Ann Thorac Surg 1998;66:1739-1744
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Uncut Collis-Nissen fundoplication: learning curve and long-term results
Victor F. Trastek, MDa,
Claude Deschamps, MDa,
Mark S. Allen, MDa,
Daniel L. Miller, MDa,
Peter C. Pairolero, MDa,
Ann M. Thompson, RNa
a Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Address reprint requests to Dr Trastek, Section of General Thoracic Surgery, Mayo Clinic, 200 First St, SW Rochester, MN 55905
e-mail: (trastek.victor{at}mayo.edu)
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
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Abstract
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Background. Between September 1985 and July 1990, the first 100 consecutive patients (50 female and 50 male) undergoing primary uncut Collis-Nissen fundoplication performed by one surgeon were reviewed.
Methods. Median age was 62 years and ranged from 19 to 89 years. Indications for repair included gastroesophageal reflux in 56 patients, obstructive symptoms in 34, and a combination of both in 10. An upper gastrointestinal endoscopy was performed in 99 patients; all were abnormal. Esophagitis was documented in 53 patients, large diaphragmatic hernia in 36, stenosis in 18, "Cameron’s erosions" in 17, Barrett’s disease in 13, and other findings in 9 patients. An abnormal upper gastrointestinal series was demonstrated in 96 of 97 patients evaluated. Motility studies were performed in 95 patients, and 11 had abnormal peristalsis. All procedures were performed through a left thoracotomy.
Results. Complications occurred in 23 patients and included respiratory failure in 6, atrial fibrillation in 3, atelectasis in 3, pneumonia in 2, myocardial infarction in 2, and chylothorax, severe dysphagia, early breakdown of repair, cardiac tamponade, hematuria, spinal headache, and intraoperative perforation by dilator in 1 each. There were 2 postoperative deaths, both cardiac in origin. Median hospitalization was 8 days (range, 6 to 76 days). The first 25 patients had 10 complications (40%) and 2 deaths (8%). The remaining 75 patients had 13 complications (17%) and no deaths (mortality, p = 0.06; morbidity, p = 0.03). Follow-up was complete in all patients for a median of 100 months (range, 3 to 138 months). Eighty-six of the 98 operative survivors are currently alive. At last follow-up, excellent functional results were observed in 58 patients (59%), good in 24 (25%), fair in 8 (8%), poor in 7 (7%), and unknown in 1 (1%).
Conclusion. We conclude that the uncut Collis-Nissen fundoplication provides good to excellent long-term results in 84% of patients. Operative mortality and morbidity is acceptable but is associated with a learning curve.
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Introduction
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Gastroesophageal reflux and diaphragmatic hernia at the esophageal hiatus are common abnormalities affecting millions of people on a daily basis. Gastroesophageal reflux is due to a functional abnormality of the lower esophageal sphincter causing reflux and its related complications. A large diaphragmatic hernia or complete intrathoracic stomach can cause obstructive symptoms including nausea, vomiting, bloating, substernal pain, and less commonly, chronic anemia [1]. It may or may not be associated with gastroesophageal reflux. Over the years numerous surgical procedures have been developed to correct these problems. The uncut Collis-Nissen fundoplication is a combination of a modified Collis maneuver and the Nissen fundoplication [2–10]. To better understand the learning curve and long-term results, we reviewed the initial experience of one surgeon performing this procedure at our institution.
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Material and methods
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Between September 13, 1985 and July 30, 1990, the first 100 consecutive patients seen at the Mayo Clinic having an uncut Collis-Nissen fundoplication by the same surgeon (V.F.T.) were reviewed. These were all primary repairs performed using the same surgical technique. Indications for repair included incompetent lower esophageal sphincter with gastroesophageal reflux refractory to medical treatment or with associated complications of stenosis, ulcer, bleeding, or Barrett’s disease. It was also performed for patients with large diaphragmatic hernia or intrathoracic stomach causing obstructive symptoms, such as nausea, vomiting, bloating, substernal pain, and occasionally chronic anemia. All patients underwent preoperative evaluation with a barium swallow, esophagogastroduodenoscopy, and motility and manometric studies. Selected patients with atypical symptoms had pH studies before their operations that included either a stress reflux test where 300 mL of acid was placed in the stomach and provocative measures were performed or, more recently, a 24-hour pH test.
The records of these 100 patients were analyzed for demographic data, presenting signs and symptoms, preoperative evaluation, operative indications, intraoperative and postoperative complications, and long-term results. Follow-up was accomplished by review of patient records, telephone interview with the patient or family member, or both. After the operation, functional results were considered excellent if the patient was eating a general diet without experiencing preoperative symptoms or requiring medication, good if symptoms were minimal and neither medications on a regular basis nor dilation was needed, fair if symptoms were improved by medication on a regular basis or dilation was required, and poor if symptoms were unchanged or worse, or the patient required another operation. Operative mortality included all deaths within the first 30 days of the operation, or during the same hospital stay if longer than 30 days. Early mortality and morbidity and long-term results for the first 25 patients and the next 75 patients were compared using an exact 
2 test. The threshold for statistical significance was p = 0.05.
Technique
The procedure was performed using a double lumen endotracheal tube, and the chest was entered through a left thoracotomy over the eighth rib (Fig 1A). The inferior pulmonary ligament was divided and the lung retracted cephalad. The esophagus was freed from the mediastinum by dividing pleura parallel to the pericardium and aorta and surrounding it with a Penrose drain to include the vagal nerves. The right crus was identified and the lesser sac entered. The left crus was freed from the sac. The sac entered anteriorly and divided circumferentially, including a division of the hepatic branches of the vagal nerves. All short gastric vessels were divided. Crural sutures were placed using figure-8 #1 Prolene (Ethicon, Somerville, NJ). The gastroesophageal fat pad was removed, carefully preserving the vagal nerves, and a 50 Fr dilator passed through the mouth by the anesthesiologist. The uncut Collis maneuver was performed using a TA-30, 4.8 stapler (without inserting the pin) placed parallel to the dilator forming a 3-cm stapled gastric tube (Fig 1B). A 2-cm fundoplication was performed around the gastric tube using 2.0 silk placed from the stomach to the gastric tube to the stomach and a second layer of 3.0 silk placed from the stomach to the stomach inverting the first layer of sutures (Fig 1C). The wrap was constructed loosely so that one finger could be placed inside the wrap with the dilator in place. Three 2-0 Prolene anterior anchoring sutures were placed from the esophagus to the fundoplication to the underside of the diaphragm. These are similar to the last row of the Belsey repair. The fundoplication was then reduced below the diaphragm and the anterior and crural sutures were tied, leaving one fingertip posteriorly with the dilator in place (Fig 1D). The dilator was then removed, nasogastric and chest tubes placed, and the incision closed. Postoperative care included removal of the nasogastric tube the next morning and beginning oral intake 48 hours after the procedure. Once the patient could tolerate a regular diet and the chest tubes were removed, the patient was dismissed from the hospital.
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Fig 1. Technical aspects of the uncut Collis-Nissen fundoplication. (A) The patient is positioned in right lateral decubitus position and the chest is entered through a left thracotomy over the eighth rib. (B) The uncut Collis is performed using a TA-30, 4.8 stapler without the pin. The staple line is placed parallel to a 50 Fr dilator forming a 3-cm gastric tube. (C) A 2 cm-fundoplication is formed around the gastric tube and secured with two layers of interrupted silk. (D) The fundoplication is reduced below the diaphragm and the three anterior anchoring and crural sutures tied, leaving one fingerbreadth posteriorly with the dilator in place.
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Clinical findings
The patient group reviewed included 50 men and 50 women with a median age of 62 years (range, 19 to 89 years). Symptoms were present in all patients and included heartburn in 72 patients, regurgitation in 42, obstructive symptoms consisting of nausea, vomiting, bloating, or substernal pressure in 40, dysphagia in 31, blood loss in 28, respiratory symptoms in 12, and cough in 1. Barium swallow obtained in 97 patients was abnormal in 96. Findings included diaphragmatic hernia in 63 patients, evidence of free reflux or reflux esophagitis in 52, a large diaphragmatic hernia with intrathoracic stomach in 33, stenosis in 17, motor incoordination in 5, ulcers in 3, tiny Zenker’s diverticulum in 2, and a Schatzki’s ring, irregular distal esophageal wall, and a filling defect in 1 each.
Esophagogastroduodenoscopy was performed in 99 patients and all were abnormal. Esophagitis was documented in 53 patients, large diaphragmatic hernia in 36, stenosis in 18, "Cameron’s erosions" in 17, Barrett’s disease in 13, esophageal ulcers in 5, Schatzki’s ring in 2, and fresh bleeding and a nodular polyp in 1 each. Esophageal manometry and motility was performed in 95 patients; reduced peristalsis was noted in 10, and features suggestive of a nutcracker’s esophagus and pharyngeal dysmotility in 1 each. No patients exhibited an aperistaltic esophagus. pH Studies were conduced in 13 patients; all presented with atypical symptoms. Stress reflux tests were performed in 12; all were abnormal. One patient had a 24-hour study that was abnormal with 12% reflux time. Operative indications included treatment for gastroesophageal reflux in 56 patients, obstructive symptoms in 34, and a combination of both obstruction and gastroesophageal reflux esophagitis in 10.
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Results
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There were two postoperative deaths, both cardiac in origin. The first occurred in a 40-year-old man who underwent a repair due to failure of medical treatment for gastroesophageal reflux. The night of the operation, he became hypotensive and was believed to have cardiac tamponade. A bedside pericardiocentesis was performed with temporary improvement. On returning to the operating room he coded and died on the operating table. Findings showed a laceration of a coronary vessel. The second death occurred in a 63-year-old woman who underwent successful repair for obstructive symptoms of an intrathoracic stomach. On the 24th postoperative day, while at home, she underwent an elective catherization for evaluation of arrhythmia and potential coronary artery disease and died during the procedure.
Seventy-six patients had no postoperative complications. Of the 23 patients who did develop complications, 15 were considered major and 8 were minor (Table 1). The patient who had intraoperative perforation by the dilator had immediate repair without further sequelae. Ninety-eight patients had a routine postoperative Gastrografin swallow without evidence of leak. Three patients required reoperation. One patient developed recurrence of a diaphragmatic hernia the first postoperative day after a severe bout of coughing. She was returned to the operating room immediately and a crural breakdown was rerepaired successfully. The second patient developed a small bowel obstruction and made a complete recovery after abdominal laparotomy and lysis of adhesions. The last patient developed a right hemithorax and was reexplored for bleeding. He was unexpectedly found to have amyotrophic lateral sclerosis during the postoperative period and developed numerous complications, including pneumonia and respiratory failure requiring reintubation. He had a slow recovery and was discharged on the 76th postoperative day. Median hospitalization for all patients was 8 days (range, 6 to 76 days).
Follow-up was complete in all surviving patients and ranged from 3 to 138 months (median, 100 months). Twelve patients died during the follow-up period. Cause of death included myocardial infarction in 5 patients, malignancy (renal cell and multiple myeloma) in 2, and perforated gastric ulcer, suicide, motor vehicle accident, amyotrophic lateral sclerosis, and gastrointestinal bleeding in 1 each. Time from repair to death was a median of 35 months with a range of 3 to 114 months. At last follow-up in 98 patients excellent results were observed in 58 (59%), good in 24 (25%), fair in 8 (8%), poor in 7 (7%), and unknown in 1 (1%) (Fig 2). One patient was followed up postoperatively for 9 months with failure to thrive and ultimately died of renal cell carcinoma. It was never possible to adequately determine whether her preoperative symptoms of obstruction were relieved. Of the 8 patients with fair results, the findings included dysphagia in 4, recurrence of reflux symptoms in 3, and recurrence of hernia in 1. In the 7 patients with "poor" results, findings include recurrence of reflux symptoms in 2, recurrence of hernia in 2, dysphagia in 2, and a myotrophic lateral sclerosis in 1.
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Fig 2. Functional results of 98 patients after uncut Collis-Nissen fundoplication. Length of follow-up was a median of 100 months (range 3 to 138 months).
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During follow-up, objective findings were not acquired in all patients. Upper gastrointestinal barium swallow was performed in 24 patients, and results were normal in 16; for those with abnormal results, findings include recurrent hernia in 7 and moderate reflux in 1. Upper esophagogastroduodenoscopy was performed in 31 patients and was normal in 18; persistent Barrett’s disease was found in 3, recurrent hernia in 3, esophagitis in 3, stenosis in 2, and superficial ulcer in 2. Motility procedures were performed in 3 patients and were normal in 2; a nonspecific motor disorder was noted in 1. A 24-hour pH study was performed in 1 patient and was abnormal.
The early results (learning curve) were evaluated comparing the first 25 patients with the next 75 patients in the group. In the first 25 patients, there were 2 operative deaths (8%) with 10 complications (40%). In the next 75 patients, there were no deaths and 13 complications (17%) (Fig 3A). The p value for mortality was p = 0.06 and for morbidity was p = 0.03. Of the 3 patients having reoperation during the postoperative period, 1 occurred in the first group of 25 patients and 2 occurred in the next 75 patients. Follow-up revealed that in the first 25, there were excellent results in 15 patients (60%), good in 6 (24%), and poor in 4 (16%). In the next 75 patients, there were excellent results in 43 patients (57%), good in 18 (24%), fair in 8 (11%), poor in 5 (7%), and unknown in 1 (1%) (p = 0.086) (Fig 3B). Follow-up in the first 25 patients was a median of 125 months (range, 3 to 138 months) and in the next 75 patients the median was 96 months (range, 3 to 120 months).
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Fig 3. Learning curve of the uncut Collis-Nissen fundoplication for the initial 100 procedures by a single surgeon comparing the first 25 patients with the next 75 patients. (A) Mortality and morbidity. Mortality (p = 0.06) and morbidity (p = 0.03). (B) Long-term functional results (p = 0.86). (NS = not significant)
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Comment
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The surgical treatment of diaphragmatic hernia repair, whether it be for gastroesophageal reflux from an incompetent lower esophageal sphincter or for obstruction due to a large diaphragmatic hernia, has evolved over time. Initially, the reduction of the hernia was thought to be sufficient, as reported by Allison and Harrington [11, 12]. Because this did not adequately address the incompetent lower esophageal sphincter, it frequently did not correct the problem. Currently the three major techniques for creation of an antireflux valve include the Nissen fundoplication [13], the Belsey-Mark IV [14] repair, and the Hill repair [15]. Mr Collis first described a gastroplasty in 1957, which allowed lengthening of the stomach for those patients with a shortened esophagus [4, 5]. More recently, the addition of laparoscopic fundoplication provides another way to perform this procedure [16].
Several authors, including Bingham [2, 3] in 1974, Demos [6] in 1975, Evangelist and coworkers [10] in 1978, Paris and colleagues [7] in 1981, and Piehler and associates [8] in 1984, reported the combination of an uncut Collis maneuver with the Nissen fundoplication. This technique has evolved at our institution over time to include shortening of the uncut Collis maneuver from 5 to 3 cm and a lessening of the length of the fundoplication from 5 to 2 cm. The potential advantages of this procedure include the ability to better anchor the wrap using the uncut staple line and by formation of the fundoplication around the gastric tube rather than the esophagus. Approximately 2 cm of length is added. If the esophagus is aperistaltic a Belsey procedure would be performed.
The mortality for this series was 2%. One patient died during cardiac catheterization after leaving the hospital after a successful repair. The second patient died after a pericardiocentesis for suspected tamponade. Both of these deaths occurred in the first 25 patients; none occurred in the next 75. The mortality for this operation reported by others has been extremely low [1, 3, 8, 9].
Seventy-six patients had uneventful postoperative recoveries, whereas morbidity occurred in 23 patients. Respiratory failure requiring reintubation was the most common complication. Three patients returned to the operating room during the postoperative period for bleeding, small bowel obstruction, and repair of a crural breakdown. Ninety-eight patients had a postoperative Gastrografin swallow without evidence of leak. Others have reported similar experiences as Piehler’s study, which showed that 97 (71%) had uneventful postoperative course while 39 (29%) had complications [8]. Allen and associates’ report with 78 patients showed that 30.8% had complications, including 3.9% with leak [1]. In Pera and colleagues’ group, 5 patients (19%) had complications, none with leak [9].
Results over the long term have been good. In this series 84% were either excellent or good at a median 100 months (range, 3 to 138 months). Despite this, 8 patients were fair, 7 were poor, and 2 additional patients died from the operation. Findings in the 15 patients with fair or poor results included dysphagia in 6 patients, recurrence of reflux symptoms in 5, recurrent hernia in 3, and amyotrophic lateral sclerosis in 1. Our results were based mainly on subjective follow-up in that we had objective findings in only approximately one third of the patients. Pera and Duranceau, with mean follow-up of 22 months range of 8 to 45 months in 27 patients, showed subjective resolution of reflux symptoms in all patients [9]. Six complained of slow esophageal emptying, 3 had occasional episodes of dysphagia, and none required postoperative dilations. Ulcers and erosions healed initially in all 27 patients and postoperatively in 2. Total percent of acid exposure was reduced from 8.7% preoperatively to 1.7% postoperatively.
The learning curve shows that in the first 25 patients there were 2 deaths (8%) and 10 complications (40%) as compared with no deaths and 13 complications (17%) in the next 75 patients. The difference was significant for morbidity (p = 0.03) and nearly so for mortality (p = 0.06). In comparison, Deschamps and colleagues reported on the first 60 patients undergoing laparoscopic Nissen fundoplication at our institution. The first half of the series had longer operative time, hospitalization, and an increased requirement for laparotomy (23.6% versus 6.7%). There was no difference in mortality but two major complications; perforation and bleeding occurred in the first group. It is suspected that any surgeon performing an antireflux repair procedure will have a learning curve regardless of the technique or approach [19]. It is important to recognize this fact as we bring on new procedures. A learning curve is acceptable as long as the associated mortality and morbidity is reasonable and the long-term results warrant continuing the procedure.
Because of the several types of surgical procedures available for treating gastroesophageal reflux disease and large diaphragmatic hernias, it is important to have criteria to evaluate both the short-term and the long-term results. Only then will we be able to determine which procedures are most acceptable for treatment of these problems. Operative mortality, morbidity, hospital stay, and cost are all extremely important short-term criteria to evaluate the procedure. Long-term follow-up of at least 10 years is critical to define the success of an operation and should be measured not only subjectively but objectively when possible. Although complete objective follow-up is the gold standard, it is still important to recognize, as Belsey has stated when discussing the follow-up progress, "the recognition that the patient himself remains the most sensitive instrument for assessing the late results of antireflux surgery" [18].
The surgical treatment of gastroesophageal reflux due to incompetent lower esophageal sphincter and obstructive symptoms due to lower diaphragmatic hernia has evolved over the past several decades. Currently there are several techniques to accomplish improvement in these abnormalities, of which the uncut Collis-Nissen fundoplication is one. It is our belief that this operation has withstood the test of time with low mortality, acceptable morbidity, and satisfactory long-term results. It is reproducible and can be taught to others. There is a learning curve involved with this operation, as with all others, and we continue to use this procedure in a majority of our patients but acknowledge that there is no perfect operation for the patient. Continued analysis of short-term and long-term results are needed [17].
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References
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- Allen M.S., Trastek V.F., Deschamps C., Pairolero P.C. Intrathoracic stomach: presentation and results of operation. J Thorac Cardiovasc Surg 1993;105:253-259.[Abstract]
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- Collis J.L. Gastroplasty. Thorax 1961;16:197-206.
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Abstract
Introduction
