Overview
Definition:
Collis gastroplasty is a surgical procedure involving the creation of an artificial esophagus from a portion of the stomach, typically used to manage a short esophagus secondary to chronic gastroesophageal reflux disease (GERD) or paraesophageal hernia, facilitating a tension-free repair of a hiatal hernia.
Epidemiology:
Short esophagus is most commonly seen in patients with long-standing, severe GERD, often complicated by peptic strictures or Barrett's esophagus
Prevalence is difficult to quantify precisely as it is a consequence of another condition, but significant GERD affects millions globally.
Clinical Significance:
A short esophagus poses a significant challenge in the surgical management of GERD and hiatal hernias, as it prevents adequate mobilization of the stomach for standard anti-reflux procedures without excessive tension
Collis gastroplasty provides a solution by lengthening the esophagus, enabling a more durable and effective repair, crucial for preventing recurrence and long-term complications of GERD.
Indications
Primary Indications:
Symptomatic gastroesophageal reflux disease (GERD) refractory to medical management
Recurrent hiatal hernia repair after previous surgery
Severe strictures of the distal esophagus that cannot be managed by simple dilatation
Large paraesophageal hernias where significant intrathoracic stomach requires reduction and cannot be achieved without tension
Esophageal shortening due to peptic stricture, corrosive injury, or radiation therapy.
Contraindications:
Uncontrolled coagulopathy
Unfit for major abdominal and thoracic surgery
Active peptic ulcer disease
Esophageal malignancy in the distal esophagus that is unresectable or where radical oncologic resection is indicated
Severe malnutrition or cachexia.
Patient Selection:
Careful patient selection is paramount, focusing on those with documented short esophagus, often diagnosed by barium swallow or intraoperative findings, who are candidates for definitive anti-reflux surgery and can tolerate a complex procedure.
Preoperative Preparation
Diagnostic Workup:
Upper GI endoscopy with biopsy to assess for Barrett's esophagus or malignancy
Barium swallow to evaluate esophageal length, strictures, and gastric anatomy
24-hour pH monitoring or impedance testing to confirm GERD
Esophageal manometry to assess motility
Pulmonary function tests to assess respiratory reserve.
Medical Optimization:
Aggressive proton pump inhibitor (PPI) therapy for weeks to months to heal esophagitis and reduce inflammation
Nutritional support for malnourished patients
Smoking cessation
Management of comorbidities.
Surgical Planning:
Discussion of the procedure, potential risks, and alternatives with the patient
Preoperative antibiotic prophylaxis
Preparation of the surgical team and equipment.
Procedure Steps
Approach:
Typically performed through a combined abdominal and thoracic approach (laparotomy and thoracotomy) or laparoscopically with thoracic assistance
An abdominal approach is essential for gastric mobilization and creation of the gastric tube.
Gastric Mobilization:
The stomach is mobilized by dividing the short gastric vessels, carefully preserving the gastroepiploic arcade
The greater curvature is dissected free from the spleen.
Creation Of Gastric Tube:
A gastric tube (Collis tube) is created from the greater curvature of the stomach, typically 10-15 cm in length, using stapling devices
This tube effectively lengthens the stomach to mimic an esophageal segment.
Hiatal Hernia Repair And Fundoplication:
The gastroesophageal junction is identified
The hiatus is prepared, and a standard anti-reflux procedure, such as a Nissen fundoplication or a Toupet fundoplication, is performed around the gastroesophageal junction and the gastric tube
Crucially, the fundoplication must be performed without tension on the neo-esophagogastric junction.
Reconstruction And Closure:
The abdominal and thoracic incisions are closed
A nasogastric tube may be placed for decompression
Drains are placed as necessary.
Postoperative Care
Immediate Postoperative Period:
Close monitoring of vital signs, fluid balance, and respiratory status in the intensive care unit
Pain management with IV analgesics
Intravenous PPI therapy initiated
Gradual reintroduction of oral intake as per protocol.
Dietary Progression:
Patients start with clear liquids, progressing to full liquids, pureed foods, and then a soft diet over several weeks
Diligent chewing is encouraged
Avoidance of trigger foods for reflux.
Monitoring And Follow Up:
Regular follow-up appointments with the surgical team
Assessment of symptoms of reflux, dysphagia, and regurgitation
Endoscopic surveillance may be necessary depending on the presence of Barrett's esophagus preoperatively
Nutritional status assessment.
Complications
Early Complications:
Bleeding
Leakage from staple lines
Anastomotic leak
Pneumonia
Atelectasis
Injury to adjacent organs (spleen, liver, diaphragm)
Gastric tube obstruction
Disruption of repair
Suture dehiscence.
Late Complications:
Recurrent reflux
Dysphagia requiring dilatation
Gastric tube ischemia or necrosis
Stomal stenosis
Marginal ulceration
Dumping syndrome
Bile reflux gastritis
Formation of a pseudotumor.
Prevention Strategies:
Meticulous surgical technique, adequate mobilization of the stomach, creation of a well-formed gastric tube without tension, secure and leak-free closure of staple lines, careful dissection to avoid injury, and thorough postoperative monitoring and management are key to minimizing complications.
Prognosis
Factors Affecting Prognosis:
The success of Collis gastroplasty is highly dependent on the surgeon's experience, the extent of esophageal shortening, the presence of comorbidities, and adherence to postoperative dietary and medical regimens
Good patient selection and meticulous surgical technique yield better outcomes.
Outcomes:
When performed appropriately for selected patients, Collis gastroplasty can provide significant relief from severe GERD symptoms and facilitate tension-free repair of large hiatal hernias, with good long-term control of reflux
However, the risk of dysphagia and the need for long-term PPI therapy remain.
Long Term Management:
Lifelong follow-up and management are often required, including regular medication with PPIs and periodic endoscopic evaluation, especially in patients with Barrett's esophagus.
Key Points
Exam Focus:
Collis gastroplasty creates a gastric tube to lengthen a short esophagus, enabling anti-reflux surgery
It is indicated for severe GERD with significant esophageal shortening
The procedure involves creating a gastric tube from the greater curvature and then performing a fundoplication around the gastroesophageal junction and the neo-esophagogastric junction.
Clinical Pearls:
Always suspect a short esophagus in patients with recurrent hiatal hernias or severe peptic strictures
Intraoperative assessment of esophageal length is critical
if a standard fundoplication causes tension, a Collis gastroplasty should be considered
Careful preservation of the gastroepiploic arcade is vital for gastric tube viability
A tension-free fundoplication is essential for success.
Common Mistakes:
Performing anti-reflux surgery on a short esophagus without lengthening it, leading to recurrent hernia or early failure of the repair
Inadequate gastric mobilization, resulting in tension on the anastomosis
Creation of a poorly formed or ischemic gastric tube
Improperly performed fundoplication leading to dysphagia or persistent reflux.