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464 The uncut Collis-Nissen procedure
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Removal of the gastroesophageal fat pad
The gastroesophageal fat pad is divided in the midline
6
and removed, with the division proceeding cephalad
from the stomach to the gastroesophageal junction and
esophagus. Both vagal trunks should be carefully preserved.
The trunks may be visualized and palpated, but at no time
should they be put in jeopardy. The remaining fatty tissue,
including the vagus nerves, is allowed to retract and will be
included within the wrap. Meticulous cauterization or ligation of multiple gastric nutrient vessels is required to avoid
formation of a hematoma. This maneuver clears a portion of
the gastric serosa and gastroesophageal junction for the later
steps of the operation and exposes sound tissue in which to
place the fundoplication sutures.
6
7a
Uncut Collis gastroplasty
A 50-Fr Maloney dilator is passed by mouth
7a,b
stomach, for use as a mandrel about which an uncut tubular
extension of the esophagus will be fashioned from the lesser
curvature of the stomach. This is accurately and simply
achieved by applying a TA 30 stapler using 4.8-mm staples to
the stomach at the angle of His, parallel to the lesser curvature
of the stomach and the indwelling dilator. Because the alignment pin is not used in this application, special care should be
taken to ensure that the staples and crimping anvil are accurately aligned.
through the gastroesophageal junction into the
7b
Nissen fundoplication
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After the staples have been placed and the
8a,b
lized fundus is imbricated 360 degrees around the 30-mm
uncut Collis gastroplasty tube or neo-esophagus, following
the technique developed by Nissen. The wrap is fashioned
loosely with the dilator in place and is maintained with one
row of interrupted seromuscular 2/0 silk sutures, which initially approximate the fundus to the Collis gastroplasty tube
over a 2-cm length. A second, outer row of 3/0 silk is used to
reinforce these sutures, going from stomach to stomach. The
vagi are located within the fundal wrap in their normal position. At each step of the procedure injury to these nerves must
be avoided – accidental vagotomy is the most common cause
of ‘gas bloat’ syndrome in the postoperative period. It is noteworthy that the fundoplication, as described, avoids placing
sutures near the vagal trunks: the anchoring sutures for the
plication are all on the stomach, not the esophagus. The purpose of the uncut staple line is to establish a frenula that will
prevent the neo-esophagus from telescoping out of the fundoplication and to reduce tension.
stapling device removed, the previously mobi-
Operation 465
8a
8b
466 The uncut Collis-Nissen procedure
Pericardium
Esophagus
Anchoring
suture
Dilator
Crural suture
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Reduction of the wrap and closure of the hiatus
Once the fundoplication is complete, the
9a–c
diaphragm and is held in place with three interrupted horizontal mattress sutures of 2/0 polypropylene (Johnsrud
sutures). These sutures catch the esophagus just above the
gastroesophageal junction, passing through the stomach and
underneath the crus and diaphragm. These sutures cover 270
degrees, beginning medially at the level of the last posterior
crural suture at the insertion of the pericardium. The second
suture should be positioned halfway between the first and
third sutures. The final suture should be placed at the last
suture of the left or anterior crus. The wrap is then reduced
with the dilator in place, and the anchoring Johnsrud sutures
are tied and divided. The crural sutures are then tied and
divided; the surgeon works from the aorta to the pericardium, ensuring that there is one finger’s breadth posteriorly between the esophagus and the crus with each suture
tied. If the last suture is too tight, one throw (or an entire
suture) should be removed to allow adequate space posteriorly. This ensures a hiatus large enough to prevent dysphagia.
At this stage the dilator is removed and a nasogastric tube is
passed into the stomach. Hemostasis is secured, a chest tube
is placed, and the incision is closed in the usual manner.
reconstructed area is reduced below the
9a
9b
9c
Further reading 467
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POSTOPERATIVE CARE
The morning after the day of the operation, the nasogastric
tubes may be removed. Oral feeding may begin safely on the
next day and progresses from a liquid to a general diet during
the next 2–3 days. Chest tubes are removed once drainage has
reduced to less than 250 mL. Total hospitalization time is
approximately 6 days.
Complications
Minor leakage from any site is usually asymptomatic, localized, and confined. If leakage is suspected, a fluoroscopic
study should be performed using a water-soluble medium
(Gastrografin). If a leak is observed, chest and nasogastric
tubes should remain in place for 5–7 days. After this period,
repeat radiographical examination almost invariably shows
that the leaks have sealed completely. Oral feeding may be
resumed safely after tapering off parenteral feeding and
removing all the drainage tubes.
OUTCOMES
The results of the uncut Collis–Nissen procedure have been
described extensively in the literature by the authors and their
colleagues. Mortality has been extremely low. The reports by
Piehler et al (1984), Allen et al (1993), and Deschamps et al
(1997) collectively reported on 300 patients who had the
transthoracic uncut Collis–Nissen procedure with no operative deaths. Trastek et al in 1998 reported on the first 100 consecutive patients undergoing primary uncut Collis–Nissen
procedure by one surgeon. In that series, there were two postoperative deaths (2%) both cardiac in origin and both occurring in the first 25 patients. Morbidity remains acceptable and
consistent: Piehler (29%), Allen (30.8%), and Trastek (23%).
Similar to so many procedures, Trastek et al (1998) demonstrated a learning curve with the uncut Collis–Nissen procedure. In the first 25 patients there were 10 complications
(40%) compared with 13 complications (17%) in the next 75
patients (p = 0.03). The leak rate in our series ranged from
0% to 3.9%, with most being contained and never requiring
further treatment.
While complete objective follow-up is the gold standard,
we at Belsey feel that the patients remain the most sensitive
tool for assessing the late results of antireflux surgery. In
general, postoperative studies were not routinely performed
on totally asymptomatic patients but were often performed
to evaluate specific symptoms. Trastek et al (1998) described
subjective long-term results for the uncut Collis–Nissen procedure. Median follow-up was 8.3 years. Results were excellent (no symptoms) in 59% of the patients, good (mild
reflux without treatment necessary) in 25%, fair (moderate
reflux controlled with medication or dilations needed) in
8%, and poor (severe reflux unrelieved with medication, or
worse postoperatively, or reoperation required) in 7%.
Dysphagia was present in 6%, recurrence of reflux symptoms in 5%, and hiatal hernia recurrence in 3%. This was
similar to the findings of Piehler et al – excellent to good
results in 84% of patients, fair results in 7.8%, and poor
results in 8.4%.
ACKNOWLEDGMENTS
All the illustrations used in this chapter have been redrawn
from originals supplied by the Mayo Foundation, for which
copyright is held by the Mayo Foundation.
FURTHER READING
Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach:
presentation and results of operation. Journal of Thoracic and
Cardiovascular Surgery 1993; 105: 253–59.
Deschamps C, Trastek VF, Allen MS, Pairolero PC, Johnson JO, Larson DR.
Long-term results after reoperation for failed antireflux procedures.
Journal of Thoracic and Cardiovascular Surgery 1997; 113: 545–51.
Piehler JM, Payne WS, Cameron AJ, Pairolero PC. The uncut
Collis–Nissen procedure for esophageal hiatal hernia and its
complications. Problems in General Surgery 1984; 1: 1–14.
Trastek VF, Deschamps C, Allen MS, Miller DL, Pairolero PC, Thompson A.
Uncut Collis–Nissen fundoplication: learning curve and long-term
results. Annals of Thoracic Surgery 1998; 66: 1739–44.
Trastek VF, Visbal AL. The Collis gastroplasty for gastroesophageal reflux.
In: Yang SC, Cameron DE eds. Current therapy in cardiovascular
surgery. Philadelphia: Mosby, 2004: 410–13.
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Reoperative antireflux surgery using the
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thoracic approach
ALEX G. LITTLE MD
Elizabeth Berry Gray Chair and Professor, Department of Surgery, Wright State University School of Medicine, Dayton, Ohio, USA
44
HISTORY
Although the history of antireflux surgery is relatively brief, a
multitude of surgical options are available that have been performed through both thoracic and abdominal routes.
Predictably, failure and/or success rates have varied. Globally
speaking, however, a long-term success rate of approximately
90% has been the standard. The 10% failure rate may be due
either to the recurrence of reflux or the substitution of new
symptoms, such as dysphagia or bloating for heartburn.
The limited long-term follow-up of laparoscopic antireflux
surgery patients means that neither its failure rate as an initial
operation nor its appropriateness as an option for reoperative
surgery can yet be determined. Speculatively, the failure rate
can be expected to remain relatively unchanged, as laparoscopic surgical technique now appears to be identical to that
used in the open approach.
PATHOPHYSIOLOGY
Diagnosis
An antireflux operation may seem to fail because it was an
inappropriate procedure. An antireflux procedure performed
for a primary motility disorder of the esophagus, for cardiac
disease, or for cholecystitis obviously will not succeed. For
this reason, before surgical intervention for gastroesophageal
reflux disease is undertaken, any doubts regarding the diagnosis should be eliminated, and esophageal function tests,
both esophageal manometry and pH monitoring, should be
performed if there is any question. Patients with classic heartburn and endoscopically confirmed esophagitis probably do
not routinely need this level of testing. However, patients
with atypical symptoms, patients with significant dysphagia,
and patients without endoscopically identified esophagitis
should all be strongly considered for function testing before
operation to avoid this type of error.
Surgical technique
Although surgeons differ regarding some aspects of surgical
technique, such as the need for division of the short gastric
vessels, some principles are clearly essential. These include
the need to close the esophageal hiatus posteriorly before
construction of a fundoplication, the need to ensure placement of a gastric wrap around the distal esophagus rather
than the proximal stomach, and the requirement of performing a fundoplication that is neither too tight nor too long.
When these principles are violated, failure is more likely.
Closure of the hiatus retards mediastinal dislocation of the
wrap, which potentiates its disruption. Wrapping the proximal stomach can result in recurrent reflux or cause obstruction or dysphagia, or both. Finally, either an excessively tight
or long wrap can cause both dysphagia and severe bloating.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Functional tests
Whereas esophageal function tests should be obtained selectively before primary antireflux surgery, they should routinely be performed in all patients before reoperative surgery.
They provide essential information regarding remaining
esophageal peristaltic capability and document the presence
or absence of recurrent reflux.
470 Reoperative antireflux surgery using the thoracic approach
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Anatomical study
All patients should be studied both with a barium contrast
radiological examination and an endoscopic examination.
These examinations provide essential information about the
relationship of the esophagus and fundus to each other and to
the diaphragm. Endoscopy not only supplements the radiographical information but also is used to assess the absence
or presence and the severity of esophagitis and the tightness
of the wrap.
SURGICAL OPTIONS
Reoperative surgery can be carried out through either an
abdominal or a thoracic approach, can utilize either open or
minimally invasive techniques, and can consist of either a
redo of the standard antireflux procedure, a standard antireflux procedure complemented by an esophageal lengthening
technique such as the Collis gastroplasty, or resection of diseased tissue and reconstruction with colon interposition. The
author’s opinion, based on painful experience, is that the thoracic approach is necessary for many patients. The supradiaphragmatic, virginal esophagus is easily mobilized. After
peripheral detachment of the diaphragm, ready access to and
exposure of the left upper quadrant is achieved, which allows
safe and expeditious lysis of adhesions and mobilization of
the necessary structures.
Experience has also shown that patients undergoing their
first reoperation can usually be adequately treated with a redo
of the standard procedure, with or without a Collis gastroplasty. In patients undergoing their third reoperation, functional deterioration and anatomical compromise are both
usually present, and a more reliable outcome can be obtained
with resection and interposition of either colon or jejunum.
When a patient is undergoing a second reoperation, the surgeon must use judgment as to the wisdom of performing a
redo procedure versus resection.
OPERATION
After induction of anesthesia, a double-lumen endotracheal
tube is inserted, the stomach is decompressed with a nasal
gastric tube, the patient is placed in the right decubitus position, and the operation is performed either through the bed
of the resected left seventh rib or in the seventh intercostal
space.
The inferior pulmonary ligament is divided up to the
1
level of the inferior pulmonary vein, and the lung is collapsed and packed anteriorly and superiorly to provide exposure of the thoracic esophagus. The esophagus is dissected
from its mediastinal bed at a location above any inflammatory changes and encircled with a Penrose drain. The esophagus is subsequently mobilized fully from the aortic arch to the
esophageal hiatus. The diaphragm is then incised peripherally
approximately 2 cm from its insertion into the chest wall.
This incision begins at the pericardial fat with avoidance of
the phrenic nerve and extends laterally until the spleen is
identified and accessible.
The stomach is initially separated from the spleen with
division of the short gastric vessels if they were not previously
divided. This provides access to the lesser sac. The dissection
is then carried superiorly and medially with complete release
of the fundus from the diaphragm and retroperitoneum. The
stomach and diaphragm are typically nearly fused. Separating
them requires patience and persistence. Adhesions between
the anterior stomach and the liver are also lysed, and the liver
is retracted free. When the adhesions and scar tissue binding
the esophagus and stomach to the esophageal hiatus are being
divided, it is helpful for the surgeon’s left hand to be placed in
the hiatus below the diaphragm while the sharp dissection is
performed from the thoracic side.
Stomach
Spleen
Diaphragm
Esophagus
Aorta
1
With complete freedom of the distal esophagus and the
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2
fundus, the anatomy is inspected to determine the cause
of failure. This is carried out in the context of the data
obtained from the preoperative assessment. Most frequently
what is found is either a partial or total disruption of the initial wrap, placement of a Nissen fundoplication around the
proximal stomach, or excessive length or tightness of a Nissen
wrap. All remnants of the previous wrap need to be dissected
free to try to restore normal anatomy. At this point, based on
operative assessment of the integrity of the tissues and the
preoperative data, the surgeon chooses between the surgical
options.
It is always difficult and sometimes impossible to identify
and/or preserve the integrity of the vagus nerves.
Nonetheless, clinically important problems with delayed gastric emptying are uncommon, and the sequelae of pyloroplasty can be quite unpleasant. Consequently, the author does
not routinely perform any type of gastric emptying procedure. This can be done at a later date for the small number of
patients who require it.
Diaphragm Esophagus
Gastric pouch
above misplaced wrap
Operation 471
Aorta
2
3
Stomach
Esophagus
Left vagus
nerve
Aorta
When a redo approach is chosen, the same principles as
3
for primary antireflux surgery should be used. In the
author’s experience, a Nissen fundoplication is usually possible. This is performed with a large bougie in the esophagus
and consists of the usual three-stitch-length fundoplication
around the distal esophagus with closure of the hiatus posteriorly.
472 Reoperative antireflux surgery using the thoracic approach
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When patients are being reoperated for the third time,
4
when the esophagus has been rendered nonfunctional, or
when there is loss of tissue integrity with either a nondilatable
stricture or an actual chronic fistula, the distal esophagus
should be resected and replaced with a segment of healthy
colon or jejunum. The author’s experience is with the use of a
short segment of left colon, which provides good long-term
function. This means that for all patients undergoing reoperative surgery, the bowel should be mechanically cleansed preoperatively. At surgery, enough colon is prepared to bridge
the short gap between the distal esophagus and the stomach;
division of the midcolic vessels is usually not required. The
colon is placed in isoperistaltic fashion and sutured in an endto-side fashion to the posterior fundus.
Descending colon
Omentum
4
OUTCOME
The outcome of repeated antireflux surgery is not as good as
for primary surgery. Experience shows that after one previous
operation and when a redo procedure is performed, 75–85%
of patients have a good result with elimination of heartburn
and only minor dysphagia or bloating. Although these are
good results, they are significantly worse than for primary
operations. In patients who have undergone multiple previous operations, it is essential that the surgeon maximize the
chances of a good outcome. For this reason the conservative
approach of resection and interposition with healthy tissue
should be considered in the presence of extensive functional
or anatomic compromise.
FURTHER READING
Hunter JG. Approach and management of patients with recurrent
gastroesophageal reflux disease. Journal of Gastrointestinal Surgery
2001; 5: 451–57.
Little AG, Ferguson MD, Skinner DB. Reoperation for failed antireflux
operations. Journal of Thoracic and Cardiovascular Surgery 1986; 91:
511–17.
Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally
invasive reoperation for gastroesophageal reflux disease. Annals of
Thoracic Surgery 2002; 74: 328-32.
Smith CD, McClusky DA, Rajad MA, Lederman AB, Hunter JG. When
fundoplication fails. Annals of Surgery 2005; 241: 861–69.
Thoracoscopic cardiomyotomy for achalasia
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CHRISTOPHER JOHN MARTIN MB BS, MSC, FRACS
Professor of Surgery, University of Sydney; Head of Surgery, Nepean Hospital, Sydney, Australia
45
HISTORY
Longitudinal myotomy of the distal esophagus through a thoracotomy was first reported for achalasia by Heller in 1914.
The morbidity of the thoracotomy wound, both immediate
and delayed, led to popularization of distal esophageal
myotomy by laparotomy.
Since the early 1990s the procedure has been performed
increasingly using a minimally invasive technique such that open
operations are now only rarely performed. Initially most operations were performed thoracoscopically rather than laparoscopically. That balance has now changed for several reasons.
Firstly, the incidence of persistent dysphagia after thoracoscopy
would appear to be higher because an adequate distal extent of
longitudinal myotomy is more difficult to achieve. Secondly, the
rate of convalescence would appear to be slower after the thoracoscopic approach. Thirdly, the incidence of pathological gastroesophageal reflux is probably higher than initially thought
after thoracoscopic cardiomyotomy, and addition of an antireflux procedure is technically difficult by the thoracoscopic but
not the laparoscopic approach. At this stage, however, these
comparisons have not been made in a randomized study.
Nevertheless there is still a place for thoracoscopic cardiomyotomy. For instance, the laparoscopic approach might
be precluded by postoperative adhesions or the operating
surgeon might feel more adept operating in the chest rather
than the abdomen.
In this section thoracoscopic cardiomyotomy will be
described in detail, with limited additional remarks only
made to cover the operation performed by thoracotomy.
are a low perforation rate, an ability to recognize and remedy
perforation at the time should it occur, and a long-term
improvement in quality of swallowing for a higher percentage
of patients.
PREOPERATIVE ASSESSMENT
The diagnosis of achalasia is suspected on clinical history of
dysphagia, supported by contrast radiology and endoscopy of
the esophagus and proven by esophageal manometry.
Complications of achalasia, such as gross malnutrition and
severe respiratory impairment due to repeated aspiration are
rarely seen these days.
PREPARATION
Preoperative discussion with the patient should cover the following issues: intraoperative perforation, incomplete
myotomy leading to persistent dysphagia, and postoperative
gastroesophageal reflux. Patients should be aware that associated dysfunction of the esophageal body can result, in the
long term, in dysphagia, irrespective of the therapy chosen.
The patient is advised to take fluids only in the 24 hours
before surgery to ensure that no residual solid matter is left in
the esophagus. This interval may need to be adjusted depending upon the amount of food noted at the diagnostic
endoscopy after a standard 6- to 8-hour fast.
PRINCIPLES AND JUSTIFICATION
The principal alternative approach to surgery for achalasia is
forceful disruption of the lower esophageal sphincter with an
endoscopic balloon. The advantages of the surgical approach
OPERATION
Anesthesia
Deflation of the left lung during the procedure is achieved
after insertion of a double-lumen endotracheal tube.
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