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Ann Thorac Surg 1995;60:921
© 1995 The Society of Thoracic Surgeons
DR NICHOLAS J. DEMOS (Jersey City, NJ): I was delighted to hear the outstanding work of Drs Pera, Duranceau, and associates.
In 1974 at the New York Society for Thoracic Surgery I presented the experimental basis of this procedure and the first cautious clinical application. Since then I have performed 145 stapled uncut gastroplasties and fundoplication with only two possible recurrences.
The procedure we are discussing now may also be performed for short esophagus. The stomach can be stapled 5 or 6 cm below the cardia and the plication done and comfortably sutured under the diaphragm. Moreover, in the aperistaltic or dyskinetic esophagus a partial plication is performed after the stapling, and the sutures are taken only on the gastric wall. No sutures are taken on the fragile esophageal wall.
In the last three years I have performed this procedure thoracoscopically with the video-assisted thoracoscopic surgical technique, to the dismay of some members here today. You need only four portals to do the operation: one for the camera, one for the lung retractor, and two working channels. You need only one assistant to hold the thoracoscopic camera, and of course you do not have to use CO2 insufflation in the chest as people do in the abdomen.
DR VICTOR F. TRASTEK (Rochester, MN): I commend Dr Pera and Dr Duranceau for an excellent presentation. In particular, the strength of this presentation was the rigorous preoperative and postoperative testing of this one particular procedure, the uncut Collis-Nissen gastroplasty. Certainly your results were superb. You had symptomatic or subjective improvement in all patients and objective improvement by testing in almost all, as there were a few who had persistent acid reflux and some with linear erosions. There was no mortality and minimal morbidity. I think this is an operation that certainly can be used for this disease process. As you know, we have used this procedure at our institution now for nearly 20 years and have had many patients with equally good results. It is an operation that is teachable, reproducible, and effective. A point of caution is that postoperative dysphagia is a problem with fundoplications of all types, and this procedure is not excluded, as was shown by Dr Pera.
I would like to make one further point when talking about antireflux procedures. That is, what is a success? Today we have many operations to treat this disease, even more so now with the addition of laparoscopic Nissen fundoplication. I think we need to better clarify how we determine what is a successful outcome. How long should follow-up be, and what criteria should we use to determine a successful antireflux operation? Along this line, I would like to ask Dr Pera to comment on what he thinks a successful operation is.
DR F. GRIFFITH PEARSON (Toronto, Ont, Canada): I just wanted to raise the issue of the potential for an uncut stapled line where you staple two mucosal surfaces together to separate with time. Indeed, the next paper is on a stapling technique that within 25 days has dissolved, to use their term, in a majority of cases.
Many years ago, at the time when Dr Demos first reported his uncut gastroplasty, one of our surgeons, Langor, used simply a line of silk sutures to create an uncut gastroplasty. We followed up 12 of those patients 5 or more years later, and there was a proportion in whom it had reopened. Now, maybe the technique you use for stapling prevents that reopening from occurring. But I recall very well some years ago when Mark Ravitch was visiting our service and I had just used a stapling device, a TA-30, to exclude a main bronchus in a bronchopleural fistula using a transsternal approach. About 10 days later it just opened up, we watched it open up, and when I told him about it he reminded me that Halsted had defined the principles of healing, if I had only read his papers, and if I thought that by keeping my mouth shut and my lips together for a year that they would seal and heal, I had some learning to do. I still think that question is raised with the uncut gastroplasty. Also, there is an occasional patient with such a degree of shortening that the uncut gastroplasty will not allow you to reduce the hernia or to reduce your repair. I think it is very rare, I would put that at a tiny percent, but it is worth noting.
DR PERA: Regarding Dr Trastek's question, this technique has been used at Hotel-Dieu de Montreal over the last 5 years. In patients with scleroderma, a short total fundoplication through the abdomen is the current operation of choice. In patients with achalasia, the Belsey partial fundoplication is the procedure we use as added antireflux protection after the myotomy.
We consider any type of antireflux operation as successful when on a long-term basis (more than 10 years) it provides control of documented reflux disease or offers protection against potential reflux. Objective documentation of success cannot be measured from symptoms or radiologic observations. A successful operation should be quantitated from endoscopic findings, biopsies, esophageal mobility studies, 24-hour pH recordings, and scintigraphic emptying studies.
In answer to Dr Pearson's question, we realize that the concept of mucosal apposition to create an uncut Collis-Nissen repair is a point open to criticism. In this initial experience on 27 patients, in only 1 patient did we observe a partial disruption of the gastroplasty. This was observed 14 months after the operation during the first endoscopic reassessment.
The disruption was traced back to a technical problem during the operation where misalignment of the lineal stapler line occurred because the pin of the stapler was not pushed through the gastric wall. We accept the fact that mucosal opposition, by not offering healing along the gastroplasty line, is a point for criticism. However our short-term follow-up observation shows that in all patients in whom the gastroplasty was constructed properly, the fundoplication seems to protect the stapler line from being disrupted. In patients in whom a short esophagus is documented with an esophagogastric junction that cannot be reduced below the diaphragm, we do not hesitate to perform a cut Collis-Niessen gastroplasty.
Related Article
Ann. Thorac. Surg. 1995 60: 915-920.
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