Giant Paraesophageal Hiatal Hernia repair

Giant Paraesophageal Hiatal Hernia
repair: the need for the Collis
operation?
Ross M. Bremner MD, PhD
William Pilcher Chair : Department of Thoracic Surgery and
Transplantation
Director, Norton Thoracic Institute
St Joseph’s Hospital and Medical Center
Professor of Surgery
Creighton University
Disclosures
Institutional Support for research and
education from Ethicon
Surgical Consultant for Endostim
Neither relevant to this talk
St Joseph’s Hospital
• Largest Hospital
• Oldest Hospital
University of Pittsburg
Fear the Underdog!
The large hiatal hernia – the need for
a lengthening procedure
Lets take a “grand view”
Pathophysiology of Hiatal Hernia
•
•
•
•
•
Natural weakening “hiatus” in the diaphragm
Congenital predisposition – Collagen I/III
Activity
Obesity
Normal forces at the hiatus – over time
•
•
•
•
•
Respiration
Swallowing
Coughing/Sneezing
Heaving/Vomiting
Activity - lifting
Edmundowicz SA, Clouse RE: Am J Physiol 260:G512–G516, 1991
Hiatal Hernia
 60% of people over
age 60 yrs
 Normal
Breathing : Negative Inspiratory
Pressure
• Breathing
• 20 000x day
• 438 000 000 x in 60 yrs
• Each breath – 10 mmHg
Normal Shortening with
Swallowing
• Swallow
– 2000x day
– Shortens up to 3-5 cm at
hiatus
Coughing and Sneezing
Addington WR: Cough, 2008, April 30:4;2
Normal Physiologic GE Junction
forces
Jumping
>170 mmHg
Further, increased change in intraabdominal
pressure with increased BMI!
Cobbs WS: J Surg Res, 2005 Dec;129(2) 231.
Obesity
Increased
intraabdominal
pressure
Associated with
increased risk of
recurrence
With Time…..little surprise
• Diaphragm widens
• Phreno-esophageal
ligament stretches
• Proximal Stomach
herniates
Control any Heartburn
• With Time….
• GIANT
PARAESOPHAGEAL
HERNIA
Point # 1
Many forces exist at the hiatus that
tend to pull and push the stomach into
the chest
This is our battle as surgeons!!
The large hiatal hernia – the need for
surgery
Why do we operate
Symptoms associated with the hernia
itself
GERD
And to prevent:
Torsion
Hemorrhage
Large Paraesophageal HH
What do we know?
• Becoming more common!
• Different beast
• Operation more complex
•
More mobilization, larger defect,
poorer diaphragmatic tissue
• Recurrence COMMON
• UP TO 50%!!!..Maybe higher
The large hiatal hernia
• Why so many?
– Use of PPI’s –Pts (and GI’s) treat the disease medically for decades
– Aging Population
– Epidemic of obesity – GERD and hiatal hernia
The large hiatal hernia
• Recurrence!
• How to mitigate against recurrence
•Suture techniques
•Patches
•Glues
•Relaxing incisions
•Esophageal lengthening
Recurrence – Why?
Crural Tension
Poor Diaphragm Tissue
No reinforcement of crural repair
Loose crural repair
Perioperative heaving/straining
Repetitive dry heaving
Obesity
Trauma
Esophageal shortening
J Leigh Collis (1911-2003)
• Oesophageal surgeon with
superior outcomes
• 1957 devised a procedure to
overcome peptic stricture and
the “short esophagus”
• No Nissen/Belsey
Collis JL, Thorax 1957;12:181-188
Transthoracic
Thoracotomy
Pearson, FG, Cooper JD, Patterson GA
(1987) Ann Surg 206
Laparoscopic
Collis- Thoracoscopic
Approach
Collis- Laparoscopic Linear Stapler
Approach (Wedge Gastroplasty)
Completed Collis-Nissen
Problem 1
Acid secreting
epithelium above
“wrap”
Esophagitis
11-80%
Zehetner J: Ann Surg 2014
Martin, C Aust.N.Z. J. Surg 1992, 62,
126-129
Problem 2
Amotile
neoesophagus
-Dysphagia
Dilation of
neoesophagus
with time
Problem 3
Staple line
Leaks
“Ischemic Collis”
Point #2
Collis is a reasonable option IF the
esophagus really is SHORT
Not Physiologic, and may have
immediate and long term side effects
The Short Esophagus
How do we predict?
EGD?
Manometry?
What is too short?
20 cm
Pathophysiology of the Short
Esophagus
• Repeated chemical trauma
and mucosal sloughing
• PMN Infiltration
• Fibroblast Induction
Today:
Scleroderma
• Collagen Deposition
(submucosa and muscularis)
•
Shortening (axial and
circumferential)
Oberg, Ann Surg, 1997
RARE for
stricture in giant
HH
Can we predict a SHORT esophagus
– how often does it occur?
Esophageal Length
102 pts with redo or PEH
(1/3 Vagotomy – inadvertent or intentionally)
No Collis needed in any case!
Satisfied>90%
“The Short Esophagus is an uncommon problem”
Oelschlager,B: J Gastrointest Surg (2008) 12:1155-1162
Typical Example
Large Hiatal Defect
Dissect out the sac
Identify Vagus
Identify Posterior Vagus
Close Crus…just right
The Crus!
The Achilles heal
Nissen or Toupet
Intraop Endoscopy
St Joes Data – ongoing study
Prospective onlay patch
2009-present
>680 LARS with patch
435 PEH
<2% Collis
Reoperation <3%
But we still see Recurrences!!
Recurrence due to:
• Intraabdominal forces
Greater in Hi BMI
• Inherent weakness at the hiatus
• Disruption of the phreno-esophageal
ligament??
Pig experiment 1992
• CUSA with Nissen
• 5 Pigs
• Nissen fundoplication (with
circumferential dissection of the
esophagus) then mucosal ablation – no
HH – no crural repair
• In 3 weeks
- 3 animals acutely herniated their
stomach into the chest
Why?
What can we learn from new procedures?
The Phreno-esophageal membrane
The Phreno-Esophageal
Ligament
Have we forgotten?
Hayward, J: Thorax March 1961: 16(1); 41-45.
Phreno-esophageal membrane
Hayward, J: Thorax March 1961: 16(1); 41-45.
Short Esophagus
John Hayward
“I have never been unable to reduce the
hernia. An oesophagus too short to allow
reduction of a hiatal hernia must be an
unusual finding. Doubtless I shall
encounter one sooner or later.”
Hayward, J: Thorax March 1961: 16(1); 41-45.
Why the failures
Recurrent hiatal hernias:
We repair the hernia
• BUT
• We have done nothing
to change the normal
pressure gradients at the
hiatus
• And no PEL
With Time…..little surprise
• Herniated stomach
– Often only “portion” of
stomach
– Same whether Collis
used or not.
Point #3
Same forces that caused hernia in first
place…..STILL EXIST post-op
And the PEL is disrupted
No wonder we get
recurrences!
How important is a recurrence?
Fact is: most are asymptomatic
Long Term Recurrence
Multicenter Randomized Trial PEH
6 months : 9% (vs 24%)
58 months: 50%!
But, almoat all were better
Only 3% reoperation!
Oelschlager B, Pelligrini C, Hunter J, Soper N, Swanstrom L: Am College Surg 2010
Oelschlager B: J Gastrointest Surg (2012) 16:453
Analysis of the impact of radiographic
recurrence on gastroesophageal reflux
disease-related and overall patient health
status at current clinical follow-up
Radiographic Recurrence
All Patients
Yes
No
________________________________________________
Satisfied with surgery and current symptoms
n = 493
n = 41
n = 314
Yes
No
440 (80%)
53 (11%)
37 (90%)
4(10%)
284 (90%)
30 (10%)
P
.79+
Point #4
“Recurrence”
Radiographic recurrence common
And will likely continue….
MOST ASYMPTOMATIC
But… risk of Torsion and
Hemorrhage Gone!
But, you say….
The Collis will lengthen the
esophagus and prevent recurrence??
Does the Collis Mitigate against
Recurrence?
68 pts with Collis
Mean follow up 30 months!
17% recurrence hiatal hernia
(80% esophagitis)
“Calls into question the LIBERAL
application of this technique”
Lin, E, Smith C D: J Gastrointest Surg 2004;8:31-39
Collis(454 pts) vs No Collis(341)
Radiographic recurrence similar!
17% vs 20%
(>3 months)
Reoperation Similar 3-5%
Nason K, Luketich J, Ann Thorac Surg 2011;92:1854
Point # 5
The Collis Does NOT
Prevent Recurrence
How Good is the Collis?
Short Term.
Is this a safe operation we should be
advocating?
Collis(454 pts) vs No Collis(341)
Leaks
No Collis: 2 pts
Collis: 12 pts
Reoperation < 30 days
Collis : 6
No-Collis : 3 p<0.05
Nason K, Luketich J, Ann Thorac Surg 2011;92:1854
Outcomes
“Long-term symptomatic outcomes
after Collis gastroplasty”
52 pts
Long-term = >9 months!
Resolution:
HB
Chest Pain
Dysphagia
52%
22%
29%
Conclude “good long term symptom control”
Garg, N: Diseases of the Esophagus (2009) 22, 532
Collis vs No-collis
Long term outcomes:
“SIMILAR”
But
Very little >5 or 10 year data on
Collis Nissen and its functional
outcomes
Why use a Collis?
•
Esophageal shortening result of panmural fibrosis,
uncommon in todays world
•
Collis is unphysiologic – problems!
•
High recurrence rate of paraesophageal hernia not due
to shortening
• Most are asymptomatic
•
Most recurrences do not need reoperation! Pt’s are
satisfied!
•
“Lengthening” the esophagus does not mitigate against
recurrence
The Collis - Conclusion
Not necessary in almost all
repairs of Giant
Paraesophageal Hiatal Hernia!
(but learn how to do it so you can be comfortable when you
do need it!!!!)
Counter Point
Collis – just how good is it?
Why do you do less Collis procedures today
than previously?
86% down to 53%
Dai, Q: Dig Dis Sci. 2006 Jan;51(1):105-9
Nason K, Luketich J, Ann Thorac Surg 2011;92:1854
Quotes
“ When are esophageal surgeons
going to abandon the Collis
operation? Having experienced the
same results as Dr S….., I have
stopped using it for the most part”
Pelligrini, C: Discussion: J Gastrointest Surg, 2004; 8:31-39
The Collis - Conclusion
Not necessary in almost all
repairs of Giant
Paraesophageal Hiatal Hernia!
Counterpoint
Collis – just how good is it?
Long Term
150 pts Collis - 14 yr period
85 pts lap – wedge fundectomy
5.3% of all antireflux procedures
Good outcomes
But 11% esophagitis above the Collis
Median follow up 12 months
Zehetner J, DeMeester TR: Ann Surg 2014
Conclusion
High recurrence rate – not a result of
shortening in most cases PEH repairs
Role of PEL??
True Shortening is uncommon!
Collis is unphysiologic – problems!
Not so great LONG term results
“Lengthening” the esophagus does not
mitigate against recurrence
Collis- Laparoscopic Linear Stapler
Approach (Wedge Gastroplasty)
Data:
Summary: Good operation when necessary
Question, how often is it necessary?
Point #4
Similar recurrence rates whether the
Collis is used or not!
Point #4
BUT…..
Small recurrences are OK!
Most asymptomatic, and rarely
dangerous
We have still made our patients
better!
Recurrence?
Lin, E, Smith C D: J Gastrointest Surg 2004;8:31-39
Distension of the Stomach
Fitzgerald RC, GUT 2002, 50:451
What is wrong with the operation??
What is wrong with our patients??
Most recurrences are
asymptomatic
And the risk of torsion or hemorrhage
Is MINIMAL
The New OR’s
UPMC
Short Esophagus
John Hayward
In the experience of different surgeons there
is a wide variation in the number of
oesophagi alleged to be too short for
reduction of the hernia, and recent reports
suggest that they are fewer than was
originally thought.
Hayward, J: Thorax March 1961: 16(1); 41-45.
The Giant Hiatal Hernia
• Collis – what, how, and why?
• Giant hiatal hernia
• Why so many?
• Why so many recurrences
– Due to short esophagus?
– Forces at the hiatus – tissue issues
– Does recurrence matter?
Recurrence?
Recurrence due to:
• Shortening??
• Intraabdominal forces
Greater in Hi BMI
• Inherent weakness at the hiatus
• Disruption of the phreno-esophageal
ligament