Combined Collis-Nissen Reconstruction. of the esophagogastric junction at. Mark B. Orringer, M.D., and Herbert Sloan, M.D.

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1 Combined Collis-Nissen Reconstruction of the Esophagogastric Junction Mark B. Orringer, M.D., and Herbert Sloan, M.D. ABSTRACT Recent reports have indicated that combined Collis-Belsey reconstruction of the esophagogastric junction fails to control reflux in 30 to 46% of patients undergoing the procedure. The major factor thought to be responsible for this result is the limited Belsey fundoplication possible after construction of the gastroplasty tube. This report describes our technique of combining the Collis gastroplasty with a 360-degree Nissen type fundoplication. The radiographic and manometric characteristics of the distal esophageal high-pressure zone produced by the Collis-Nissen operation are discussed. Following the initially favorable results from combined Collis-Belsey reconstruction of the esophagogastric junction [3, 5-71, recent reports have indicated an unexpectedly high (30 to 46%) rate of failure to control reflux in patients undergoing this repair [l, 41. Our data, based on patient interview, barium swallow examination, and preoperative and postoperative esophageal manometric and intraesophageal acid reflux testing, suggest that construction of the gastroplasty tube so reduces the amount of gastric fundus available for fundoplication that a standard 240-degree Belsey wrap around the new distal esophagus cannot be achieved [4]. Thus, with an inadequate fundoplication, gastroesophageal reflux may not be prevented despite the presence of a 3 to 7 cm intraabdominal segment of functional distal esophagus. In an effort to improve reflux control after performance of the Collis gastroplasty, we have begun to use a 360-degree Nissen type fundoplication. This report describes our technique for the combined Collis-Nissen procedure and the radiographic and initial manometric data obtained in our patients postoperatively. From the Department of Surgery, Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, MI. Accepted for publication May 18, Address reprint requests to Dr. Orringer, C7175 University Hospital, Ann Arbor, MI Clinical Material Over a recent one-year period, 30 patients, 19 women and 11 men ranging in age from 25 to 83 years, underwent combined Collis-Nissen reconstruction of the esophagogastric junction at the University of Michigan Medical Center. The esophageal lesions necessitating operation in these patients were reflux esophagitis with peptic stricture in 9; reflux esophagitis without stricture in 11; gastroesophageal reflux without esophagitis producing symptoms refractory to medical management in 5; paraesophageal hiatal hernia in 2; and esophageal spasm associated with gastroesophageal reflux in 3. Additional factors predisposing to recurrent gastroesophageal reflux after standard hiatal hernia repairs were common. Ten patients had periesophagitis from prior operations at the esophagogastric junction: hiatal hernia repair in 6 and vagotomy at the time of antrectomy in 4. Two patients had reflux esophagitis associated with scleroderma, 4 patients were obese, and 1 had severe chronic obstructive pulmonary disease. Preoperative evaluation included a barium swallow examination and esophagoscopy in all cases. In addition, all patients except for an 83- year-old woman with a type IV incarcerated paraesophageal hiatal hernia ("upside-down stomach") had preoperative esophageal function tests, including manometric and acid reflux testing, as described previously [3]. Operative Technique Our protocol for dilation of peptic strictures has been published elsewhere [41. If the patient has a peptic stricture, biopsy and dilation to a size 40F Hurst-Maloney bougie are performed after induction of general anesthesia. If the patient has no stricture but rather another indication for the Collis esophageal lengthening procedure, a 56 to 60F Hurst-Maloney bougie is positioned within the esophagus prior to turning the patient to his right side. Through a left lateral thoracotomy in the by The Society of Thoracic Surgeons

2 17 Ornnger and Sloan: Combined Collis-Nissen Esophagogastric Reconstruction A, \ _..- Incisi on.. ii Fig I. Main drawing illustrates the elongated, narrowedgastric fundus available for fundoplication after completion of the Collis procedure. Inset A shows the placement of the incision, through the left sixth intercostal space. lnsets B and C show the gastric fundus being wrapped around the gastroplasty tube and adjacent stomach. Note that the posterior crural sutures are left untied for the moment. sixth intercostal space (Fig 1, inset A), the inferior pulmonary ligament is divided and the esophagus is mobilized to the level of the inferior pulmonary vein. When there is extensive mediastinal inflammation or periesophagitis, no attempt is made to mobilize the esophagus higher since additional length will be gained distally by the gastroplasty procedure and ischemic necrosis of the mobilized, severely inflamed esophagus may result [4]. The gastric fundus is mobilized into the chest through the diaphragmatic hiatus as for a standard Belsey repair, dividing 3 to 6 high short gastric vessels between clamps. If extensive perihiatal adhesions from prior operations prevent mobilization of the stomach through an exclusively thoracic approach, the left costal arch is divided after the skin incision has been extended forward to the lateral margin to the left rectus sheath. The diaphragm is incised at its periphery, 2 to 3 cm from its costochondral attachments. Mobilization of the esophagogastric junction and fundus from their diaphragmatic attachments is completed. Care is taken to avoid injury to the spleen and vagus nerves; if the latter cannot be adequately visualized because of periesophagitis, it is better to perform a gastric drainage procedure at this point rather than risk the morbidity of delayed gastric empty-

3 18 The Annals of Thoracic Surgery Vol 25 No 1 January 1978 ing secondary to vagal nerve injury. A pyloromyotomy or pyloroplasty is easily performed through this incision. Posterior crural sutures of No. 1 silk are placed but left untied for the moment (Fig 1). If indicated, intraoperative dilation of the peptic stricture is performed. With a 56 to 60F Hurst-Maloney bougie crossing the esophagogastric junction, the Collis gastroplasty maneuver is performed with one or two applications of the GIA surgical stapler, thus lengthening the functional distal esophagus by 5 to 10 cm Fig 2. Placement of the seromuscular sutures from gastric fundus to gastroplasty tube, to gastric fundus for the proximal three or four sutures, and from gastric fundus to anterior stomach wall and then gastric fundus for the distal three or four sutures. After these sutures are tied, the fundoplication includes the distal 3 to 4 cm of gastroplasty tube and the proximal 3 to 4 cm of stomach (inset A). The fundoplication, reduced into the abdomen, rests below the diaphragm without tension on the distal esophagus after the posterior crural sutures are tied (inset B). [2]. The esophageal dilator is removed, and the staple suture line is oversewn with a single running Lembert suture of 4-0 Prolene. Silver clip markers are placed at the new esophagogastric junction, i.e., the distal end of the gastroplasty tube. A 46F Hurst-Maloney bougie is then inserted perorum, and the elongated, narrowed gastric fundus that remains (Fig 1) is passed behind the gastroplasty tube. With interrupted seromuscular 2-0 silk sutures placed approximately 1 cm apart, a fundoplication 6 cm long is begun (Fig 2). Each suture passes through gastric fundus, then gastroplasty tube or adjacent stomach, and finally through gastric fundus again. The gastric wrap enfolds the distal 3 to 4 cm of the gastroplasty tube and the proximal 3 to 4 cm of adjacent fundus of the stomach (Fig 2, inset A). The sutures are tied with the 46F dilator still lying within the gastroplasty tube. The dilator is removed, and the suture line is oversewn with a 4-0 running Prolene Lembert stitch through the seromuscular layers on each side. A nasogastric

4 19 Orringer and Sloan: Combined Collis-Nissen Esophagogastric Reconstruction tube is inserted, the fundoplication is reduced beneath the diaphragm, and the posterior crural sutures are tied so that the hiatus will admit one finger alongside the esophagus. Silver clips are placed at the edge of the diaphragmatic hiatus. The repair results in a 3 to 5 cm tension-free intraabdominal segment of functional esophagus, encircled completely by the gastric wrap (Fig 2, inset B). Results There was 1 postoperative death, that of a 72- year-old woman who died from cardiovascular Fig3. (A) Detail of esophagogastricjunction in a patient with recurrent hiatal hernia, reflux, and peptic stricture after two previous Belsey repairs. (B, C) Two views of the esophagogastric junction following the Collis-Nissen procedure. Dense lower mediastinal fibrosis prevented application of the GIA stapler flush against the esophagus, resulting in a diverticulum of stomach at the proximal end ofthe gastroplasty tube (B). A 10 cm longgastroplasty tube was constructed. Note horizontal gastric folds in the fundoplication around the distal 5 to 7 cm of functional esophagus. (In all views the large arrow is at the diaphragmatic hiatus and the small arrow at the esophagogastric junction.) collapse associated with esophageal perforation at the site of plication of a midesophageal diverticulum. One 36-year-old man with a recurrent hiatal hernia and extensive lower mediastinal, perihiatal, and abdominal adhesions had necrosis of his gastroplasty tube on the fourth postoperative day and required esophagectomy and, later, colon interposition. Postoperative complications in the remaining 28 patients included 1 instance of bleeding from a short gastric vessel that necessitated laparotomy for hemostasis; pulmonary embolus in 1 patient; and superficiai wound infection in 2 patients. Barium swallow examinations obtained one week after operation in these 28 patients showed a 3 to 7 cm intraabdominal segment of gastroplasty tube encircled in a characteristic fashion by the 360-degree fundoplication below the diaphragm (Fig 3) and no gastroesophageal reflux. Symptomatically, reflux has been eliminated in all 28 patients; 2 have experienced mild transient bloating. Nineteen patients have been evaluated by postoperative esophageal manometric and acid reflux testing within four months of operation (Table). In all but 1 patient there has been an increase in the tone of the lower esophageal A B C

5 20 The Annals of Thoracic Surgery Vol 25 No 1 January 1978 Results of Esophageal Function Tests in 19 Patients Before and After Collis-Nissen Operation Test Preoperative Value Postoperative Value" HPZ manometric testing Average mean pressure (mm Hg) Average peak pressure (mm Hg) Average length (cm) Acid reflux test (no. of patients with degree of reflux) 0 (no reflux) (minimal reflux) (moderate reflux) (severe reflux) 19 0 "One week to four months. high-pressure zone (HPZ) over preoperative levels. In 15 patients the length of the HPZ has also increased, in 11 by 3 cm or more over the preoperative length. Postoperatively, with the intraesophageal ph probe, gastroesophageal reflux has been demonstrated in only 1 patient. Comment The average follow-up of only six months in these patients is obviously too short to allow any Fig 4. Postoperative manometric resting pullback tracing of the distal HPZ in the same patient as in Figure3, who had no HPZ before his Collis-Nissen operation. Note the broad, 6 cm long HPZ demonstrated through all three lumens of the recording catheter. conclusions regarding the long-term success of this operation in controlling reflux. Nevertheless, several differences between the early results after the Collis-Belsey and Collis-Nissen operations are already apparent. In 75 patients of ours who had postoperative esophageal function tests after their Collis-Belsey operation, HPZ pressures increased over preoperative levels in 47 (63%), decreased in 17 (23%), and remained unchanged in 11 (14'/0), while HPZ length increased in 50 (67%), decreased in 17 (23%), and remained unchanged in 8 (loo/,) [41. In our present 19 patients evaluated after their Collis-Nissen operation, HPZ tone has increased in 18 and remained unchanged in only 1, while HPZ length has increased in 15, decreased. I, cm.-prox. to Nostril,,..,,,.,,,,., RESF! HPZ H DISTAL H PZ

6 21 Orringer and Sloan: Combined Collis-Nissen Esophagogastric Reconstruction in 2, and remained unchanged in 1. The average mean and peak HPZ pressures of 4.94 and mm Hg, after the Collis-Nissen operation are approximately the same as the 4.98 and mm Hg obtained after the Collis-Belsey procedure. But a more uniform distal HPZ is created by the 360-degree fundoplication (Fig 4), and we have not seen the asymmetrical HPZ found in one-quarter of our patients after the Collis- Belsey repair [4]. Average HPZ length following the Collis-Nissen procedure has been 4.21 cm, while that after the Collis-Belsey operation is 3 cm. Thirteen (17%) of our 75 patients who underwent acid reflux testing within six months of their Collis-Belsey repair were found to have moderate to severe acid reflux, indicating that their gastroesophageal reflux had not been controlled by the operation from the outset [41. To date only 1 of our patients studied within four months of Collis-Nissen repair has demonstrable gastroesophageal reflux. Postoperative "gas bloating" has occurred in 2 patients after the Collis-Nissen procedure and in both cases has been mild and transient. These preliminary studies support Henderson's contention [l] that better control of gastroesophageal reflux after the Collis gastroplasty is achieved with a 360-degree fundoplication than with an attempted Belsey type partial fundoplication. While the potential for gas-bloat syndrome is greater after the Collis-Nissen combination, it may be wiser to risk this complication than to settle for less complete reflux control. Only continued, objective, long-term follow-up data will provide the answer to these questions and resolve the issue of whether attempts to salvage the esophagus in some patients should be abandoned and replaced by a policy of distal esophagectomy and colon interposition. References 1. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206, Orringer MB, Sloan HE: An improved technique for the combined Collis-Belsey approach to dilatable esophageal strictures. J Thorac Cardiovasc Surg 68:298, Orringer MB, Sloan HE: Collis-Belsey reconstruction of the esophagogastric junction. J Thorac Cardiovasc Surg 71:295, Orringer MB, Sloan H: Complications and failings of the combined Collis-Belsey operation. J Thorac Cardiovasc Surg , Pearson FG, Henderson RD: Experimental and clinical studies of gastroplasty in the management of acquired short esophagus. Surg Gynecol Obstet 136:737, Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty, and Belsey hiatus hernia repair. Surgery 80:391, Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus hernia repair. J Thorac Cardiovasc Surg 61:50, 1971 American Board of Thoracic Surgery The 1979 annual certifying examination of the Please address all communications to the Ameri- American Board of Thoracic Surgery (written can Board of Thoracic Surgery, E Seven and oral) will be held Mar 22-24, 1979, in Mile Rd, Detroit, MI Chicago, IL. Final date for filing application is Aug 1, 1978.