Collis Gastroplasty. In patients with a short esophagus secondary to a stricture, Barrett esophagus, or a

large hiatal hernia, the esophagus is lengthened with a Collis gastroplasty. The gastroplasty lengthens

the esophagus by forming a gastric tube or “neoesophagus” along the lesser curvature. The procedure

allows a tension-free construction of a total or partial fundoplication around the newly formed gastric

tube, with placement of the repair in the abdomen. A gastroplasty can be readily performed via either

an abdominal or thoracic approach. A number of techniques have been reported for the laparoscopic

performance of Collis gastroplasty, and the surgeon opting to manage the shortened esophagus

laparoscopically must be able to perform such a procedure should the need arise.192 The authors prefer

the wedge fundectomy technique initially described by Hunter et al. In a series of 85 patients that had a

wedge fundectomy Collis gastroplasty and either a Nissen or Toupet fundoplication there were no staple

line leaks or abscesses in the perioperative period, and at a median follow-up of 12 months 93% were

free of heartburn. Dysphagia was significantly less common then preoperatively with new-onset

dysphagia in only two patients. On upper endoscopy in 54 patients at a median of 6 months

postoperatively esophagitis was only present in 11% of patients. These results suggest that a wedge

fundectomy can be added safely and with good results in patients where a shortened esophagus is found

intraoperatively.

INDICATIONS/CONTRAINDICATIONS

Table 42-9 Indications for Performing an Antireflux Procedure by a Transthoracic

Approach

Outcomes Following Antireflux Surgery. Any discussion regarding results following fundoplication

must consider:

1. Perioperative morbidity and mortality

2. Control of typical and atypical symptoms

3. Side effects

4. Objective relief from excessive esophageal acid exposure

5. Anatomic failure rates, such as recurrent hiatal herniation or slippage, and the need for reoperation

Complications of Antireflux Surgery. Carlson and Frantzides

193 reported on complications and results

of primary minimally invasive antireflux operations based on a literature review. Included in their

analysis were 41 papers comprising 10,489 procedures. Postoperative complications were found to

occur in approximately 8% of patients, with the rate of conversion to an open procedure of about 4%.

The most common perioperative complication was early wrap herniation (1.3%), defined as occurring

within 48 hours of surgery. This is one complication that may be more common with the laparoscopic

than open approach. The explanation for this is unclear but may be related to the opening of tissue

planes by the pneumoperitoneum, the reduced tendency for adhesion formation after laparoscopic

compared to open surgery, and inadequate bites of crural tissue related to the magnified view with the

laparoscope. An adequate crural repair is critical in laparoscopic antireflux surgery (LARS).

Both pneumothorax and pneumomediastinum have been reported. The occurrence of pneumothorax is

related to breach of either pleural membrane, usually the left, during the hiatal dissection. Chest drain

insertion is usually not required because accumulated carbon dioxide rapidly dissipates following release

of pneumoperitoneum by a combination of positive pressure ventilation and absorption. Tension

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pneumothorax intraoperatively is typically related to a ball-valve effect from a small opening in the

pleura. In this setting the laparoscopic capnoperitoneum gets into the pleural space with exhalation, but

cannot escape rapidly with inhalation. Creating a large pleural defect solves this issue, and since the

anesthesiologist can increase the ventilation pressure above the 15 mm used for laparoscopic

pneumoperitoneum there should be no difficulty ventilating the patient adequately.

As with any laparoscopic procedure, instrumental or trocar perforation of a hollow viscera may occur.

Esophageal perforation may arise intraoperatively during passage of the bougie, during the

retroesophageal dissection, or as a consequence of suture pull-through. Late esophageal perforation is

typically related to diathermy or dissection injury at the time of mobilization. Gastric perforations

usually result from excessive traction on the fundus particularly when reducing a PEH without first

mobilizing the hernia sac. Gastric perforation also occurs during reoperative fundoplication procedures.

The key is to recognize the injury and repair it appropriately since generally major complications are a

result of unrecognized injuries.

Hemorrhage during the course of laparoscopic fundoplication usually arises from the short gastric

vessels or spleen. Rarer causes include retractor trauma to the liver, injury to the left inferior phrenic

vein, an aberrant left hepatic vein, or the inferior vena cava. Cardiac tamponade as a result of right

ventricular trauma has also been reported. Major vascular injury mandates immediate conversion to an

open procedure to achieve hemostasis. One complication that has been virtually eliminated since the

advent of laparoscopic fundoplication is incidental splenic injury necessitating splenectomy (0.06%),

which occurred with a frequency of around 2% to 5% during the open era. The mortality rate for

primary minimally invasive antireflux surgery has fortunately been quite low, reported at 0.08%.

Symptomatic Outcomes Following Antireflux Surgery. Studies of long-term outcome following both

open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve

typical reflux symptoms (heartburn, regurgitation, and dysphagia) in more than 90% of patients at

follow-up intervals averaging 2 to 3 years and 80% to 90% of patients 5 years or more following

surgery.35,194–201 The data include evidence-based reviews of antireflux surgery,198 prospective

randomized trials comparing antireflux surgery to PPI therapy199 and open to laparoscopic

fundoplication,200 and analysis of U.S. national trends in utilization and outcomes.201 The results of

laparoscopic fundoplication compare favorably with those of the “modern” era of open fundoplication.

They also indicate the less predictable outcome of atypical reflux symptoms (cough, asthma, laryngitis)

after surgery being relieved in only two-thirds of patients.202

A few recent trials deserve emphasis. Results were updated on a prospective, randomized trial

comparing PPI therapy to antireflux surgery.203 The outcome of the study previously had been reported

at a follow-up of 5 years,199 while the latest update provided follow-up of at least 7 years. The

proportion of patients in whom treatment did not fail during the 7 years was significantly higher in the

surgical arm than in the medical arm. A smaller difference in outcomes was noted after dose

adjustments in the medical group. More patients in the surgical cohort, however, complained of side

effects such as dysphagia, inability to belch or vomit, and hyperflatulence. Disease control was

essentially stable between 5 and 7 years of follow-up. The authors concluded that surgery was more

effective in controlling overall GERD symptoms, though postfundoplication side effects were a concern.

Another prospective trial from the United Kingdom compared laparoscopic Nissen fundoplication to

PPI and reported follow-up at a median of 6.9 years.142 Some patients initially randomized to PPI

therapy were offered the opportunity to undergo surgery. While both the medical and surgical cohorts

reported an improvement in GERD-related symptoms after 12 months, further symptomatic

improvement was noted in those patients subsequently undergoing surgery despite optimal PPI therapy.

A multicenter, European, prospective randomized trial comparing LARS to medical therapy with

esomeprazole is ongoing (the LOTUS trial). Three-year outcomes in 288 patients assigned to LARS and

266 assigned to medical therapy were reported in 2008.204 The proportion of patients remaining in

symptomatic remission was similar between the two groups (90% for LARS, 93% for medical therapy in

an intention-to-treat analysis, p = 0.25). No major perioperative complications were noted and

esomeprazole appeared to be well tolerated.

Recent reports have called attention to the observation that many patients are prescribed acid

suppression medications after antireflux surgery. Spechler et al.205,206 reported on the long-term followup of patients with complicated GERD enrolled in the Department of Veterans Affairs randomized trial

of medical versus surgical therapies. In the first report, almost half (46.9%) of the patients treated by

fundoplication had taken acid suppression medications at some point during the 11- to 13-year follow-up

period.205 In the second report, 62% of the surgically treated patients had used medications.206 The

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reasons for and the necessity of acid suppression medication usage was not explored in this study. In

contrast, Lord et al.207 reported on 86 patients who had symptoms after Nissen fundoplication severe

enough to warrant evaluation with 24-hour ambulatory esophageal pH monitoring. Thirty-seven (43%)

of these patients were taking acid suppression medications, and only nine of them (24%) were found to

have abnormal pH scores. Heartburn and regurgitation were the only symptoms that were significantly

associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients

with a disrupted or abnormally positioned fundoplication had a 52.6 times increased risk of abnormal

esophageal acid exposure. Based on these data, most patients using acid suppression medications after

antireflux surgery do not have abnormal esophageal acid exposure, and objective evidence of reflux

should be obtained prior to restarting acid suppression medications in patients with symptoms after a

fundoplication.

The goal of surgical treatment for GERD is to relieve abolish reflux by reestablishing the GE barrier.

This will alleviate symptoms related to reflux and protect the esophageal and laryngeal mucosa from

reflux-related injury. The challenge is to accomplish this without inducing dysphagia or other untoward

side effects. Dysphagia that existed prior to surgery usually improves following laparoscopic

fundoplication. Temporary dysphagia is common after surgery and generally resolves within 3 months.

Dysphagia persisting beyond 3 months has been reported in up to 10% of patients. In our experience,

dysphagia, manifested by occasional difficulty in swallowing solids, was present in 7% of patients at 3

months, 5% at 6 months, 2% at 12 months, and a single patient at 24 months following surgery.35

Others have observed a similar improvement in postoperative dysphagia with time. Induced dysphagia

is usually mild, does not require dilatation, and is temporary, often related to edema from the surgery.

Other side effects common to antireflux surgery include the inability to vomit and increased flatulence.

Most patients cannot vomit through an intact wrap, though this is rarely clinically relevant.

Hyperflatulence is a common and noticeable problem, likely related to increased air swallowing that is

present in most patients with reflux disease and the inability to belch.

Objective Outcomes Following Antireflux Surgery. Laparoscopic fundoplication results in a

significant increase in LES pressure and length, generally restoring these values to normal. The ability

of an antireflux operation to restore esophageal acid exposure to normal depends on the type of

fundoplication performed. Complete (Nissen) fundoplications generally are more reliable and durable

than partial (e.g., Toupet) fundoplications at preventing pathologic acid reflux. Objective studies have

shown that more than 90% of patients will have normal pH studies at 1 to 3 years following complete

fundoplication, whereas only 50% of patients will have normal esophageal acid exposure following a

partial fundic wrap.187

Quality-of-life analyses have become an important part of surgical outcome assessment, with both

generic and disease-specific questionnaires in use, in an attempt to quantitate quality of life before and

after surgical intervention. In general, these measures relate the effect of disease management to the

overall well-being of the patient.208 Most studies have utilized the Short Form 36 (SF-36) instrument,

because it is rapidly administered and well validated. This questionnaire measures 12 different healthrelated quality-of-life parameters encompassing mental and physical well-being. Data from Los Angeles

indicate significant improvements in scores for the area of bodily pain and in a portion of the general

health index.35 Most other measures were improved but failed to achieve statistical significance. Trus et

al.209 have also analyzed SF-36 scores before and after LARS. In contrast to our data, scores in all fields

were significantly better after surgery. In this study, preoperative scores were dramatically lower than

were found in our study. Thus, the difference is likely to be secondary to the relatively high scores of

our patients prior to surgery (perhaps reflecting good disease control on medical therapy) and to our

small sample size.

Other investigators have also reported improvement in quality of life following antireflux surgery.

Glise et al.210 utilized two standardized and validated questionnaires, the Psychological General WellBeing Index and the Gastrointestinal Symptom Rating Scale, to evaluate quality of life in a cohort of 40

patients following LARS. Scores with both instruments were improved following antireflux surgery and

better than in untreated patients. Of particular note was that scores were as good as or better than those

of patients receiving optimal medical therapy. Velonovich et al.,211 using a 10-item health-related

quality-of-life questionnaire specific for GERD, have also shown an improvement in quality of life

following antireflux surgery.

Fernando et al.212 reported on quality of life after antireflux surgery compared with nonoperative

management for severe GERD. Follow-up quality of life was measured using the SF-36, and heartburn

severity was measured using the Health-Related Quality-of-Life (QOL) scale. Detailed outcomes were

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available for 101 surgical patients and 37 medical patients. Mean QOL scores were better in the surgical

group. More of the medical patients were dissatisfied with therapy. SF-36 scores were better in six of

eight domains for surgical patients. These data support the notion that antireflux surgery, performed on

properly selected patients, can significantly improve quality of life and may outperform medical therapy

in this regard.

Anatomic Failure Following Antireflux Surgery. An important and often underemphasized point is

that the rate of failure of fundoplication is largely dependent upon the size of the underlying hiatal

hernia. Repair of large sliding and PEHs is associated with a higher risk of recurrent hiatal herniation

compared to fundoplication for GERD in the setting of no or small hiatal hernias. Multiple potential

explanations exist to explain this differential, including the presence of a widened hiatus with weakened

or attenuated crural fibers that must be brought together under tension, the coexistence of esophageal

body shortening, the generally older and frailer nature of patients with a PEH, and underlying

anatomic, muscular, or connective tissue deficits that contributed to the pathogenesis of the hernia. In

particular, the association between kyphosis and intrathoracic stomach is becoming increasingly

recognized, as skeletal abnormalities likely are contributory to the pathogenesis of paraesophageal

hiatal herniation.213

The need for reoperation after fundoplication for GERD is only approximately 5% over the patient’s

lifetime, whereas the risk can run as high as 42% after repair of a giant PEH.214 In a trial from Finland,

objective outcomes were assessed by endoscopy and demonstrated a 40% disruption rate following open

Nissen fundoplication and a 13% disruption rate following a laparoscopic procedure.215 Despite these

relatively high rates of objective breakdown, only 8% of patients in the open group and 2% in the

laparoscopic group had undergone repeat operation for fundoplication failure.

A recent trial compared two techniques of laparoscopic PEH repair, with or without the use of a

biologic prosthesis placed at the esophageal hiatus.216 At 6 months, 9% of patients with the prosthesis

and 24% of patients without mesh reinforcement had developed a recurrent hiatal hernia as assessed by

a barium upper gastrointestinal examination, underscoring the potential for failure when operation is

undertaken for PEHs. However, at a median of 58 months follow-up the authors updated their results

and reported that greater than 50% of patients in both the mesh and nonmesh groups had objective

evidence of hernia recurrence.21 This has led to controversy about the role of mesh at the hiatus,

particularly in patients with large or paraesophageal-type hiatal hernias. It is likely that mesh use alone

is inadequate to prevent hernia recurrence if tension on the crural closure or related to esophageal

shortening is unaddressed. If mesh is to be used most experienced esophageal surgeons avoid the use of

large or esophageal-encircling permanent mesh to minimize the risk of erosion. A small strip of

synthetic mesh placed across the crural closure posterior to the esophagus may have less tendency to

erode and lead to a reduction in hernia recurrence. Bridging the crura with synthetic mesh should be

avoided since this leads to the highest risk for mesh erosion. An absorbable or biologic mesh bridge

should also be avoided since this will lead to hernia recurrence in essentially all patients. Instead, a

diaphragm relaxing incision should be used when the crura cannot be reapproximated or to do so

requires excessive tension. Increasingly biologic or bioresorbable mesh reinforcement of the primary

crural closure is being reported with good results.22 However, it is likely that mesh use increases the

complexity of a reoperation if necessary, and has been shown to lead to a higher risk for the need for

resection rather than redo fundoplication in the reoperative setting.23

Relaxing incisions have been used for hernia repairs at other sites in the abdomen, and logically

would be useful in patients with a widely splayed hiatus where the crura are unable to be approximated

without tension. A right-sided diaphragmatic relaxing incision is easiest and usually suffices, but in a

very large hiatus or in reoperations sometimes a left diaphragm relaxing incision is necessary. The

defect created in the diaphragm should be repaired with permanent mesh to avoid herniation of

abdomen contents into the thorax. The authors prefer a Gore Tex patch for this purpose and reinforce

the primary crural closure with an absorbable or biologic mesh.24

It is likely that efforts to reduce the high objective hernia recurrence rate after laparoscopic PEH

repair will require addressing crural tension, esophageal tension from a shortened esophagus, and mesh

reinforcement of the primary crural closure. When these adjunct techniques are added as necessary

during a laparoscopic PEH repair the authors have reported a very reasonable short-term objective

recurrence rate of 4%.25

FUTURE DIRECTIONS

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