Introduction: Short-esophagus in GERD can be due to advanced disease and/or a reason for failure after antireflux procedures without esophageal lengthening. Decision to perform esophageal lengthening depends on data of preoperative diagnostic work-up and intraoperative anatomical findings such as inability to mobilize the LES less than 2 cm below the hiatal arch. Experience with a comuter assisted flexible stapling system has allowed in the past years for a method of laparoscopic Collis -Nissen procedure without increasing access trauma via the chest nor resection steps at the stomach. The purpose of this study is the assessment of initial clinical experience with this new technique.
Methods: Patients with advanced GERD and short esophagus were selected for a possible Collis procedure by findings of preoperative endoscopy and/or radiography (Cardia > 6 cm above the hiatal level, roentgenographic size of hiatal hernia > 6 cm). Final selection was performed after proper intraoperative moblilisation of the esophagus in the lower and middle mediastium and its impossibility to gain a tension-free position of the LES of at least 2 cm below the hiatal arch. All patients underwent esopahgeal manometry, 24-h-pH-monitoring and endoscopic assessment. During laparoscopic antireflux procedure a flexible shaft stapling system was introduced into the abdomen via a trocard incision in the lower abdomen and advanced either along the right or left subphrenic area in retroflex position. This allowed for a Collis stapling line from the angle of His down the lengthening line in the stomach. Intar- and postoperative course was documented as well as quality of life following surgery.
Results: 12 patients (6 primary cases with GERD and short esophagus; 6 redo-cases, 4 being multiple redos) were operated upon with the flexible stapler(median operating-time: 190 min). Patients characteristics: Among the redos 2 lacerations of the gastric wall after adhesiolysis were first resected with the stapler. Postop problems: 1 abscess; postop results (pre-/post-op data): quality of life: GIQLI: (89/112) (primary//redo: 84/108//95/117); acid exposure DeMeesterscore: (88/18); reflux-recurrency 2 (12), both in redo-cases; reoperation 1 (12). The results were better in primary cases compared to redo-cases, which can be expected.
Conclusion: Collis plasty remaines a possible option for GERD-patients with short esophagus. Even though acid exposure control is not complete, it can improve quality of life. Laparoscopic application of the flexible shaft stapling system allows for true minimal access approach.