CLASSICS IN THORACIC SURGERY
Collis Gastroplasty: Origin and Evolution Richard H. Adler, MD Division of Cardiothoracic Surgery, Department of Surgery, State University of New York at Buffalo, Buffalo General Hospital, Buffalo. New York
In 1957 J. Leigh Collis published his innovative operation for treating the difficult problem of the irreducible hiatal hernia, esophagitis, and stricture. The design of the operation was based on the relatively primitive understanding of hiatal hernia and the newly emerging concept of reflux esophagitis. A variety of antireflux operations by different surgeons emerged over the years
A
n invitation to write a commentary on J. L. Collis’ 1957 classic “An operation for hiatus hernia and short esophagus” [l]as a contribution to today’s surgical management of hiatal hernia (HH) and gastroesophageal reflux disease awakens dormant memories of that remarkable period during the 1950s through which I lived as a thoracic surgeon. Today’s younger thoracic surgeon need only read the discussions following Collis’ 1957 presentation, which include operations such as moving the esophagus forward to the dome of the diaphragm for a shortened esophagus, interposing a segment of bowel containing the ileocecal valve to eliminate reflux, and pyloroplasty for promoting an empty stomach, to appreciate the advances since the 1950s. After completion of my thoracic surgery residency in Ann Arbor almost four decades ago, I was fortunate to have been granted a fellowship at the Brompton Hospital for Chest Diseases, London, England. During this time I was privileged to visit with Mr Collis in Birmingham. This fellowship also afforded me the unique opportunity of spending time with two other pioneer English esophageal surgeons, P. R. Allison of Leeds and N. R. Barrett of London. These British surgeons played a major role in changing the established perception of the sliding HH from that of an anatomical mechanical condition to a functional physiologically based disorder with reflux esophagitis and its complications as the fundamental problem.
The 1957 Collis Operation Collis sought and devised a relatively uncomplicated operation for the difficult HH with short esophagus, esophagitis, and stricture particularly in “the frail and aged.” He wished to avoid the two extreme practices of either the risky, more complicated resectional operations of that day or the programs of endless esophageal dilations with ineffective medical management. Of the various factors thought to control gastroesophageal compeAddress reprint requests to Dr Adler, Buffalo General Hospital, 100 High St, Buffalo, NY 14203.
0 1990 by The Society of Thoracic Surgeons
to follow. The original Collis gastroplasty has been subsequently modified with the addition of both partial and complete fundoplication procedures. The place of the modified Collis gastroplasty-fundoplication operations in today’s approach to the problems of hiatal hernia and gastroesophagealreflux disease remains unsettled. (Ann Thoruc Surg 1990;50:83942)
tence at that time, Collis believed ”the acute angle of implantation of the esophagus into the stomach which in turn is produced by the normally functioning crural muscle . . . was the one which could be effective alone.” Collis created a narrow, somewhat distally tapered tube along the proximal lesser curvature of the stomach that connected in continuity the shortened esophagus above with the stomach below (Fig 1).The gastric tube (gastroplasty), fashioned by suturing the stomach divided between two parallel clamps, met his two major objectives: (1) reestablishing the normal, more acutely angled (flapvalve) subdiaphragmatic junction with the stomach and (2) eliminating the irreducible stomach bulk from the hiatus. Collis also sutured the crura of the widened hiatus together anterior to the gastric tube displacing the tube further posteriorly, resulting in a more oblique angulation. Collis used a thoracoabdominal incision with division of the costal arch. Today, the operation is generally carried out transthoracically. Subdiaphragmatic exposure can be obtained when needed by a peripheral circumferential opening of the diaphragm. In his 1957 paper, Collis noted that the esophagus became lengthened after its transthoracic dissection and complete mobilization, now an established thoracic surgery principle: ”In some cases it will be found that so much extra length of the esophagus can be obtained by this dissection that a standard repair can be done.“ This statement also carries an important implication for the modern esophageal surgeon, which is that one must be prepared to alter plans in response to unexpected operative findings.
Stricture and Dysphagia Concerning peptic strictures, Collis wrote in 1957, ”many strictures which are believed to be fibrous are, in fact, mainly produced by reflux spasm. In these cases when the irritation of reflux has been removed and the esophagitis has subsided the dysphagia will no longer be present.” Today, there is general agreement that if a reflux stricture can be adequately dilated preoperatively 0003-4975/90/$3.50
840
Ann Thorac Surg
CLASSICS ADLER COLLIS GASTROPLASTY
1990;50:839-42
Fig 1 . (A) Position of clamps on herniated stomach. (B)The n m l y created gastric tube (gastroplasty)connects the short esophagus and stomach beneath the diaphragm (see text). (Reproduced from 111 with permission from the publishers.)
CONNKTING
ABDOMEN A
or at operation, proper control of reflux should prevent stricture recurrence. Postoperative dilations may be required over a period of time for the occasional more severe stricture until the inflammatory reaction subsides. Resection of an esophageal stricture is now reserved for relatively uncommon situations such as an extremely resistant stricture associated with panmural fibrosis and inflammation, inadequate tissues for repair resulting from previously failed antireflux operations, and premalignant dysplastic changes associated with a Barrett esophagus. Although Collis reported that 7 of his 8 postoperative patients had "excellent" results, all had dysphagia for weeks to several months after operation. It might be noted here that Collis did not have available the more effective flexible tapered-tip Maloney bougies nor modern balloon dilators. At that time it was also common HH surgical teaching to suggest that postoperative dysphagia was to be expected. Collis wrote, "some degree of immediate postoperative dysphagia is regarded as desirable and it is felt that if it is not present the operation has not been done properly." Today, surgeons try to avoid postoperative dysphagia by carefully tailoring the diameter of the hiatus and the antireflux procedure. A delicate balance must be achieved between maintaining normal food passage from above and preventing reflux from below.
Is Collis Gastroplasty a Barrett Esophagus? Collis was aware that he was leaving "stomach" above the diaphragm proximal to the junction of tube and stomach. He defended this by citing references that this lesser curvature area of the stomach (Magenstrasse) used for his connecting tube was "devoid of peptic cells and relatively innocuous." Collis additionally drew on the analogy to those patients "often referred to as having gastric-lined esophagus and in whom symptoms are often slight." It is interesting to note that N. R. Barrett [Z]also published his classic paper in 1957 that described a condition related to
B
---
reflux esophagitis that came to bear his name. The Barrett esophagus was soon noted to add further complications [3], some of which may have a relationship to the Collis gastroplasty. Skinner and Demeester [4, 51 have questioned whether the Collis gastroplasty might be an iatrogenic Barrett esophagus and carry the same biological potential for the development of malignancy as has been well documented in the acquired Barrett esophagus associated with chronic reflux esophagitis. A few patients found to have carcinoma in association with modified Collis gastroplasty for chronic esophagitis have been cited to support this contention. Pearson and associates [ 6 ] , however, strongly question this assumption, suggesting that the tumor is related to the presence of an acquired Barrett mucosa rather than the gastric tube itself. This unsettled issue illustrates the need for thorough evaluation of all patients, particularly preoperatively, which would include at endoscopy circumferential brushings with washings for cytologic studies and multiple biopsies around and within strictures.
Collis Gastroplasty, Inert or Dynamic? Both Skinner and Demeester consider the Collis gastroplasty to be an adynamic and inert tube. There is also a question as to whether the gastroplasty itself might act as an obstructing factor particularly in the presence of decreased esophageal motility. Cooper and co-workers [7] and Pearson and associates [6], however, have demonstrated that the gastroplasty has a synchronous function with the lower esophageal sphincter. Their manometric studies show that the gastroplasty responds to swallowing as well as to specific hormonal stimuli. The tone of the gastroplasty appears to be enhanced by the fundoplication. The exact function of the modified gastroplasty remains unsettled at this time.
CLASSICS ADLER COLLIS GASTROPLASTY
Ann Thorac Surg 1990;5083942
Modified Collis Gastroplasty The 1957 Collis gastroplasty by itself did not prove to entirely control reflux esophagitis. About that time, experimental studies were published that showed that creating an oblique gastroesophageal angle (flap-valve),even if exaggerated, failed to prevent reflux unless the opposite part of the esophagus was effectively buttressed, supported, or wrapped [8]. It should be recalled that the question of the existence of a functioning lower esophageal sphincter, not demonstrable anatomically, was not finally established until the development of new manometric techniques at the end of the 1950s [9]. The decade of the 1960s was a time when various buttressing and wrapping antireflux operations became established. In 1961 Nissen [lo] published an important clinical experience treating HH with a complete 360-degree gastric wrap around the esophagus termed a fundoplication. Belsey, after trials and careful study, published his Mark IV operation [ 111, a transthoracic telescoping procedure with stomach partially wrapped around the esophagus all anchored beneath the diaphragm.
Collis Gastroplasty with Belsey Operation Pearson and associates of Toronto [12] deserve credit for combining the Collis gastroplasty with the Belsey procedure. This made the gastroplasty a more effective antireflux operation and addressed the long-term unsatisfactory results with the Belsey repair alone in the presence of subtle esophageal shortening, thereby eliminating the factor of tension. Pearson’s combined Collis-Belsey operation also helped popularize the transthoracic approach to HH and reflux esophagitis. The Collis-fundoplication repairs are used for a select group of patients with a shortened esophagus, stricture, transmural ulcerative esophagitis, large combined sliding and paraesophageal HH difficult to reduce without tension, and a previously failed antireflux operation. The Toronto Collis-Belsey series has been followed up for more than 15 years with excellent subjective and objective results in approximately 90% of their patients. The outcome is less favorable after multiple previous antireflux operations, advanced scleroderma, and certain esophageal motility disorders. It is probably contraindicated in the presence of achalasia, difficult strictures, and multiple destructive previous HH-antireflux operations.
Collis-Nissen Fundoplication Orringer and Sloan of Ann Arbor [13] discontinued using the Collis-Belsey procedure because of an unacceptably high failure rate and changed to the Nissen complete 360-degree antireflux gastric wrap. Not only did the gastroplasty create a longer pseudoesophagus, but tension-free sutures could be placed in the gastric tube rather than the often tenuous and friable distal esophagus. The Ann Arbor group [14] has reported excellent results with the Collis-Nissen procedure comparable with the Toronto Collis-Belsey series for roughly the same type of patient with similar indications and contraindications. Both the
841
Toronto and Ann Arbor series represent the largest, longest followed and most carefully studied consecutive series of patients having combined Collis gastroplasty and fundoplication operations. One can only speculate on what subtle differences in case selection, surgical technique, and follow-up methodology play in the results from these two highly competent centers of esophageal surgery, one using the Collis-Belsey and the other the Collis-Nissen gastroplasty. The Nissen fundoplication may offer better reflux control but it carries the potential for producing dysphagia and inability to belch or vomit. This has prompted the call for a shorter and looser gastric wrap. The Belsey-type repair carried out with gastroplasty, when adequate stomach is available, would be preferable in the presence of an esophageal motility disorder.
Intrathoracic Fundoplication Procedures Another approach to the short esophagus and irreducible HH is an intrathoracic Nissen fundoplication left above the diaphragm. When the HH was associated with a tight stricture, Thal and colleagues [15] incised the stricture longitudinally suturing the side of the stomach as a patch over the esophageal opening. An intrathoracic Nissentype fundoplication was subsequently added to control reflux. This so-called Thal-Nissen operation [16] has gained very limited acceptance. Fundoplication procedures leaving the stomach in the chest expose the patient to the well-documented serious complications associated with a paraesophageal HH. The Collis lengthening-antireflux concept is a preferable approach. With a long, upper thoracic or intractable esophageal stricture, resection would be indicated in the goodrisk patient.
The Stapling Device and Modified Collis Gastroplasty Introduction of the gastrointestinal anastomosis stapling device has simplified creation of the Collis gastroplasty. Unfortunately, the gastroplasty has probably been unnecessarily used in uncomplicated cases where attention to established principles of adequate esophageal mobilization and complete dissection would permit a tension-free antireflux procedure without the need to add the gastroplasty. The stapler has also been used for forming a gastric tube without cutting and oversewing the stapled edges, the so-called uncut gastroplasty [17]. The undivided stapled stomach does not eliminate staple cutthrough and the occasional leak and fistula associated with the Collis gastroplasty.
Conclusions The Collis gastroplasty combined with an antireflux procedure is an effective operation for a select set of adult patients. With the increasing availability of new reflux measuring techniques in competent gastroesophageal testing facilities throughout the country, the place of the
842
CLASSICS
ADLER
Ann Thorac Surg 1990;50839-42
COLLIS GASTROI'LASTY
modified Collis gastroplasty operation should become delineated more precisely than t h e current situation, in which t h e operation is practically never u s ed by s om e or almost routinely used by others. Furthermore, a new generation of endoscopically trained gastroenterologists a r m e d w i t h a n ever-increasing arsenal of more sophisticated drugs for managing gastroesophageal reflux disease will challenge t h e practicing s u r g eo n to produce standardized statistically valid d at a to s u p p o r t t h e place of mode rn Collis gastroplasty. The esophageal s u r g eo n of tomorrow will certainly be u n d e r stricter scrutiny i n selecting the appropriate operation for each patient i n a changing population w i t h m o re complex reflux disease.
and fundoplication for complex reflux problems: long-term results. Ann Surg 1987;206473-81. 7. Cooper JD, Gill SS, Nelems JM. Intraoperative and postoperative esophageal manometric findings with Collis gastroplasty and Belsey hiatal hernia repair for gastroesophageal reflux. J Thorac Cardiovasc Surg 1977;74:744-51. 8. Adler RH, Firme CN, Lanigan JM. A valve mechanism to prevent gastroesophageal reflux and esophagitis. Surgery 1958;44:63-76. 9. Code CF, Creamer B, Schlegel JF, et al. An atlas of esopha-
geal motility in health and disease. Springfield, IL: Charles C. Thomas, 1958. 10. Nissen R. Gastropexy and "fundoplication" in surgical treatment of hiatal hernia. Am J Dig Dis 1961;6:95p61. 11. Skinner D, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 1967;53: 33-54.
References 1. Collis JL. An operation for hiatus hernia with short esophagus. J Thorac Surg 1957;34:76%78. 2. Barrett NR. The lower esophagus lined by columnar epithelium. Surgery 1957;41:881-94. 3. Adler RH. The lower esophagus lined by columnar epithe-
lium: its association with hiatal hernia, ulcer, stricture and tumor. J Thorac Cardiovasc Surg 1963;45:13-34. 4. Skinner DB, Belsey R. Management of esophageal disease. Philadelphia: W.B. Saunders, 1988:594-6. 5. DeMeester TM, Skinner D. Discussion of Pearson FG, Cooper JD, Patterson AG, et al. Gastropexy and fundoplication for complex reflux problems: long-term results. Ann Surg 1987; 206:47%31. 6. Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty
12. Pearson FG, Langer 8, Henderson RD. Gastroplasty and Belsey hiatus hernia repair: an operation for the management of peptic stricture with acquired short esophagus. J Thorac Cardiovasc Surg 1971;61:50-63. 13. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 1978; 25:1621. 14. Stirling MC, Orringer MB. Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989;47 224-30. 15. Thal AP, Hatafuku T, Kurtzman R. A new operation for distal esophageal stricture. Arch Surg 1965;90:464-72. 16. Maker JW, Hocking MP, Woodward ER. The fate of the intrathoracic fundoplication: a review of 112 cases. In: De-
meester TR, Skinner DB. Esophageal disorders: physiology and therapy. New York: Raven Press, 1985:191-5. 17. Demos NJ. Stapled, uncut gastroplasty for hiatal hernia: 12-year follow-up. Ann Thorac Surg 1984;38:393-9.
Collis Gastroplasty: Origin and Evolution Richard H. Adler, MD Division of Cardiothoracic Surgery, Department of Surgery, State University of New York at Buffalo, Buffalo General Hospital, Buffalo. New York
In 1957 J. Leigh Collis published his innovative operation for treating the difficult problem of the irreducible hiatal hernia, esophagitis, and stricture. The design of the operation was based on the relatively primitive understanding of hiatal hernia and the newly emerging concept of reflux esophagitis. A variety of antireflux operations by different surgeons emerged over the years
A
n invitation to write a commentary on J. L. Collis’ 1957 classic “An operation for hiatus hernia and short esophagus” [l]as a contribution to today’s surgical management of hiatal hernia (HH) and gastroesophageal reflux disease awakens dormant memories of that remarkable period during the 1950s through which I lived as a thoracic surgeon. Today’s younger thoracic surgeon need only read the discussions following Collis’ 1957 presentation, which include operations such as moving the esophagus forward to the dome of the diaphragm for a shortened esophagus, interposing a segment of bowel containing the ileocecal valve to eliminate reflux, and pyloroplasty for promoting an empty stomach, to appreciate the advances since the 1950s. After completion of my thoracic surgery residency in Ann Arbor almost four decades ago, I was fortunate to have been granted a fellowship at the Brompton Hospital for Chest Diseases, London, England. During this time I was privileged to visit with Mr Collis in Birmingham. This fellowship also afforded me the unique opportunity of spending time with two other pioneer English esophageal surgeons, P. R. Allison of Leeds and N. R. Barrett of London. These British surgeons played a major role in changing the established perception of the sliding HH from that of an anatomical mechanical condition to a functional physiologically based disorder with reflux esophagitis and its complications as the fundamental problem.
The 1957 Collis Operation Collis sought and devised a relatively uncomplicated operation for the difficult HH with short esophagus, esophagitis, and stricture particularly in “the frail and aged.” He wished to avoid the two extreme practices of either the risky, more complicated resectional operations of that day or the programs of endless esophageal dilations with ineffective medical management. Of the various factors thought to control gastroesophageal compeAddress reprint requests to Dr Adler, Buffalo General Hospital, 100 High St, Buffalo, NY 14203.
0 1990 by The Society of Thoracic Surgeons
to follow. The original Collis gastroplasty has been subsequently modified with the addition of both partial and complete fundoplication procedures. The place of the modified Collis gastroplasty-fundoplication operations in today’s approach to the problems of hiatal hernia and gastroesophagealreflux disease remains unsettled. (Ann Thoruc Surg 1990;50:83942)
tence at that time, Collis believed ”the acute angle of implantation of the esophagus into the stomach which in turn is produced by the normally functioning crural muscle . . . was the one which could be effective alone.” Collis created a narrow, somewhat distally tapered tube along the proximal lesser curvature of the stomach that connected in continuity the shortened esophagus above with the stomach below (Fig 1).The gastric tube (gastroplasty), fashioned by suturing the stomach divided between two parallel clamps, met his two major objectives: (1) reestablishing the normal, more acutely angled (flapvalve) subdiaphragmatic junction with the stomach and (2) eliminating the irreducible stomach bulk from the hiatus. Collis also sutured the crura of the widened hiatus together anterior to the gastric tube displacing the tube further posteriorly, resulting in a more oblique angulation. Collis used a thoracoabdominal incision with division of the costal arch. Today, the operation is generally carried out transthoracically. Subdiaphragmatic exposure can be obtained when needed by a peripheral circumferential opening of the diaphragm. In his 1957 paper, Collis noted that the esophagus became lengthened after its transthoracic dissection and complete mobilization, now an established thoracic surgery principle: ”In some cases it will be found that so much extra length of the esophagus can be obtained by this dissection that a standard repair can be done.“ This statement also carries an important implication for the modern esophageal surgeon, which is that one must be prepared to alter plans in response to unexpected operative findings.
Stricture and Dysphagia Concerning peptic strictures, Collis wrote in 1957, ”many strictures which are believed to be fibrous are, in fact, mainly produced by reflux spasm. In these cases when the irritation of reflux has been removed and the esophagitis has subsided the dysphagia will no longer be present.” Today, there is general agreement that if a reflux stricture can be adequately dilated preoperatively 0003-4975/90/$3.50
840
Ann Thorac Surg
CLASSICS ADLER COLLIS GASTROPLASTY
1990;50:839-42
Fig 1 . (A) Position of clamps on herniated stomach. (B)The n m l y created gastric tube (gastroplasty)connects the short esophagus and stomach beneath the diaphragm (see text). (Reproduced from 111 with permission from the publishers.)
CONNKTING
ABDOMEN A
or at operation, proper control of reflux should prevent stricture recurrence. Postoperative dilations may be required over a period of time for the occasional more severe stricture until the inflammatory reaction subsides. Resection of an esophageal stricture is now reserved for relatively uncommon situations such as an extremely resistant stricture associated with panmural fibrosis and inflammation, inadequate tissues for repair resulting from previously failed antireflux operations, and premalignant dysplastic changes associated with a Barrett esophagus. Although Collis reported that 7 of his 8 postoperative patients had "excellent" results, all had dysphagia for weeks to several months after operation. It might be noted here that Collis did not have available the more effective flexible tapered-tip Maloney bougies nor modern balloon dilators. At that time it was also common HH surgical teaching to suggest that postoperative dysphagia was to be expected. Collis wrote, "some degree of immediate postoperative dysphagia is regarded as desirable and it is felt that if it is not present the operation has not been done properly." Today, surgeons try to avoid postoperative dysphagia by carefully tailoring the diameter of the hiatus and the antireflux procedure. A delicate balance must be achieved between maintaining normal food passage from above and preventing reflux from below.
Is Collis Gastroplasty a Barrett Esophagus? Collis was aware that he was leaving "stomach" above the diaphragm proximal to the junction of tube and stomach. He defended this by citing references that this lesser curvature area of the stomach (Magenstrasse) used for his connecting tube was "devoid of peptic cells and relatively innocuous." Collis additionally drew on the analogy to those patients "often referred to as having gastric-lined esophagus and in whom symptoms are often slight." It is interesting to note that N. R. Barrett [Z]also published his classic paper in 1957 that described a condition related to
B
---
reflux esophagitis that came to bear his name. The Barrett esophagus was soon noted to add further complications [3], some of which may have a relationship to the Collis gastroplasty. Skinner and Demeester [4, 51 have questioned whether the Collis gastroplasty might be an iatrogenic Barrett esophagus and carry the same biological potential for the development of malignancy as has been well documented in the acquired Barrett esophagus associated with chronic reflux esophagitis. A few patients found to have carcinoma in association with modified Collis gastroplasty for chronic esophagitis have been cited to support this contention. Pearson and associates [ 6 ] , however, strongly question this assumption, suggesting that the tumor is related to the presence of an acquired Barrett mucosa rather than the gastric tube itself. This unsettled issue illustrates the need for thorough evaluation of all patients, particularly preoperatively, which would include at endoscopy circumferential brushings with washings for cytologic studies and multiple biopsies around and within strictures.
Collis Gastroplasty, Inert or Dynamic? Both Skinner and Demeester consider the Collis gastroplasty to be an adynamic and inert tube. There is also a question as to whether the gastroplasty itself might act as an obstructing factor particularly in the presence of decreased esophageal motility. Cooper and co-workers [7] and Pearson and associates [6], however, have demonstrated that the gastroplasty has a synchronous function with the lower esophageal sphincter. Their manometric studies show that the gastroplasty responds to swallowing as well as to specific hormonal stimuli. The tone of the gastroplasty appears to be enhanced by the fundoplication. The exact function of the modified gastroplasty remains unsettled at this time.
CLASSICS ADLER COLLIS GASTROPLASTY
Ann Thorac Surg 1990;5083942
Modified Collis Gastroplasty The 1957 Collis gastroplasty by itself did not prove to entirely control reflux esophagitis. About that time, experimental studies were published that showed that creating an oblique gastroesophageal angle (flap-valve),even if exaggerated, failed to prevent reflux unless the opposite part of the esophagus was effectively buttressed, supported, or wrapped [8]. It should be recalled that the question of the existence of a functioning lower esophageal sphincter, not demonstrable anatomically, was not finally established until the development of new manometric techniques at the end of the 1950s [9]. The decade of the 1960s was a time when various buttressing and wrapping antireflux operations became established. In 1961 Nissen [lo] published an important clinical experience treating HH with a complete 360-degree gastric wrap around the esophagus termed a fundoplication. Belsey, after trials and careful study, published his Mark IV operation [ 111, a transthoracic telescoping procedure with stomach partially wrapped around the esophagus all anchored beneath the diaphragm.
Collis Gastroplasty with Belsey Operation Pearson and associates of Toronto [12] deserve credit for combining the Collis gastroplasty with the Belsey procedure. This made the gastroplasty a more effective antireflux operation and addressed the long-term unsatisfactory results with the Belsey repair alone in the presence of subtle esophageal shortening, thereby eliminating the factor of tension. Pearson’s combined Collis-Belsey operation also helped popularize the transthoracic approach to HH and reflux esophagitis. The Collis-fundoplication repairs are used for a select group of patients with a shortened esophagus, stricture, transmural ulcerative esophagitis, large combined sliding and paraesophageal HH difficult to reduce without tension, and a previously failed antireflux operation. The Toronto Collis-Belsey series has been followed up for more than 15 years with excellent subjective and objective results in approximately 90% of their patients. The outcome is less favorable after multiple previous antireflux operations, advanced scleroderma, and certain esophageal motility disorders. It is probably contraindicated in the presence of achalasia, difficult strictures, and multiple destructive previous HH-antireflux operations.
Collis-Nissen Fundoplication Orringer and Sloan of Ann Arbor [13] discontinued using the Collis-Belsey procedure because of an unacceptably high failure rate and changed to the Nissen complete 360-degree antireflux gastric wrap. Not only did the gastroplasty create a longer pseudoesophagus, but tension-free sutures could be placed in the gastric tube rather than the often tenuous and friable distal esophagus. The Ann Arbor group [14] has reported excellent results with the Collis-Nissen procedure comparable with the Toronto Collis-Belsey series for roughly the same type of patient with similar indications and contraindications. Both the
841
Toronto and Ann Arbor series represent the largest, longest followed and most carefully studied consecutive series of patients having combined Collis gastroplasty and fundoplication operations. One can only speculate on what subtle differences in case selection, surgical technique, and follow-up methodology play in the results from these two highly competent centers of esophageal surgery, one using the Collis-Belsey and the other the Collis-Nissen gastroplasty. The Nissen fundoplication may offer better reflux control but it carries the potential for producing dysphagia and inability to belch or vomit. This has prompted the call for a shorter and looser gastric wrap. The Belsey-type repair carried out with gastroplasty, when adequate stomach is available, would be preferable in the presence of an esophageal motility disorder.
Intrathoracic Fundoplication Procedures Another approach to the short esophagus and irreducible HH is an intrathoracic Nissen fundoplication left above the diaphragm. When the HH was associated with a tight stricture, Thal and colleagues [15] incised the stricture longitudinally suturing the side of the stomach as a patch over the esophageal opening. An intrathoracic Nissentype fundoplication was subsequently added to control reflux. This so-called Thal-Nissen operation [16] has gained very limited acceptance. Fundoplication procedures leaving the stomach in the chest expose the patient to the well-documented serious complications associated with a paraesophageal HH. The Collis lengthening-antireflux concept is a preferable approach. With a long, upper thoracic or intractable esophageal stricture, resection would be indicated in the goodrisk patient.
The Stapling Device and Modified Collis Gastroplasty Introduction of the gastrointestinal anastomosis stapling device has simplified creation of the Collis gastroplasty. Unfortunately, the gastroplasty has probably been unnecessarily used in uncomplicated cases where attention to established principles of adequate esophageal mobilization and complete dissection would permit a tension-free antireflux procedure without the need to add the gastroplasty. The stapler has also been used for forming a gastric tube without cutting and oversewing the stapled edges, the so-called uncut gastroplasty [17]. The undivided stapled stomach does not eliminate staple cutthrough and the occasional leak and fistula associated with the Collis gastroplasty.
Conclusions The Collis gastroplasty combined with an antireflux procedure is an effective operation for a select set of adult patients. With the increasing availability of new reflux measuring techniques in competent gastroesophageal testing facilities throughout the country, the place of the
842
CLASSICS
ADLER
Ann Thorac Surg 1990;50839-42
COLLIS GASTROI'LASTY
modified Collis gastroplasty operation should become delineated more precisely than t h e current situation, in which t h e operation is practically never u s ed by s om e or almost routinely used by others. Furthermore, a new generation of endoscopically trained gastroenterologists a r m e d w i t h a n ever-increasing arsenal of more sophisticated drugs for managing gastroesophageal reflux disease will challenge t h e practicing s u r g eo n to produce standardized statistically valid d at a to s u p p o r t t h e place of mode rn Collis gastroplasty. The esophageal s u r g eo n of tomorrow will certainly be u n d e r stricter scrutiny i n selecting the appropriate operation for each patient i n a changing population w i t h m o re complex reflux disease.
and fundoplication for complex reflux problems: long-term results. Ann Surg 1987;206473-81. 7. Cooper JD, Gill SS, Nelems JM. Intraoperative and postoperative esophageal manometric findings with Collis gastroplasty and Belsey hiatal hernia repair for gastroesophageal reflux. J Thorac Cardiovasc Surg 1977;74:744-51. 8. Adler RH, Firme CN, Lanigan JM. A valve mechanism to prevent gastroesophageal reflux and esophagitis. Surgery 1958;44:63-76. 9. Code CF, Creamer B, Schlegel JF, et al. An atlas of esopha-
geal motility in health and disease. Springfield, IL: Charles C. Thomas, 1958. 10. Nissen R. Gastropexy and "fundoplication" in surgical treatment of hiatal hernia. Am J Dig Dis 1961;6:95p61. 11. Skinner D, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 1967;53: 33-54.
References 1. Collis JL. An operation for hiatus hernia with short esophagus. J Thorac Surg 1957;34:76%78. 2. Barrett NR. The lower esophagus lined by columnar epithelium. Surgery 1957;41:881-94. 3. Adler RH. The lower esophagus lined by columnar epithe-
lium: its association with hiatal hernia, ulcer, stricture and tumor. J Thorac Cardiovasc Surg 1963;45:13-34. 4. Skinner DB, Belsey R. Management of esophageal disease. Philadelphia: W.B. Saunders, 1988:594-6. 5. DeMeester TM, Skinner D. Discussion of Pearson FG, Cooper JD, Patterson AG, et al. Gastropexy and fundoplication for complex reflux problems: long-term results. Ann Surg 1987; 206:47%31. 6. Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty
12. Pearson FG, Langer 8, Henderson RD. Gastroplasty and Belsey hiatus hernia repair: an operation for the management of peptic stricture with acquired short esophagus. J Thorac Cardiovasc Surg 1971;61:50-63. 13. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 1978; 25:1621. 14. Stirling MC, Orringer MB. Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989;47 224-30. 15. Thal AP, Hatafuku T, Kurtzman R. A new operation for distal esophageal stricture. Arch Surg 1965;90:464-72. 16. Maker JW, Hocking MP, Woodward ER. The fate of the intrathoracic fundoplication: a review of 112 cases. In: De-
meester TR, Skinner DB. Esophageal disorders: physiology and therapy. New York: Raven Press, 1985:191-5. 17. Demos NJ. Stapled, uncut gastroplasty for hiatal hernia: 12-year follow-up. Ann Thorac Surg 1984;38:393-9.
