Patient Expectations After Collis Gastroplasty

Abstract

This case series study examines short-term and long-terms outcomes in patients who have undergone Collis gastroplasty with fundoplication and hiatal hernia repair.

When repairing large hiatal hernias (HH) and encountering a short esophagus (SE), surgeons are presented with the option of performing a higher mediastinal dissection or creating a Collis gastroplasty (CG). Collis gastroplasty is a procedure that creates a neoesophagus below the gastroesophageal junction by removing a portion of the gastric fundus. In addition to the technical challenge of creating a CG, surgeons have concerns about potential staple line leaks, as well as the long-term effects of an aperistaltic neoesophagus with acid-secreting gastric tissue above the fundoplication.^1,2 This study was undertaken to review the short- and long-term outcomes in patients who have undergone a CG with fundoplication and HH repair.

Methods

With institutional board approval from Cedars Sinai Medical Center, Los Angeles, California, all patients undergoing a laparoscopic HH repair and CG (technique described in the eMethods in the Supplement) from 2002 to 2018 by 4 surgeons at a single institution were studied. Patients provided oral consent for the telephone interview and further informed consent was waived because the study was a retrospective medical record study. Demographic data, diagnostic studies, and outcomes were collected. Postoperative complications were separated into early (<30 days) and late (≥30 days). Telephone surveys were conducted, including gastroesophageal reflux disease health-related quality of life (HRQL) questionnaires. Preoperative and postoperative symptoms were compared using univariate analyses (SPSS, version 26 [IBM]; statistical significance set at 95%).

Results

A total of 183 patients were identified. The mean age was 72 years (range, 28-98 years) and 106 (58%) were women. Of these, 161 (88%) underwent a primary operation and 22 (12%) underwent a revisional operation. Preoperative esophagogastroduodenoscopy reports in 126 (69%) showed that the mean hiatal hernia size was 5.7 cm (range, 2-11 cm), 34 (27%) had esophagitis, and 22 (17%) had Barrett esophagus confirmed with histology results. Esophageal manometry data were present in 153 (84%): the mean esophageal length was 20.5 cm (range, 16.5-29.0 cm), 23 (15%) were categorized as having SE, and 36 (20%) had ineffective esophageal motility. Preoperative esophagram reports were found in 130 (71%): HH was reported as small in 18 (14%), medium in 18 (14%), large in 80 (62%), and not mentioned in 14 (11%); SE was noted in 20 patients (15%). Esophagram and manometry results collectively identified 41 patients with SE (25%).

All patients had fundoplications: 128 (70%) were complete and 55 (30%) partial. The median operative time was 208 minutes (range, 186-246 minutes). The median length of stay was 4 days (range, 3-40 days). There were no perioperative leaks or mortalities (Table 1). Ninety-seven phone surveys (54%) were completed. Median follow-up was 4.8 years (range, 0.6-12.6 years). Heartburn, regurgitation, and dysphagia were significantly reduced. Thirty-three patients reported continued antacid medication use and 16 of 33 (48%) reported reduced medication use. Mean HRQL scores improved from 18.1 to 2.9 (P < .001) (Table 2). Eighty-four patients (86.6%) reported a satisfaction score of 8 or more of 10 after 1 year. There were no long-term differences in postoperative gastroesophageal reflux disease HRQL scores in patients with and without ineffective esophageal motility (2.4 vs 2.7; P = .12).

Table 1. Summary of Postoperative Complications.

Postoperative complications	No. (%)
<30 d
Atrial fibrillation	10 (5.5)
Urinary retention	6 (3.3)
Pneumonia	3 (1.6)
Myocardial infarction	1 (0.5)
Pulmonary embolus	1 (0.5)
Deep vein thrombosis	1 (0.5)
Bleeding	1 (0.5)a
Recurrent hiatal hernia	1 (0.5)a
Slipped wrap	1 (0.5)a
≥30 da
Slipped wrap	1 (0.5
Persistent dysphagia	2 (1.1)
Recurrent hiatal hernia	1 (0.5)
Reoperation	7 (3.8)

^aIndicates reoperation needed.

Table 2. Comparison of Preoperative and Long-term Postoperative Symptoms.

Characteristic	No. (%)		P value
	Preoperative	Postoperative
Antacid medication use	183 (100)	33 (34.0)a	<.001
Heartburn	131 (71.6)	17 (17.5)	<.001
Dysphagia	81 (44.2)	15 (15.5)	<.001
Regurgitation	98 (53.6)	6 (6.2)	<.001
Chronic cough	58 (31.7)	7 (7.2)	<.001
Chest pain	74 (40.4)	10 (10.3)	<.001
Nausea	61 (33.3)	15 (15.5)	.002
Gas bloat	NA	19 (19.6)	NA
GERD HRQL score, mean	18.1	2.89	<.001

Abbreviations: GERD HRQL, gastroesophageal reflux disease health-related quality of life; NA, not applicable.

^aSixteen patients (48.5%) reported de-escalation in medication from prescription to an over-the-counter antacid medication.

Discussion

Patients requiring a CG can expect significant long-lasting reductions in heartburn, regurgitation, dysphagia, antacid medications, and HH recurrence. Prior reports of CG resulting in poor symptomatic outcomes, believed to be because of aperistaltic gastric tissue above the fundoplication, may have limited its use.^3,4

As this is a single-center, retrospective study, our findings should be interpreted cautiously. For instance, our protocol is to perform esophagogastroduodenoscopy and esophagrams in all patients preoperatively to identify mucosal abnormalities and define anatomy respectively. Nonetheless, reports could not be found for 30% of patients. Also, hernia recurrence and slipped wrap incidence may be underreported, as it has not been our group’s practice to obtain routine imaging for asymptomatic patients. Additionally, patients lost to long-term follow-up may have undergone reoperation at outside facilities, preventing data capture from our network’s record. Our findings parallel more recent studies suggesting comparable efficacy profiles with patients undergoing antireflux surgery with and without a CG.^5,6 It is important to emphasize that diagnostic studies cannot reliably diagnose SE preoperatively. This should compel surgeons who operate on HH to learn how to perform CG to achieve similar outcomes.

Supplement.

eMethods. Collis Gastroplasty Surgical Technique