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A Hill Gastropexy Combined With Nissen Fundoplication Appears to Mitigate the Shortcomings of Collis-Nissen in the Management of Short Esophagus
Oliver C. Bellevue*, Brian E. Louie, Zeljka Jutric, Alexander S. Farivar, Ralph W. Aye
Swedish Cancer Institute, Seattle, WA
Background: A Collis gastroplasty combined with a Nissen fundoplication is commonly used when a shortened esophagus is encountered during surgery for large hiatal hernia, peptic stricture, Barrett’s esophagus and/or severe erosive esophagitis. Lengthening reduces axial tension and restores intraabdominal length but places the acid secreting mucosa of the tubularized stomach against the already diseased esophagus. An alternative is to combine intra-abdominal fixation of the GE junction via a Hill gastropexy with Nissen to reduce tension, maintain length and avoid juxtaposing acid secretion against the disease esophagus. We hypothesized that a Hill-Nissen (HN) repair may be more effective in patients with short esophagus than a traditional Collis-Nissen (CN).
Methods: A retrospective case-controlled analysis of consecutive patients with short esophagus defined as less than 2 cm of intra-abdominal length undergoing HN or CN from 2007 to 2015 identified from a prospectively maintained database followed by chart review. Primary outcomes were pre- and post-operative PPI use, acid exposure, quality of life scores (GERD-HRQL, QOLRAD, Dysphagia Severity) and evidence of anatomic recurrence.
Results: A total of 54 underwent HN and 59 CN. There were no differences in age (64.8 v 64.8 years, p=0.99), gender (46% v 49% male, p=0.71), BMI (29.5 v 29.2, p=0.71), ASA class (2.2 v 2.3, p=0.63), presence of paraesophageal hernia (69% v 78%, p=0.15), duration of symptoms (11.9 v 15.9 years, p=0.21), previous dilations (8% v 10%, p=0.72), or Barrett’s esophagus (37% v 29%, p=0.42).
Pre-operatively, the groups had similar rates of medication use, grades of esophagitis, DeMeester scores and quality of life scores. (Table 1)
At a median follow up of 30.3 months, both groups demonstrated significant improvement over preoperative baseline (p values not shown). However, DeMeester scores were higher in the CN group (20.1 v 10.1, p=0.19), GERD-HRQL scores were worse in the CN group (10.4 v 3.7, p=0.003) and swallowing function was worse in the CN group (38.8 v 43.3, p=0.03). QOLRAD scores and PPI use were similar between the groups as were anatomic recurrences (8 v 6, p=0.78). (Table 1)
Conclusions: Management of the shortened esophagus with HN and CN results in significant improvement. Anatomic recurrences are similar; however, HN appears to address the shortcomings of the Collis with improved swallowing and reflux control by avoiding the need for a neoesophagus created from acid-secreting tubularized stomach.
Table 1.
| | Nissen-Collis | Nissen-Hill | P-value | | Pre-operative medication use | 80% | 93% | 0.06 | | Post-operative medication use | 42% | 31% | 0.36 | | | | | | | Pre-operative LA Grade | | | | | None | 61% | 53% | 0.44 | | A | 13% | 10% | 0.77 | | B | 13% | 18% | 0.43 | | C | 7% | 10% | 0.73 | | D | 7% | 8% | 1.00 | | Post-operative LA Grade | | | | | None | 82% | 77% | 0.52 | | A | 11% | 6% | 0.66 | | B | 4% | 10% | 0.61 | | C | 4% | 6% | 1.00 | | D | 0% | 0% | 1.00 | | | | | | | Pre-operative DM Score | 63.1 | 62.6 | 0.97 | | Post-operative DM Score | 20.1 | 10.1 | 0.19 | | | | | | | Pre-operative GERD-HQRL | 18.5 | 20.4 | 0.42 | | Post-operative GERD-HQRL | 10.4 | 3.7 | 0.003 | | | | | | | Pre-operative QOLRAD | 4.4 | 4.6 | 0.54 | | Post-operative QOLRAD | 6.6 | 6.5 | 0.85 | | | | | | | Pre-operative Dysphagia Score | 35.6 | 34.4 | 0.64 | | Post-operative Dysphagia Score | 38.8 | 43.3 | 0.03 |
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