Collis Gastroplasty



Collis Gastroplasty


John G. Hunter

Mark J. Eichler





PATIENT HISTORY AND PHYSICAL FINDINGS



  • Secondary to chronic acid inflammation and subsequent fibrotic remodeling of the distal esophagus, approximately 10% to 25% of patients with reflux have a shortened esophagus.3,4 The majority of these patients, however, do not need an esophageal lengthening procedure for a tension-free fundoplication if adequate mediastinal dissection gains return of abdominal esophageal length.5 Sufficient intraabdominal length can be evidenced by the GEJ lying intraabdominally with a distance between the diaphragmatic hiatus and the GEJ of at least 2.5 cm. It is at this threshold of 2.5 cm (approximately the length of a fully opened atraumatic laparoscopic grasper) after adequate mediastinal and crural dissection should the decision to perform a Collis gastroplasty take place,3 with an overall incidence of implementation of 3% to 4% of reflux operations.


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • The preoperative workup for reflux disease spans endoscopy (esophagogastroduodenoscopy [EGD]), esophagography (upper gastrointestinal contrast swallow or esophagram), manometry, and pH probe testing. However, there is no gold-standard radiologic imaging study for preoperative preparation in reflux disease, as the surgical decision making to perform a Collis gastroplasty is done ultimately intraoperatively. Yet, esophagography and endoscopy may be the optimal studies to demonstrate a foreshortened esophagus by the following signs6:



    • Hiatal hernia of 5 cm or more


    • Giant type III paraesophageal hernia (FIG 1)


    • Esophagitis, Barrett’s changes, and/or stricture


SURGICAL MANAGEMENT


Preoperative Planning



  • Because the Collis gastroplasty is an adjunctive procedure during gastric fundoplication, the principles of a proper antireflux procedure (wrap) or gastropexy apply, including left and right crural exposure, adequate mediastinal dissection, atraumatic esophageal retraction, and division of the short gastric vessels. Please refer to Chapters 19 and 22 for further details.


  • All studies, including esophagram, EGD, manometry, and pH testing should be readily available and reviewed prior to and at the time of surgery. The esophagram should be displayed on a spare or dedicated monitor in the operating theater and EGD images be loaded as well for intraoperative reference.


  • Attention to fine detail of the manometric report may avoid an unnecessary and detrimental 360-degree fundoplication, as a complete wrap may worsen symptoms in the light of the following findings7:



    • Severe esophageal dysmotility


    • Very low residual postrelaxation lower esophageal sphincter (LES) pressures less than 30 mmHg during wet swallow


Positioning



  • Although there are many port placement techniques, the stapled Collis gastroplasty necessitates a left upper quadrant, endoscopic, angulating stapler by the surgeon’s right hand through a 12-mm trocar. Steep reverse Trendelenburg is the position of choice (FIG 2).



  • Assume extensive mediastinal dissection will be warranted, and therefore, risk of pleural compromise (FIG 3). The sterile skin preparation must be wide enough on either flank in case tube thoracostomies are necessary from resultant pneumothorax. However, a red rubber catheter between 10 and 14 Fr may be placed in a witnessed pleural defect intraabdominally spanning the diaphragm to the hemithorax in question. This reduces the resultant pneumothorax and peak ventilatory pressures with the aid of lowering insufflation pressures as well as anesthesia-assisted ventilatory Valsalva.






FIG 1 • Esophagram demonstrating tortuous esophagus with shortening, distal narrowing or strictures, and a type III paraesophageal hiatal hernia.

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Jul 24, 2016 | Posted by in GENERAL | Comments Off on Collis Gastroplasty

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