There is a Role for Collis Extension in the Treatment of Giant

There is a Role for Collis Extension in the
Treatment of Giant Paraesophageal Hernia
Matthew J. Schuchert, Katie S. Nason, Arjun Pennathur,
Ryan M. Levy, Omar Awais, James D. Luketich
Department of Cardiothoracic Surgery,
University of Pittsburgh Medical Center,
Pittsburgh, PA
Disclosures
None
Giant Paraesophageal Hernia
• 5-15% of all hiatal hernias
• Incidence = 15-45/100,000
• Type III or Type IV
• No uniform definition for “giant”
• Frequently symptomatic –
careful patient questioning
• Significant surgical challenge
(Recurrence in 5-42%)
Recurrence After GPEH Repair
Rathore et al, JSLS. 2007 Oct-Dec;11(4):456-60.
Surgical Tenets
•
•
•
•
•
•
•
Hernia sac reduction
Extensive esophageal mobilization
Mobilization of crura
Preservation of vagal nerve integrity
Subdiaphragmatic fundoplication
Closure of crural defect
Tension-free repair
Esophageal Foreshortening
• Can be suspected on
barium swallow or
endoscopy
• Inability to reduce the
GE junction below the
level of the hiatus
without tension
• Incidence of short
esophagus varies
– Type I: 0-13%
– GPEH: 15-80%
The Short Esophagus
• 3 types
– Apparent short esophagus
• Normal length esophagus, due to mediastinal
compression/migration
– True, reducible short esophagus
• Shortened, but with adequate mediastinal
mobilization, adequate intra-abdominal length
(2.5 cm) attainable
– True, non reducible short esophagus
• Shortened despite adequate mediastinal
mobilization
Horvath et al Ann Surg 2000
The Short Esophagus
Horvath et al Ann Surg 2000
The Clinical Problem
Crus
GE Junction
What is the incidence of short
esophagus?
Series
Year
Incidence (%)
N
Legacy
1996
14
238
USC
1999
15.6
236
Pittsburgh
2000
27
100
(PEH)
Emory
2001
2.9
1000
Toronto
1998
80
94
Pittsburgh
2002
56
200
(PEH)
Hill
Career
0
Career
Emory
2003
4.3
1579
Collis Gastroplasty
• First described by J. L . Collis 1957
– Thoracoabdominal incision
• Combined gastroplasty with hiatal hernia repair
• Collis : “Designed to help frail patients with
hiatus hernia associated with short esophagus”
• “It seems reasonable to put forward
a plan for using a gastric connecting
link between the short esophagus
above and the main body of the
stomach below the diaphragm”
• First report of 32 patients in 1961
Subsequent Modifications of Collis Gastroplasty
• Henderson 1977,Orringer and Sloan 1977
– Addition of Nissen Fundoplication instead of Belsey
(Collis-Nissen) via transthoracic approach
• Demos 1975,Langer 1973
– Uncut Gastroplasty
• Steichen 1986/Moores:
– Trans-abdominal approach, end to end anastomotic
(EEA) stapler
• Johnson et al. 1998:
– Laparoscopic Collis-Nissen (Steichen EEA technique)
• Hunter 2004: Wedge Gastroplasty
– Based on Champion’s lap VBG technique
Open Transthoracic Repair of GPEH
• 94 patients with intra-thoracic stomach (type III
GPEH) operated upon over a 20 year period
• Operative approach
– Left thoracotomy
– sac excision
– Collis lengthening procedure for shortened
esophagus
– Belsey
• Mean follow 94 months, median 72 months
Maziak/Pearson, JTCVS 1998
Open Transthoracic Repair of GPEH
• Results
– 75/94 (80%) had Collis gastroplasty for short esophagus
– Collis leak (5%)
• 2 required reoperation for leak
– 2 operative mortalities
– 2 symptomatic recurrences (2%) requiring reoperation
• Both had short esophagus and needed Collis
– 94% with good to excellent results
• This is the GOLD STANDARD
Maziak/Pearson, JTCVS 1998
Largest Open Series of PEH Repair
Series
Ellis 1986
Approach
Transabdominal + Transthoracic,
G tube (50%)
Collis (80%),
Belsey (98%)
Transthoracic,
Collis-Nissen
(96%)
# Cases
55
94
240
LOS (days)
9.5
NR
7
Mortality
1.8%
2%
1.7%
Recurrences
1.8%
2%
2.6%
* recurrences requiring re-operations
Maziak 1998
Patel 2004
Concerns from Initial Laparoscopic Experience
• Hashemi et al (J Am Coll Surg 2000)
– 42% radiographic recurrence rate at 17 months
– Worse symptom relief: laparoscopic 77% vs open 88%
• Dahlberg et al – Mayo Experience (Ann Thor Surg 2001)
– 5.4% mortality rate
– Only 55% had “excellent” functional result
– 13% anatomic recurrence rate by BaSw at mean 3
months follow up
• Mattar SG et al (Surg Endosc 2002)
– 33% hernia recurrence rate at 1 year
Essential Steps to Successful GPEH Repair
• Identification of the proper plane between the hiatal
hernia sac and mediastinal pleura
• Meticulous dissection/mobilization of the hernia sac
• Sac dissection (removal from the mediastinum,
not necessarily removal from the body)
• Sac reduction vs Sac Excision
• Mobilization of the crura, maintaining the peritoneal
lining and the integrity of the crural muscle
– Complete division of all diaphragm attachments to
stomach and spleen
– Tension-free approximation of intact crura
• Deliberate CO2 induced pneumothorax (left
side)
• if either of this condition cannot be met,
consider mesh cruroplasty
Essential Steps to Successful GPEH Repair
• Mobilization of the esophagus, maintaining vagal nerve
viability to deliver a tension free, 2-2.5 cm segment of
intra-abdominal esophagus
• If this cannot be achieved, continue mediastinal mobilization
• if this still cannot be achieved, consider an esophageal
lengthening procedure (Collis gastroplasty)
• If obstructive symptoms, no reflux, short esophagus may
consider gastropexy following as much mobilization as possible
• Perform an anti-reflux procedure
– “Floppy” or “Near” Nissen
– Aggressive gastropexy
• If these principles are followed meticulously using
an open or laparoscopic approach, good long-term
outcomes can be achieved
Assessment of GE Junction
Assessment of Esophageal Length
Cardia location
Wedge Gastroplasty
Collis-Nissen Fundoplication
Crural Closure
Laparoscopic Repair GPEH – UPMC Experience
• 662 patients had attempted non-emergent
laparoscopic repair; 652 (98.5%) completed
laparoscopically
• 63% required Collis gastroplasty (n=417)
• 13% mesh cruraplasty
• 98% fundoplication (647/662)
– Floppy Nissen 79% (512/647)
– Partial fundoplication 21% (135/647)
• LOS median 3 days
Luketich JD et al. JTCVS 2010
Laparoscopic Repair GPEH – UPMC Experience
• Overall rates of major morbidity and mortality low
– Mortality 1.7%
– Pneumonia 4%
– Post-operative leak 2.5% (3.3% among Collis group)
• 11/16 required surgical re-exploration
• Symptomatic improvement is excellent
– 89% of patients express satisfaction with surgery
– 90% report good to excellent GERD-related quality of life
– SF-36 shows preservation of physical and mental health
• 15.7% recurrence rate (16% No Collis vs. 15% Collis, p=0.65)
• 3.2% underwent reoperation in subsequent follow-up
Luketich JD et al. JTCVS 2010
Quality of Life
Nason KS et al. Ann Thorac Surg 2011
Laparoscopic Repair GPEH – UPMC Experience
• Rate of Collis gastroplasty decreased over time 86% (19972003) vs 53% (2003-2008)
– Currently, probably closer to 10-15%
• Rate of mesh cruroplasty decreased from 17% to 12% over
same time period
– Currently, probably closer to 1%
Does Gastroplasty Make a Difference?
• n = 65 undergoing repair of GPEH
• n=14 with Collis-Nissen
• Recurrence = 45.1%
(0% recurrence with Collis-Nissen)
• On multivariate analysis, hernia type(<0.05) and surgical
technique (<0.001) were found to be independent
predictors of recurrence.
Morino M et al. Surg Endosc 2006
Does Gastroplasty Make a Difference?
• Meta-analysis (1991 to 2007)
– Laparoscopic GPEH in > 25 patients with at least 6
month follow-up to address issue of recurrence.
• 13 studies were eligible with total of 965 patients
– Overall recurrence rate 10.2%
– True recurrence rate with objective evidence (BaSw)
was 25.5%
– Mandatory follow-up BaSw at 1 yr. is essential.
Gastroplasty was associated with a
reduced risk of recurrence (p<0.001)
Rathore et al, JSLS. 2007 Oct-Dec;11(4):456-60.
Does Gastroplasty Make a Difference?
•
“It is suggested that, when surgical treatment is needed for patients with hiatus
hernia, gastroplasty is the method of choice.”
- J. Leigh Collis (Thorax, 1961)
•
“Laparoscopic Collis gastroplasty is the treatment of choice for the shortened
esophagus.”
- Lee Swanstrom (Am J Surg, 1996)
•
“We believe that the frequent addition of gastroplasty in our series of patients is
responsible for the high proportion of good to excellent results and the low
incidence of anatomic recurrence of the hernia.”
- F. Griffith Pearson (JTCVS 1998)
•
“In our series, extensive esophageal mobilization was performed in the majority
of patients and no Collis procedure was added. It was obviously not enough, and
more recently gastroplasty was more liberally used”
- Bernard Dallemagne (Ann Surg, 2011)
•
“The addition of a wedge fundectomy Collis gastroplasty to a laparoscopic antireflux operation is a safe and effective strategy to manage a short esophagus
and should encourage a more liberal use of this technique by surgeons focused
on the care of patients with hiatal hernias.”
- Steven and Tom DeMeester (Ann Surg 2014)
Making the Difference
Surgical Tenets
•
•
•
•
•
•
•
Hernia sac reduction
Extensive esophageal mobilization
Mobilization of crura
Preservation of vagal nerve integrity
Subdiaphragmatic fundoplication
Closure of crural defect
Tension-free repair
Factors Contributing to Laparoscopic
Failure to Recognize Short Esophagus
• Failure to dissect fat pad and identify esophagocardia junction
• Failure to recognize a relatively tubularized gastric
cardia
• Excessive axial/downward traction on the stomach
• Caudal migration with rigid Bougie
• Cephalad migration of diaphragm with
pneumoperitoneum pressure
ALL OF THESE ERRORS CAN RESULT IN “MISPLACED
NISSEN WRAP” AND SURGICAL FAILURE
Alternative Approaches to the Short Esophagus
• Gastropexy – residual type 1 hernia, reflux
• Roux-en-Y Esophagojejunostomy – role in morbid obesity
• Esophagogastrectomy – condition of stomach not amenable
to repair
Morino M et al. Surg Endosc 2006
Conclusions
• Complex giant hiatal hernias can be managed successfully
by the laparoscopic approach in selected, experienced
centers
– Low mortality, acceptable morbidity
– Internal long term data 4% operative recurrence rate (6
years plus)
– 14-16% radiographic recurrence rate, some
asymptomatic, most small and not at risk of torsion
• Failure to recognize and treat a short esophagus contributes
to recurrences
• Selective use of Collis gastroplasty
• Good-excellent results in intermediate-term follow-up
Thank You