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Objectives: The short esophagus is a challenging problem resulting from long standing reflux, stricture, and/or hiatal hernia. Standard treatment lengthens the esophagus with a Collis gastroplasty added to an antireflux repair. This however places acid secreting mucosa in an aperistaltic segment of tubularized stomach at or above the antireflux repair and also has potential for staple line dehiscence. An alternative is to use a Hill gastropexy to lengthen the esophagus and combine it with a Nissen fundoplication, thus maintaining the intraabdominal position, preventing acid reflux, preserving motility and avoiding a staple line. We compared these two repairs to determine if a combined Nissen Hill (NH) was equivalent to a Collis Nissen (CN).
Methods: We performed a retrospective review of consecutive patients with short esophagus undergoing either primary laparoscopic CN or NH repairs between 2007 and 2012 from a prospectively collected database. Short esophagus was defined as less than 2 cm of intraabdominal length after mobilization above the inferior pulmonary veins and prior to crural closure. CN was performed via wedge fundectomy to lengthen the esophagus whereas NH used 2 Hill gastropexy sutures to provide intraabdominal length. A standard Nissen fundoplication was added to both. All patients underwent physiologic testing before and 6 months post op with quality of life (QOL) assessment at each visit.
Results: A short esophagus was identified in 38 patients. Three were excluded: transthoracic CN (1) and revision Nissen to NH (2). Thus, 14 underwent CN and 21 NH. The groups had similar demographics, GERD history, size of hiatal hernia and prior stricture. There was no mortality or major morbidity. No staple leaks occurred with CN. At mean follow up of 6 months, % time pH < 4 was 4.6 for CN vs. 1.5 for NH; Mean DeMeester scores were 20.4 vs. 6.8 respectively. There were two abnormal DMS in the CN group and one in the NH group. One CN patient reported persistent symptoms and was placed back on PPI therapy while none required PPI therapy in the NH group. Endoscopic esophagitis was seen only in the CN group (3/14). One radiographic hernia recurrence was seen in each group; both were small and asymptomatic with normal DeMeester scores and did not require PPIs. Dysphagia scores improved from pre- to postop in the NH group (31 to 42) but not in the CN group (38 to 36). QOL improved from pre op and was similar post op across the groups: QOLRAD (6 vs. 7), GERD-HRQL (10.3 vs. 5.8) in the CN and NH.
Conclusions: The CN and NH repairs achieved excellent early results in the surgical management of short esophagus. Radiographic recurrences were similar, but the CN had more frequent abnormal distal esophageal acid exposure, more endoscopic evidence of esophagitis and some persistent dysphagia. The NH is an acceptable alternative to CN.