The Combined Collis-Nissen Operation: Early Assessment of Reflwx Control

ORIGINAL ARTICLES The Combined Collis-Nissen Operation: Early Assessment of Reflwx Control Mark B. Orringer, M.D., and Jay S. Orringer, M.D. ABSTRACT This report summarizes the clinical experience with 155 patients who underwent the Collis-Nissen operation and have been followed by personal interview, esophageal manometry, barium swallow examination, and acid reflux testing for up to three years (average, 24 months). There has been 1 postoperative death. Major complications have included gastroplasty tube leak (2 patients), stricture perforation during dilation (1 patient), and splenic injury (3 patients). Subjectively, among 135 patients followed for a minimum of 6 months, reflux has been eliminated in 89% (12 patients), remains mild in 6% (8 patients), and is severe in 5% (7 patients). Early satiety ("bloats'') of varying degree has occurred in 19% (26 patients), and dysphagia requiring dilation in 15% (2 patients). The overall objective recurrence rate, as documented with the intraesophageal ph probe and the standard acid reflux test, is 13% (18 patients). Among 32 patients with peptic strictures treated with dilation and the Collis-Nissen operation, reflux symptoms have recurred in 3%, and 6% have had abnormal reflux demonstrated with the ph probe. These results substantiate excellent early reflux control with the Collis-Nissen procedure and justify its continued use in appropriately selected patients with gastroesophageal reflux and its complications. Although very favorable results with the combined Collis-Belsey reconstruction of the esophagogastric junction have been reported [l-51, the findings of unsatisfactory reflux control in 21 to 34% of patients evaluated with the intraesophageal ph electrode one to three years after this procedure [6-71 led to our decision in From the Department of Surgery, Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, MI. Presented at the Twenty-eighth Annual Meeting of the Southern Thoracic Surgical Association, Palm Beach, FL, NOV 5-7, 1981. Address reprint requests to Mark B. Orringer, M.D., Section of Thoracic Surgery, C779, Box 32, University Hospital, Ann Arbor, MI 4819. 1977 to advocate the Collis-Nissen combination as a potentially more effective antireflux operation [8]. We summarize here our clinical experience with 155 patients who underwent the Collis-Nissen operation and have been followed by personal interview, barium swallow examination, esophageal manometry, and acid reflux testing for up to three years (average, 24 months). Material and Methods From January, 1977, through June, 198, 155 patients, 85 female and 7 male, ranging in age from 5 to 86 years (average, 51 years) underwent the combined Collis-Nissen reconstruction of the esophagogastric junction at the University of Michigan Medical Center. The operative technique, as described previously [8], involved construction of the Collis gastroplasty over a size 54 to 6F Hurst-Maloney bougie and performance of the 36-degree fundoplication around a 46F dilator within the gastroplasty tube. The indications for the combined Collis- Nissen approach included factors that we believe predispose to recurrent gastroesophageal reflux after standard hiatal hernia operations: reflux esophagitis, periesophagitis from prior operations at the esophagogastric junction, obesity, the need for an esophagomyotomy for spasm, and esophageal shortening associated with a large, chronic combined sliding and paraesophageal hiatal hernia. Among the 155 patients included in this study, 59% (92) had reflux esophagitis, peptic strictures being present in 22%, or 34 of them. Among this group of 92 patients were 2 with scleroderma reflux esophagitis. Forty-six patients had periesophagitis from prior operations at the esophagogastric junction, including eighteen thoracic and seventeen abdominal hiatal hernia repairs, twelve vagotomies, two repairs of a perforation, and one repair of esophageal atresia. Fifty-five patients (35%) were obese, 18 (12%) required 534 3-497518216534-6$1.25 @ 1981 by The Society of Thoracic Surgeons

535 Orringer and Orringer: Combined Collis-Nissen Operation esophagomyotomy for spasm, and 9 (6%) had a paraesophageal hernia associated with a shortened esophagus. Preoperative evaluation in all patients included barium swallow examination and esophagoscopy. Preoperative esophageal function tests, including manometrics and acid reflux testing, as described previously [2], were performed in 146 (94%) of these patients. Results Complications Among the 155 patients, there was 1 postoperative death from sepsis which occurred in a 72-year-old woman who sustained an unrecognized perforation at the site of resection of a midesophageal diverticulum. Additional postoperative complications are shown in Table 1. Both patients who experienced leaks from the gastroplasty tubes had undergone prior antireflux operations and had extensive lower mediastinal, perihiatal, and abdominal adhesions at the time of the Collis-Nissen operation. One of these patients required esophagectomy and later colonic interposition for severe necrosis of the gastroplasty tube. A small leak developed in the other patient and was treated by rib resection and drainage, and subsequently closed spontaneously. In 1 patient undergoing intraoperative dilation, the stricture was perforated. Another patient was operated on within seven hours of sustaining a perforation of a stricture during attempted dilation at another institution. In both of these patients, a transient leak occurred at the site of closure of the injury, but responded well to drainage and continued stricture dilations until there was spontaneous closure. Two patients required a thoracotomy for postoperative intrathoracic bleeding, which in both arose from the cut edge of hypertrophied muscle following an esophagomyotomy for spasm. One patient required abdominal exploration for bleeding from a divided short gastric vessel. Three patients required splenectomy because of intraoperative splenic trauma. Delayed gastric emptying necessitating a pyloromyotomy occurred in 1 patient, presumably because of injury to the vagus nerves. In 1 patient, the barium swallow examination done routinely one week Table 1. Complications after Collis-Nissen Operation in 155 Patients Complication Gastroplasty tube leak 2 Leak from dilated stricture 2 Splenic injury 3 Hemorrhage requiring reoperation 3 Gastric atony requiring 1 pyloromyotomy Perforation of resected 1 diverticulum Dehiscence of crural repair 1 Small bowel obstruction 1 Wound infection 3 Pulmonary embolus 2 Chylothorax 1 acause of only operative death No. of Patients postoperatively demonstrated disruption of the posterior crural repair, with the fundoplication partially within the chest. Although asymptomatic, the patient was reoperated on, the hernia was again reduced, and the crura were reapproximated. Follow-tcp Barium swallow examinations routinely obtained one week after operation have consistently shown a 3 to 5 cm intraabdominal segment of gastroplasty tube encircled in a characteristic fashion by the 36-degree fundoplication below the diaphragm [8]. There have been no occult or silent leaks detected with these barium contrast studies. The leaks described were seen earlier with typical signs and symptoms of esophageal disruption, diagnosed with Gastrografin (meglucamine diatrizoate) swallows. Because no effort is made to reduce the patient s original esophagogastric junction below the diaphragm, unless the GIA stapler is closely applied to the intragastric dilator at the time of construction of the gastroplasty tube, a patulous proximal gastroplasty tube may be interpreted postoperatively by the radiologist as a hiatal hernia, since gastric mucosal folds may be seen clearly above the diaphragm in the chest. In no patient, however, was gastroesophageal reflux seen on the barium examination done one week postoperatively.

536 The Annals of Thoracic Surgery Vol 33 No 6 June 1982 Among the 155 patients in this series, 2 have either been lost to follow-up or have died of causes unrelated to the esophageal disease. Follow-up with postoperative esophageal function tests and personal interviews six months or more after operation is available for 135 patients (87%). Of these 135 patients, 97 (72%) have been restudied at one year; 65 (48%), at two years; 36 (27%), at three years; and 18 (13%), at four years. Average follow-up is 24 months. Subjectively, based on the patient s response to standard postoperative questioning during personal interview, 89% (12 patients) have no symptoms of reflux whatsoever; 6% (8 patients) have very mild, intermittent heartburn for which they take antacids occasionally, but are still able to sleep horizontally at night without reflux symptoms; and 5% (7 patients) have moderate to severe recurrent reflux symptoms necessitating reinstitution of a vigorous antireflux medical regimen. Among these 7 patients are 3 in whom the Collis-Belsey combination had failed to control reflux, and conversion to a Collis-Nissen reconstruction was performed; in each patient, severe recurrent reflux esophagitis ultimately required esophagectomy and esophageal replacement with either colon or stomach. The subjective recurrence rate for the Collis-Nissen operation has therefore been 11% (15 of 135 patients). In response to the question Do you fill up easily while eating or have a reduced food capacity since your operation? 26 patients (19 %) have answered affirmatively. In only 3 patients, however, has such early satiety or bloats been a major problem associated with marked abdominal distress. In fact, a number of markedly obese patients have regarded the postoperative early satiety as an asset, for it has forced them to eat smaller amounts and allowed them to lose weight, whereas standard weight reduction diets had failed for years! Approximately one-third (46) of our patients undergoing the combined Collis-Nissen operation have experienced postoperative low retrosternal dysphagia of varying severity and respond affirmatively to the question, Does your food ever stop or hold-up behind your breast bone since your operation? Among these 46 patients who have experienced any degree of dysphagia postoperatively, 26 have reported such mild, transient, slow emptying of the esophagus that no treatment has been required; 8 of them had esophageal spasm preoperatively and 3, peptic strictures. Twenty patients, or 43% of those who reported any dysphagia, have required postoperative dilation; of them, 8 had intermittent spasm preoperatively and underwent a concomitant esophagomyotomy at the time of Collis-Nissen repair, and 9 had strictures which were dilated intraoperatively. Mild to moderate incisional pain longer than 6 months has been experienced by 27% or 36 of our patients and dumping symptoms, presumably related to intraoperative injury to the vagus nerves, by 3 patients. Objectively as well as subjectively, the Collis-Nissen operation has provided much better reflux control in our hands than the Collis-Belsey combination. The results of preoperative and postoperative esophageal manometry and acid reflux testing in these patients are shown in Table 2. The average peak preoperative high-pressure-zone pressure and length in the 146 patients studied were 4.8 mm Hg and 1.7 cm, respectively. Ninety-five percent (138 patients) had abnormal reflux detected preoperatively with the intraesophageal ph electrode. In our Collis-Belsey series [7], we found a 17% incidence of abnormal reflux with the standard acid reflux test performed 6 months after operation. It was not possible to determine with certainty if this represented recurrence after an initially successful operation, or failure to adequately control reflux from the onset. Therefore, we repeated esophageal function tests in our first 17 consecutive Collis-Nissen patients within 3 months (generally within the first two weeks) of operation to be certain that we were achieving initial reflux control with the procedure. No patient in this group was found to have abnormal reflux, and we discontinued our policy of such early postoperative esophageal function tests after the Collis-Nissen procedure. In only 1 of the 15 patients thought to have recurrent reflux symptoms on the basis of postoperative interview, has the presence of objective abnormal reflux been substantiated with the intraesophageal ph electrode; the

537 Orringer and Orringer: Combined Collis-Nissen Operation Table 2. Results of Esophageal Function Tests before and after Collis-Nissen Operation Abnormal Acid Reflux Testa Average Peak Average Time of No. of HPZ Pressure HPZ Length No. of Test Patients (mm Hg) (cm) Patients Percent Before operation 146 4.8 1.7 138 95 After operation -3 mos 17 15.5 4.9 6 mos 114 11.6 4.3 3 3 12 mos 97 11.6 4.3 5 5 24 mos 65 1.8 4.4 6 9 36 mos 36 9.4 4. 3 8 48 mos 18 11.3 4.5 1 6 amoderate to severe, 2 to 3+. HPZ = distal esophageal high-pressure zone. standard acid reflux test has shown moderate to severe abnormal reflux in 8, and 24-hour monitoring of distal esophageal ph has demonstrated abnormal reflux in 2. Average postoperative high-pressure-zone pressures and length have been approximately 11 mm Hg and 4 cm, respectively, up to 48 months after the Collis-Nissen procedure. With the ph electrode, abnormal reflux has been found in 18 patients (13%). Eight of these latter patients, however, have no subjective reflux symptoms. Results in Patients with Peptic Strictures Our protocol for the preoperative evaluation, intraoperative dilation, and postoperative management of peptic strictures has been published elsewhere [7]. To date, we have treated 6 patients with strictures with intraoperative dilation and the Collis gastroplasty procedure combined either with a Belsey 24-degree fundoplication or a Nissen-type 36-degree fundoplication. Two of the patients in the Collis- Nissen series have been lost to follow-up. The 26 Collis-Belsey patients have been followed an average of 49 months and the remaining 32 Collis-Nissen patients, an average of 28 months (Table 3). There have been no operative deiths. The only major complication related to the procedure was perforation of a stricture during intraoperative dilation (already noted in the Results section). The esophagopleural cutaneous fistula which developed subsequently closed spontaneously, and the stricture regressed. Symptomatically, patients treated with the Collis-Nissen operation have had far better reflux control, with 97% denying any acid regurgitation or heartburn, in contrast to 19% of the Collis-Belsey patients who have moderate to severe recurrent reflux symptoms. Only 65'7' of the Collis-Belsey patients remain free from symptoms of reflux (see Table 3). If a stricture is dilated intraoperatively, the patient undergoes dilation postoperatively according to the severity of the stricture. Mild strictures that are easily dilated during the operation are not dilated again unless dysphagia recurs. Moderate or severe strictures are calibrated at the bedside with a 5F Hurst-Maloney dilator one week after operation, prior to the patient's discharge. If resistance to the passage of the dilator is encountered, outpatient dilations are continued at two- to four-week intervals, until little or no resistance is encountered, or as dictated by the recurrence of dysphagia. Of the 32 Collis-Nissen patients followed, 23 (72%) have required no further bougienage after the initial intraoperative dilation; similarly, 18 (69%) of the Collis-Belsey patients required no further dilations since operation (see Table 3). One-half of the patients with severe strictures in each group have required postoperative dilations, but only 2 at regular intervals because of inadequate stricture regression (Table 4). Among the 32 Collis-Nissen patients, roentgenographic regression of the stenosis has been complete in 24 (75%) and partial in 8

538 The Annals of Thoracic Surgery Vol 33 No 6 June 1982 Table 3. Results of Collis Gastroplasty-Fundoplication for Peptic Strictures Collis-Belsey Operation" Collis-Nissen Operation" No. of No. of Result Patients Percent Patients Percent Postop reflux symptoms None 17 Mild 4 Moderate 1 Severe 4 Postop dilations Required Not required 8 18 Objective reflux control (ph probe determination) Good (-1+ reflux) 14 Poor (2-3+ reflux) 12 65 15 4 15 31 69 54 46 "There were 26 patients, and average follow-up was 49 months. hthere were 32 patients, and average follow-up was 28 months. 31 1 9 23 3 2 97 3 28 72 94 6 (25%). Although in these latter patients the postoperative barium esophagograms have shown varying degrees of stricture regression, it is clear that symptomatic relief of dysphagia associated with a peptic stricture can be obtained even when some roentgenographic evidence of residual distal stenosis persists. All of our patients with strictures had markedly abnormal gastroesophageal reflux (3+) documented with the ph electrode preoperatively (see Table 3). Postoperatively, 12 (46%) of the Collis-Belsey patients have demonstrated moderate to severe abnormal reflux. Of these, 2 are asymptomatic, 4 have mild symptoms, 2 are moderately symptomatic, and 4 have had severe reflux symptoms which necessitated additional antireflux operations. To date, reflux control has been more reliable in the Collis- Nissen operation, with only 2 patients having measurable abnormal reflux after initial good control for one year. The remaining 3 patients (94%) have had no abnormal reflux detected from 1 to 36 months (average, 28 months) postoperatively. Comment The average follow-up of 24 months in these patients undergoing the combined Collis- Nissen operation allows only an early assessment of the efficacy of this procedure in controlling gastroesophageal reflux. Our data clearly confirm what has been demonstrated by others [9], i.e., that a complete fundoplication provides better reflux control than a partial gastric wrap. The elimination of symptomatic reflux in 97% of our patients undergoing the combined Collis-Nissen procedure has been gratifying. And although one-third (46) of our patients report some dysphagia postoperatively, fewer than half (2) of them have required dilation, 17 having had either esophageal spasm or strictures preoperatively. In general, the occasional "hesitancy" experienced by some patients as food passes through the reconstructed esophagogastric junction has been so transient and incidental that only careful questioning has provided this information and shows that swallowing may not be totally normal after operation. We believe that any successful antireflux operation which creates a static distal esophageal high-pressure zone will invariably be associated with a certain degree of postoperative dysphagia. This has not proved to be a major postoperative complication in our patients, who have gladly accepted occasional slow emptying of the esophagus for relief of the reflux symptoms. "Gas bloats" has simply not been a major problem in our patients. The outcome in our 2 patients who underwent redo hiatal hernia repair and in whom leaks developed in the gastroplasty tube post-

539 Orringer and Orringer: Combined Collis-Nissen Operation Table 4. Need for Esophageal Dilation after Collis Gastroplasty-Fundoplication for Strictures" Patients Requiring Dilation Type of Stricture Collis-Belsey (n = 26) Collis-Nissen (n = 32) Total Mild 219 (22) 2/14 (14) 4/23 (17) Moderate 4/13 (31) 218 (25) 6/21 (29) Severe 2/4 (5) 511 (5) 7/14 (5) Total 8/26 (31) 9/32 (28) 17158 (29) "Numbers in parentheses are percents. operatively emphasizes an important technical point of this procedure. When mobilizing the distal esophagus and gastric fundus in the patient who has had a prior antireflux operation, great care must be exercised to avoid unnecessary trauma to the stomach. If necessary, a layer of superficial adjacent diaphragm or liver capsule should be dissected with the stomach rather than attempt to separate these structures from the stomach. An ecchymotic, partially devitalized gastric fundus will not provide sufficiently healthy tissue for safe construction of a gastroplasty tube. In the majority of patients who have had prior unsuccessful antireflux operations, however, adequate gastric mobilization is possible and allows a very satisfactory gastroplasty tube. We have found this to be the case even in patients who have undergone two to three operations before the Collis-Nissen repair. One-half of our patients with severe peptic strictures that required extreme forceful dilation at operation have required subsequent postoperative bougienage. In all but two instances, however, the frequency with which dilation is required has been markedly reduced compared with the preoperative status. Therefore, we continue to advocate a conservative approach with regard to esophageal resection in these patients, having had to resect only two strictures in the last eighty we have treated because of inability to achieve dilation to the range of a 5F bougie. We do not regard the need for subsequent dilation in these patients as an indication of an unsuccessful operation. Our patients have readily accepted the protocol for postoperative management of strictures, for in general they understand that a process that has been active for years may require several months and an occasional dilation before it resolves. We remain satisfied with the gratifying early subjective and objective evidence of reflux control after the combined Collis gastroplasty-nissen fundoplication operation in patients with factors that predispose them to recurrent reflux after standard hernia repairs. Long-term follow-up for at least five years will be required, however, before this approach can be said to have proved its value in controlling gastroesophageal reflux and its complications. References 1. Orringer MB, Sloan HE: An improved technique for the combined Collis-Belsey approach to dilatable esophageal strictures. J Thorac Cardiovasc Surg 68:298, 1974 2. Orringer MB, Sloan HE: Collis-Belsey reconstruction of the esophagogastric junction. J Thorac Cardiovasc Surg 71:295, 1976 3. Pearson FG, Henderson RD: Experimental and clinical studies of gastroplasty in the management of acquired short esophagus. Surg Gynecol Obstet 136:737, 1973 4. Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty, and Belsy hiatus hernia repair. Surgery 8:391, 1976 5. Pearson FG, Langer 8, Henderson RD: Gastroplasty and Belsey hiatus hernia repair. J Thorac Cardiovasc Surg 61:5, 1971 6. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:26, 1977 7. Orringer MB, Sloan H: Complications and failings of the combined Collis-Belsey operation. J Thorac Cardiovasc Surg 74:726, 1977 8. Orringer MB, Sloan H: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 25:16, 1978 9. DeMeester TR, Johnson LF, Kent AH: Evaluation of current operations for the prevention of gastroesophageal reflux. Ann Surg 18:511, 1974