The first totally laparoscopic approach to a modified Collis technique was described by Johnson and colleagues [29] in 1998. With a 48-French bougie in place along the lesser curvature, a transgastric window was created in the fundus using a circular stapler. A linear stapler was then used along the bougie dividing the fundus from the fundal window to the angle of His, constructing the neo-esophagus. A floppy Nissen fundoplication was then created. Because of concerns for tissue ischemia in most cases the gastric fundus needed to be resected. This technique also needed a mini-laparotomy to introduce the circular stapler. The introduction of articulated linear staplers modified this technique and finally Terry [30] first described the stapled-wedge gastroplasty or wedge fundectomy in 2004. This technique allows performing the entire surgery through the abdomen with laparoscopic access using articulating staplers, which surgeons normally use in general surgery. After reducing the herniated stomach and removing the entire hernia sac with the epiphrenic fat pad, a 50 French bougie is placed under laparoscopic visualization and passed into the distal stomach against the lesser curvature. The ideal distance from the GEJ should be determined to ensure that at least 3 cm of esophagus or neo-esophagus lies below the hiatus. This point can be marked with a suture placed at the left edge of the bougie, to serve as a guide, marking the distal extent of the neo-esophagus. The surgeon’s left-hand grasper retracts the proximal fundus (Fig. 13.3) and the assistant grasps lower on the greater curvature, which should have already been completely mobilized. These points of retraction are used to stretch the fundus laterally to the patient’s left. An endoscopic articulating stapler is then completely articulated to the left. A 45/60 mm length stapler with 3.5 mm height staples (several fires) is passed across the fundus between the two grasping instruments at approximately 90° to the greater curvature towards the bougie and the guiding suture. Once the horizontal fires are completed, the stapler is straightened and a second staple line is begun towards the angle of His, parallel to the left edge of the bougie. Before firing, the posterior aspect of the stomach should be examined for redundant tissue. As long as the bougie is in position and the stapler is tight against it, the neo-esophagus will be of adequate diameter. Once this staple line has reached the angle of His, the resected portion of the proximal fundus is removed through the 12 mm trocar, without the need of a mini-laparotomy (Fig. 13.4) [31].

Novel techniques are available nowadays to assess tissue vitality. For example, fluorescence imaging with indocyanine green (ICG) provides a real time assessment of tissue perfusion. Adequate tissue perfusion after wedge fundus resection can be objectivized using ICG (Fig. 13.5).

Another technique for creating a Collis gastroplasty is through the thorax. It was described by Swanstrom and subsequently modified by Filipi and combines laparoscopic and thoracoscopic approach [8, 32]. This technique does not include the wedge resection of the fundus. It has also the potential advantage of creating a shorter stapler line that may be less prone to leak. The intra-abdominal part of the surgery is identical to the first technique described. The left chest is prepped and draped. The thoracoscopy is done under dual-lung ventilation so the lung can be collapsed. A scope is then introduced into the chest to evaluate the presence/absence of adhesions and to judge the path towards the mediastinal parietal pleura just above the hiatus. Then an endoscopic stapler is introduced through the thoracic port. This stapler is passed along the anterior thoracic wall, identifying the location of its tip laparoscopically. Once the stapler is in the abdomen, it is placed adjacent to the bougie and a single stapler fire creates a 3 cm segment of neo-esophagus. The pleural defect is left open and the thoracic trocar is left in place to prevent deflation of the pneumoperitoneum. Generally, a chest tube is not required. This procedure has gained less acceptance than the wedge Collis gastroplasty because it requires thoracic surgery skills, as well as potentially resulting in increased pain from a chest incision and a higher risk of postoperative pneumothorax [33].

Horgan et al. reported their experience on 31 patients who underwent surgical treatment for failed antireflux surgery. Failures were classified according to the anatomic findings as follows: Type IA The GEJ and the wrap are above the diaphragm, Type IB The GEJ is above the diaphragm, Type II paraesophageal hernia, Type III Malformation of the wrap. They reported Type IA as the most frequent anatomic anomaly found in their series (56%). They attributed these failures to defective closure of the crura, inadequate fixation of the wrap, and/or insufficient esophageal length. According to them, SE esophagus was present in only one of those patients (3%). In the remaining patients, they were able to dissect the esophagus up into the mediastinum, attaining enough esophageal length to perform a fundoplication without tension [21].

Nason et al. published their outcomes on patients undergoing giant paraesophageal hernia repair (GPEH) with fundoplication alone (n = 341) versus fundoplication with Collis gastroplasty (n = 454) (Table 13.1). Collis gastroplasty was performed using either the EEA technique [34] or the wedge technique [35]; They concluded that adding a Collis gastroplasty to the laparoscopic repair of GPEH when needed was not detrimental to the overall outcome or quality of life [36
].

Zehetner et al. reported their series of 85 patients undergoing laparoscopic Collis-Nissen gastroplasty using the wedge-fundectomy technique. At 12 months follow up, 93% of patients were free of heartburn or regurgitation. Dysphagia resolved in 71% of patients. A small recurrent hiatal hernia was seen on barium swallow in 2 patients (2.4%). They stated that the addition of a wedge-fundectomy Collis gastroplasty was a safe and effective strategy to manage a shortened esophagus [31].

Some authors strictly deny the existence of this entity. Instead, they attribute this diagnosis to insufficient mediastinal dissection. For instance, Madan et al. publish their results on 628 fundoplications; 13 (2%) patients had a benign stricture due to advanced reflux disease. According to them, once extensive mediastinal dissection was achieved, no SE was seen. There were 16 (2.5%) recurrences. After revising every case, they concluded that none of the failures were related to SE. They rather attributed them to construction of a loose wrap, disruptions of the three stitches involved in the wrap, or improper crura closure [10].

Moreover, Bochkarev et al. operated 106 patients with GERD and suspected SE on BS. None of these patients required any esophageal lengthening procedure. After proper mobilization of the esophagus, they were able to perform a regular Nissen fundoplication in every case.

All patients had abnormal preoperative pH study results. Postoperatively the median percentage time with pH < 4 dropped from 22.76% to 1.43% (p < 0.001) and the DeMeester score from 67.76 to 5.03 (p < 0.001). All 106 patients have referred improvement of symptoms (p < 0.001) [11].

On one hand, lengthening procedures allow the surgeon to accomplish all the anatomic requirements to perform a correct fundoplication. On the other hand, there is concern about parietal cells from the neo-esophagus secreting acid into the esophagus. From the last point of view, one can argue that the Collis gastroplasty would just change the mechanism of the presence of acid in the esophagus. The acid would be produced in situ instead of coming from the stomach. Here there are some published data concerning this subject.