Results of the Minimally Invasive Collis-Nissen Technique for the Treatment of True Short Esophagus

The pre-operative evaluation included a clinical interview, a barium swallow study, an upper gastro-intestinal (GI) endoscopy, and standard manometry. The type and severity of symptoms and the grade of reflux esophagitis were determined using a questionnaire with semi-quantitative scales.

The barium swallow study was performed to define the position of the E-G junction with respect to the diaphragm with the patient in the upright position, as well as the morphology and the type of HH. The migration of the E-G junction was radiologically diagnosed in three steps using the following differential diagnoses: hiatal insufficiency, concentric HH, and acquired short esophagus. Reflux esophagitis was classified according to the Los Angeles classification. In the absence of grade A esophagitis or a more severe type of esophagitis, patients underwent 24-h pH recording or intraluminal impedance/pH monitoring. The need for surgical therapy was determined according to defined parameters and to the current guidelines for GERD therapy.

The patient is placed in the lithotomic position; the pelvis and left chest are lifted 45° to the right to facilitate access for a left thoracostomy along the posterior axillary line.

Surgery begins via five laparoscopic ports: the camera port is placed 5 to 10 cm above the umbilicus, depending on the patient's body size, to enable access to the upper portion of the mediastinum. After the opening of the phreno-esophageal membrane, the E-G junction is isolated and the sac and fat pad (with the exception of the fat near the lesser curvature to preserve the integrity of the vagus nerves) are resected. A fiber endoscope is inserted trans-orally to determine the position of the upper margins of the gastric folds, which correspond to the E-G junction. The tip of the endoscope is placed at this level, which the surgeon marks with two clips. The intra-thoracic esophagus is mobilized by 9-12 centimeters to the level at which the left vagus nerve travels along the anterior aspect of the esophagus.

The distance between the E-G junction and the apex of the hiatus is measured after completely releasing the stomach, using an L-shaped instrument, which prevents errors associated with the two-dimensional video image. The upper arm of the L (90° based on the axis of the measurer) is placed at the apex of the diaphragm, and the distance between the base of the arm and the clip is measured in centimeters; the measurement is positive if the junction is above and negative if the junction is below the diaphragm. The length of the intra-abdominal portion of the esophagus that is suitable for the performance of a tension-free fundoplication is approximately 2.5 cm. If the E-G junction, with the stomach completely released, is still fixed above or astride the hiatus, the Collis technique is adopted. If the E-G junction is positioned below the hiatus by only 1-1.5 cm, a scenario in which even the application of slight downward traction on the stomach makes it possible to obtain the 2-3 cm of esophagus necessary to perform the fundoplication, its position creates a condition in which the decision of whether to perform a Collis gastroplasty becomes subjective. In such cases, the investigators generally perform the lengthening procedure if reflux symptoms have been present for many years, if the patient is obese, or if the patient is younger than 60 years. To perform the esophagus lengthening procedure, it is necessary to divide at least two short vessels. By turning the operating table toward the right side of the patient, the surgeon may simultaneously operate through the aforementioned 5 standard laparoscopic ports, as well as a left thoracoscopic port through which the instrument used to lengthen the esophagus is inserted. A thoracostomy is performed at the posterior axillary line at the V-VI-VII intercostal spaces, depending on the patient's body shape and size. A 12-mm valvular trocar may be used to prevent loss of pneumoperitoneum and to control intra-thoracic pressures.