Vol 38 No 4 October 1984 / Fig 1. Through the left sixth intercostal space, the anterior fundic wall is pulled through the hiatus. Fig 3. The surgeon's left hand wraps the fundus around the tubular gastric segment and often around the cardia to prepare for suturing of the fundoplication. Fig 2. The anterior fundus is stapled in lines parallel to the posterior wall of the stomach. Note that alignment pin is not used with staples. and the "new" tubular segment, three to five seromuscular mattress sutures of 3-0 silk are inserted to perform the plication (Figs 3, 4). The esophagus contains the nasogastric tube. If the surgeon's index finger is easily inserted between the plicating and plicated fundus, no serious dysphaga will result. In patients with aperistaltic esophagus, fewer sutures are placed, the wrapping is looser, and only about 1 cm of fundoplicating coaptation is performed using two or three mattress sutures. To produce looser plication, one has to free the stomach a bit more before performing the fundoplication in this group of patients. In 2 patients in the series, one short gastric vessel had to be interrupted in order to provide more fundus for a comfortable plication. The irreducible cardia and very short esophagus deserve special mention. As the cardia is situated up near the pulmonary hilus in such instances, a tubular portion of the stomach follows. In order to perform the gastroplasty, more gastric wall is pulled up in the chest and the stapling is done on that extra stomach tissue. The plicated valve mechanism is returned under the diaphragm, and a tubular segment of stomach is left in the chest trailing the cardia (Fig 5). The gastrophrenopexy sutures are now inserted. Four mattress sutures of 3-0 Tycron on double needles are inserted at the most superior edge of the plicated stomach. Following this, each needle is driven from the inferior to the superior phrenic surface with the aid of a

3 395 Demos: Stapled, Uncut Gastroplasty finger in addition to the esophagus to pass through the hiatus. The pleura is loosely approximated, and the chest is drained with a short tube under the left lower lobe and a longer one posteriorly. I have found it important to drain the inferior surface of the lower lobe to avoid loculated fluid collections. Prophylactic cephalosporin is given parenterally one hour before and every six hours after operation for a few days. The chest tubes and the nasogastric tube are removed on the third or fourth postoperative day. Regular diet is started on the fifth or sixth day. Fig 4. Completed fundoplication. specially designed guide to avoid suturing the stomach again (Fig 6). By pulling gently on those sutures, the surgeon can easily slide the plication under the diaphragm. These sutures are tied; then the crural heavy silk sutures are tied lightly, allowing room for the index Fig 5. In patients with vey short esophagus, the irreducible cardia is left in the chest. The flexibility of the stapled gastroplasty allows the plication to be performed lower down in the stomach and attached totally under the diaphragm. Results There were no operative deaths. Two patients were lost to late follow-up. Esophagographic and fluoroscopic studies performed five to seven days, and 6 to 18 months, and at times every 1 to 2 years after operation were judged normal in all 82 patients. In 6 patients, routine contrast studies done 6 to 18 months postoperatively revealed mild but definite gastroesophageal reflux of barium. None of these patients has experienced symptoms of reflux. Thirty-two of the 34 patients operated on at the beginning of the series have been followed up for 7 to 12 years. The 48 patients seen later in the series have been followed up for 2 to 6 years. The most frequent immediate postoperative complication was transient mild dysphagia, which subsided by seven to eight weeks after operation. Three patients underwent dilation once in the postoperative period before discharge. The average period of hospitalization was 11 days. Three patients required dilation every 6 to 12 months. One was a 27-year-old woman with severe scleroderma and lack of peristalsis in the entire esophagogastrointestinal tract but no organic strictures. The other 2 were elderly patients with complete preoperative esophageal obstructions; they bled mas- At! cardia

4 396 The Annals of Thoracic Surgery Vol 38 No 4 October 1984 Fig 6. Znsertion of sutures, which will attach and keep the plicated segment under the diaphragm. A special instrument guides the needles under the diaphragm. sively, were resuscitated, and then underwent dilation and operation in the usual fashion. Each of these patients has been followed up for 4'5, and 7 years, respectively. Of the 19 patients with organic stricture, only the 2 just mentioned had to be dilated in follow-up of 3 to 11 years. Esophageal function tests were performed in 71 patients before and after operation. In 49 preoperative tracings, the lower esophageal sphincter was recognizable. It ranged in length from 0.7 to 4.5 cm (mean f standard deviation [SD], 2.56 f cm). In 50 postoperative measurements, the length ranged from 3 to 5.5 cm (mean f SD, 3.5 f cm). The difference between the preoperative and postoperative values was highly significant (p < 0.001). The preoperative lower esophageal sphincter pressure ranged from 3 to 20 mm Hg (mean f SD, 7.14 f 4.5 mm). The postoperative pressure ranged from 20 to 40 mm Hg (mean f SD, f mm Hg). The difference was highly significant ( p = ). The percentage of tertiary esophageal contractions was reduced from 74% before to 18% after operation. In the 10 patients with collagen esophagus, the sphincter had almost no pressure and an average length of 0.7 cm before operation. Postoperatively, average pressure was 20 mm Hg and average length, 2.5 cm. Preoperative ph measurements in 48 patients showed slow alkalinization from a gastric ph of 1.5 to a ph of 5.5 to 6.5 at a distance of 6 to 10 cm above the lower esophageal sphincter. In 7 patients, a gastric ph of 4.5 to 5.5 continued throughout the length of the esophagus. In 10 patients, the gastric ph of 1.5 rose sharply to 6.0 as soon as the lower sphincter was passed. In 12 patients, spontaneous acidification of the esophagus took place up to 15 cm above the sphincter. An additional 6 patients had temporary acidification in the esophagus on epigastric pressure. Preoperative esophageal acid perfusion reproduced symptoms in 58 of 65 patients. In none of the forty postoperative studies did the perfusion give a positive response. Even though 14 patients complained of cervical dysphagia before operation, only 3 of them had evidence of upper sphincter dyskinesia with simultaneous pharyngeal and upper sphincter contraction on manometry. In only 1 of these 3, a patient who also had a severe preoperative stricture, was postoperative dilation necessary every 6 to 12 months. This patient had one of the two severe organic strictures mentioned previously. The ability to burp occasionally was reported by many patients about 2 months postoperatively. None complained of gas pains by 3 months or more postoperatively. The retrostemal and other pains and symptoms disappeared immediately after operation. Mild intercostal pain has lasted many months in 26 patients. It has responded to exercise, treatment with mild analgesics, and reassurance. It is of great help to explain to the patient before the operation about these mild, tolerable, and eventually correctable (albeit annoying) sensations. One patient required gastroenterostomy and another,

5 397 Demos: Stapled, Uncut Gastroplasty pyloroplasty for postoperative relief of epigastric or retching symptoms. Comment The operative technique described in this article is essentially a complete fundoplication such as that reported by Watkins and colleagues [5] and Rossetti [4]. Commonly called a Nissen fundoplication, this procedure is performed using the redundant anterior gastric wall [4]. I believe that the additional feature of a stapled, uncut gastroplasty enhances stability between the wrapping and the wrapped gastric fundus, thus avoiding slippage of these elements. Moreover, the technique avoids the insecure and injurious sutures between the wrapping fundus and the esophageal wall, or the cardia, or both that are required for other complete fundoplication techniques [6-91. Because it offers these two major advantages, stapled, uncut gastroplasty has become our universal antireflux operation. The technique I have described is especially suited for the correction of gastroesophageal reflux and short esophagus. Investigators performing complete fundoplication [3, 7, 9-15], even those using the Hill technique [7], strongly advocate placement of sutures on the esophageal wall to avoid recurrence. These sutures are not always effective in preventing slippage or hourglass stomach recurrence [7, 111; they may have been the cause of fistula formation and death in Woodward s series [ll]. With stapled, uncut gastroplasty, ineffectual and dangerous esophageal sutures are unnecessary. There has been no mortality, recurrence, or fistula formation in my series. The gastroplasty provides rigidity in the anatomical continuity of the plicating fundus and the plicated gastric tubular segment. As long as the plicating cuff is sutured under the diaphragm, the plicated stomach cannot slip upward [I, 16, 171 (see Figs 5, 6). Even the technique of Orringer and colleagues [8], which is a partial fundoplication, is not immune to the requirement for esophageal sutures. Because of high recurrence rates with this technique, Skinner [18] proposed total fundoplication of short esophagus. Recurrence with the procedure also led Henderson and Pearson [13, 141 to recommend the addition of a Collis lengthening gastroplasty [ 191. Because these procedures still had persistently high recurrence rates, Henderson and Manyatt [6] as well as Orringer and co-workers [8, 111 finally resorted to use of a Collis-Nissen procedure, a combination of esophageal lengthening and total fundoplication techniques. These groups both used variations of the cut gastroplasty. While Orringer and Orringer [20] reported severe postoperative reflux of 5% in an average follow-up of 24 months, Henderson and Manyatt [6] in an impressive series of 500 patients noted excellent results in 93.4% in a follow-up of 6 to 60 months. In my series of 82 patients followed for periods up to 12 years with only 2 patients lost to follow-up, there has been no anatomical or clini- cal recurrence, even though 6 patients showed mild radiographic but asymptomatic reflux on late follow-up. The lack of fistulization, splenic injury, and splenectomy in the present series can be attributed directly to the uncut feature of our technique. In their early assessment of the cut gastroplasty, Orringer and Orringer [20] reported three splenic injuries, two gastroplasty tube leaks, and one reoperation for bleeding from a divided short gastric vessel. While nonlethal in that series, these complications are of major importance and could easily have led to death. The tubelike plicating fundus they fashion by transecting the fundus may result in ischemia. I believe that the more extended dissection required to produce the cut gastroplasty is directly related to the morbidity just described. I also believe that the frugal dissection in my technique has prevented these major complications. The postoperative lower esophageal sphincter lengths and pressures in the present series showed statistically significant differences from the preoperative levels. The mean postoperative lower esophageal sphincter pressure was mm Hg compared with a mean preoperative pressure of 7.14 mm Hg. Both preoperative and postoperative pressures are much higher than those reported by Orringer [21]. The differences might be due to the method of recording pressures. The pressures I have reported are closer to those measured by Henderson and Manyatt [6]. The length of the lower sphincter rose from a mean of 2.56 cm before operation to a significantly higher mean of 3.5 cm after operation. The postoperative sphincter length was not as wide as that reported by Orringer [21]-about 4 cm. Following the suggestion of Henderson and Ryder [22], I have reduced the length of fundic coaptation during the fundoplication. However, I share DeMeester s [23] apprehension regarding a very short wrap in the usual case of reflux. The best test of an antireflux procedure is probably a strictured esophagus. Among the 19 patients in my series followed up from 3 to 11 years, 2 had to undergo dilation twice yearly without having any radiographic demonstration of recurrence of reflux. In Orringer s [21] 32 patients, 94% of results were good and 6% were poor in an average follow-up of 28 months. In the 9 patients with short esophagus in the present series, the uncut gastroplasty was easily adapted. The entire plication could be fixed in a subdiaphragmatic position, since it can be performed at a small distance below the cardia (see Fig 5). Because of the uncut feature of this technique, much less fundus is required to perform the plication. Therefore, the technique has been used in 3 patients with a relatively small gastric remnant after gastrectomy. Extensive procedures involving the creation of a gastric reservoir from jejunum as reported by Ellis [24] may not be necessary or desirable unless the gastric remnant is forbiddingly small. The postoperative gastric stasis occurring in 2 patients

6 398 The Annals of Thoracic Sur:gery Vol 38 No 4 October 1984 with ordinary reflux was perhaps a manifestation of a preexisting gastric stasis, as pointed out by Little and colleagues [25]. Orringer and Orringer [20] had 1 such patient. Supported in part by the James Nicholas Surgical Research Fund. I thank Dr. Benjamin F. Rush, Jr., and Dr. Joseph J. Timmes for early encouragement and for providing the animal laboratories for the early experimental work. I am grateful to Dr. John Hsieh for the statistical analyses. References 1. Demos NJ, Smith N, Williams D A new gastroplasty for strictured short esophagus. New York State J Med 75:57, Collis JL: Benign obstruction of the esophagus. In Rob C, Smith R (eds): Clinical Surgery. London, Butterworth, Nissen R, Rossetti M: Die Behandlung von Hiatushernien und Refluxoesophagitis mit Gastropexie und Fundoplicatio. Stuttgart, Thieme, Rossetti M: The technique of reflux surgery. In Stipa S, Belsey RHR, Moraldi A (eds): Medical and Surgical Problems of the Esophagus. London and New York, Academic, 1981, p Watkins DH, Rundles WR, Tatom L Utility of a new procedure of valvular esophagogastrostomy in cases of brachyesophagus and stricture: clinical and experimental studies of circumferential esophagofundopexy. J Thorac Cardiovasc Surg 38814, Henderson RO, Manyatt G: Total fundoplication gastroplasty: long-term follow-up in 500 patients. J Thorac Cardiovasc Surg 85:81, Hill LD: An effective operation for hiatal hernia: an eight year appraisal. Ann Surg , Omnger MB, Skinner DB, Belsey RHR Long-term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 63:25, Leonardi HK, Lee ME, El-Kurd MF, Ellis FH Jr: An experimental study of the effectiveness of various antireflux operations. Ann Thorac Surg 24:215, DeMeester TR, Johnson LF, Kent AH Evaluations of current operations for the precaution of gastroesophageal reflux. Ann Surg 180:511, Woodward ER: Discussion of [15] 12. Varsant JH, Baker JW, Ross DG: Modification of the Hill technique for repair of hiatal hernia. Surg Gynecol Obstet 143:637, Henderson RD, Pearson FG: Preoperative assignment of esophageal pathology. J Thorac Cardiovasc Surg 72512, Pearson FG, Henderson RD: Experimental and clinical studies of gastroplasty in the management of acquired short esophagus. Surg Gynecol Obstet , 1973 Polk HC Fundoplication for reflux esophagitis: misadventures with the operation of choice. Ann Surg ,1976 Demos NJ: A simplified improved technique for the C ob gastroplasty for dilatable esophageal strictures. Surg Gynecol Obstet 142:591, 1976 Demos NJ, Smith N, Williams D: A gastroplasty for short esophagus and reflux esophagitis: experimental and clinical studies. Ann Surg 181:178, 1975 Skinner DB: Benign esophageal strictures. Adv Surg 10189, 1976 Ellis FH Jr: When should the esophagus be lengthened? Ann Thorac Surg 33:531, 1982 Orringer MB, Orringer JS: The combined Collis-Nissen operation: early assessment of reflux control. Ann Thorac Surg 33:534, 1982 Orringer M: Discussion of [6] Henderson RD, Ryder DE: Reflux control following myotomy in diffuse esophageal spasm. Ann Thorac Surg 34230, DeMeester TR Discussion of (61 Ellis FH Jr: Fundoplication for hypotensive lower esophageal sphincter afier gastroplasty. Surg Gynecol Obstet 145:430, 1977 Little AG, DeMeester TR, Rezai-Ladeeh K, Skinner DB: Abnormal gastric emptying in patients with gastroesophageal reflux. Surg Forum 28347, 1977 Discussion DR. ROBERT D. HENDERSON (Toronto, Ont, Canada): During the 27 years of evolution since it was described by Collis in 1957, gastroplasty has become a science in its own right. We now have the so-called Belsey gastroplasty, described by Pearson, Langer, and Henderson in 1971; the uncut Belsey gastroplasty, described in 1973; the cut total fundoplication gastroplasty I reported in 1977; and the uncut total fundoplication described by Dr. Demos and by Bingham. Despite continued controversy, some form of gastroplasty is going to be in use over the next few years. It is important to document accurately the benefits and disadvantages of each approach. The major benefits of the gastroplasty tube are reduction of anatomical hernia recurrence to 1% and avoidance of the need to perform bowel interposition in patients with a short esophagus. The disadvantage with partial fundoplication gastroplasty is the high incidence of continued reflux, whereas with total fundoplication gastroplasty there is risk of overcompetence and dysphagia. Based on experience with more than 700 patients, I believe the problem of overcompetence with total fundoplication gastroplasty can be minimized by suturing the fundus of the gastroplasty tube with a separate line of sutures, which determines the intraabdominal length. The completion fundoplication then is maintained by approximation at 1 cm. Dr. Demos, with these points in mind, I would like clarification of your presentation. First, what is the length of the completion wrap you use? Do you agree that the completion wrap length is important in avoiding overcompetence? Second, Bingham reports a 7% breakdown of the stapled, uncut gastroplasty tube. Have you seen this as a problem? Third, the reported manometric, radiographic, and endoscopic follow-up data are incomplete. Does the high pressure zone consistently rise to a level higher than normal, even in patients demonstrated to have an intrathoracic high pressure zone? Fourth, is there radiographic evidence of anatomical recurrence or reflux? Has the water siphon test been used? In patients with dysphagia, has this been quantitated symptomatically or have you used solid bolus radiography to demonstrate obstruction? These data must be available and would greatly strengthen this paper. Finally, if gastroplasty were not available, how many of your patients would have required an interposition procedure?

7 399 Demos: Stapled, Uncut Gastroplasty I thank the Society for the privilege of discussing this important paper. DR. w. SPENCER PAYNE (Rochester, MN): One thing the world does not need is yet another antireflux procedure. But I am somewhat reluctant to pass over Dr. Demos s presentation because I think there are some valuable things here. This operation has become, in a modified version, our procedure of choice for dealing with reflux. We are perhaps a little more aggressive and bold in our approach to this problem. We free up the esophagogastric junction, take down all of the supporting structures, and deliver the uncut staples without using the pen and the TA-30 stapling device. Having created a tubular extension of the esophagus made up of the lesser curvature of the stomach, we then proceed to do a 360-degree fundoplication in this fashion and reduce it below the diaphragm with so-called Johnsrude sutures closing the crura behind. If peristalsis is absent, as in scleroderma or achalasia, we have found that the 360-degree fundoplication is obstructive to the esophagus and does not permit adequate emptying. Under these circumstances, we have used a 270- degree wraparound, which is not as obstructive and provides good results. The advantage of this procedure is that it does indeed provide a high pressure zone. I have done 142 consecutive operations of this type, 25% of which have been reoperations. The exposure is excellent. There have been no operative deaths, and splenectomy has not been required in any patient. Gas bloat syndrome, which I believe is due to accidental injury to the vagi from operation, is prevented. My associates and I have not seen any cases of this syndrome. Our follow-up is brief; 95% of our patients have had excellent control of reflux, the remaining 5%, poor. And now for the bad news. We have about a 10% incidence of dysphagia of varying degree. There has been an equal percentage of individuals in the series who have had leakage in the early postoperative period. We think that this method should not be discarded and that it does prevent telescoping of the fundoplication. DR. DEMOS: I thank Dr. Henderson and Dr. Payne for their kind comments. I wish to answer some of Dr. Henderson s questions. In 1977, Bingham reported many breakdowns of this technique. I recently operated on a 265-pound patient in whom I could not complete the stapling. For the first time in a human being, I had to use the suturing technique instead of stapling. I tried three different staplers, but they would not go through the patient s thick stomach. However, I have never observed a breakdown of the stapled, uncut gastroplasty. I encountered a serious stricture in an experimental model, which taught me how to avoid stricture in patients. I enjoyed Dr. Payne s comments. Hearing that he is doing this procedure has strengthened my resolution to continue performing it.