Uncut Collis-Nissen Gastroplasty:
Early Functional Results
Manuel Pera, MD, Claude Deschamps, MD, Raymond Taillefer, MD, and
Andr6 Duranceau, MD
Division of Thoracic Surger>, l)epartmcnt of Surgery, Univer~it6 de Montr~al, H6teI-Dieu de Montr6al, Montr6al, Qu6bec, Canada
Background. This study reviewed the short-term re-
sults of the uncut Collis-Nissen gastroplasty.
Methods. From 1990 through 1993, 27 consecutive pa-
tients (16 men, 11 women) u n d e r w e n t an uncut Collis-
Nissen gastroplasty. Mean age was 59 years (range, 30 to
75 years). Three patients had a previous failed antireflux
procedure. Indications for operation were gastroesopha-
geal reflux disease resistant to medical treatment in 18
patients and symptomatic hiatal hernia in 9 patients.
Fourteen patients had Barrett's esophagus and 4 had a
peptic stricture. Complete esophageal function testing
including b a r i u m swallow, endoscopy, manometry, and
24-hour p H recording was performed in 26 of 27 patients
preoperatively and postoperatively.
Results. Five patients (19q) had complications, which
included atelectasis in 2, cardiac d y s r h y t h m i a in 2, and
ifferent antireflux operations have been designed for
D patients with complications of gastroesophageal
reflux disease [1]. Standard antireflux repairs usually
succeed in controlling mucosal d a m a g e caused bv thi~
condition. However, when esophageal pathology has
resulted in peptic stricture and shortening of the esoph-
agus, a d e q u a t e control of reflux is more difficult when
using a s t a n d a r d operation 12]. The difficulty in obtaining
a sufficient length of intraabdominal e s o p h a g u s has been
p r o p o s e d as the explanation for the failed control of
reflux in this situation. The lengthening operation pro-
posed bv Collis in 1957 [3, 4] was modified bv Pearson
and associates in 1971 [5], who p r o p o s e d to add a partial
fundoplication to the gastroplasty. Henderson [6, 7l and
Orringer and Sloan [8[ s u b s e q u e n t l y p r o p o s e d the use of
a total fundoplication to better control the reflux.
Bingham [9, 10] and Demos 111, 12l and later Evangelist
[13], Paris [14], Van Kemmel [151, Piehler [16], Payne [17],
and their associates proposed to retain the benefits ot a
total f u n d o p l i c a t i o n a r o u n d a g a s t r o p l a s t y w i t h o u t
transecting the gastric x,~all. They created a mucosal
apposition of the anterior and posterior fundic walls bv
stapling them together and v, r a p p i n g this gastroplasty
with the remaining fundus. ] h e reported results with this
operation have suggested a control of reflux in 94'!,, or
Presented at ~lle l hirtv-[irst ,\nnua] Nh'utin~ ~.t lhe Societ\ ¢~t Ih~ia, i~
Surgeons, [~alm Springs, C,\, Inn "qt -lob I, lqC~B.
Address reprint request~ to Dr Durancuau, Departmenl of Surgcr% Hotel
Dieu de Montr6al,3840, St-Lrbain. M~mtr6al,Qu6bec, Canada H2D, llN.
© 1995 bv rile S~cietx ot Ih.*raci~ ~,ur~t,~m,
prolonged ileus in 1. There were no operative deaths.
Follow-up was complete in all patients and ranged from
8 to 45 months (mean, 22 months). Subjectively, symp-
toms of reflux were resolved in all patients. Six patients
complain of s l o w esophageal emptying and 3 have occa-
sional episodes of dysphagia. None required postopera-
tive dilation. Ulcers and erosions healed in all 26 patients
w h o underwent endoscopy but recurred in 2 at 21 and 36
months postoperatively. Mean lower esophageal sphinc-
ter gradient increased from 8.3 m m Hg p r e o p e r a t i v e l y to
14.6 m m Hg (p = 0.0001). Total percent of acid exposure
decreased from 8.0% preoperatively to 1.7% (p = 0.003).
Conclusions. We conclude that the uncut Collis-Nissen
procedure provides acceptable short-term control of gas-
troesophageal reflux disease.
(Ann Thorac Surg 199,5;60:915-21)
more of the o p e r a t e d population 114, 16]. These results,
however, were mostly subjective a n d lack the objectivity
of functional and endoscopic reassessment after treat-
ment.
Our aim in this work is to review the short-term results
of the uncut Collis-Nissen gastroplasty using the most
objective m e t h o d s at our disposal to d o c u m e n t the con-
trol of reflux disease.
Material a n d M e t h o d s
Between 1990 and 1993, 27 consecutive patients with
gastroesophageal reflux disease or type III hiatal hernia
had an uncut Collis-Nissen repair in our Thoracic Sur-
gery Division. They all u n d e r w e n t full esophageal assess-
ments before and after their antireflux operation.
The 16 men and 11 w o m e n r a n g e d in age from 30 to 75
years (mean age, 58.8 years), and their average height
and weight were 164 cm and 58.6 kg, respectively. Fol-
Imp-up ranged from 8 to 45 months (mean, 20 months).
Three patients had previous failed antireflux p r o c e d u r e s
13, 8 and 4 years before (3 Nissen fundoplications
through an a b d o m i n a l approach).
Indications for operation were g a s t r o e s o p h a g e a l reflux
disease with failure of medical antireflux t h e r a p y in 18
patients (Barrett's e s o p h a g u s in 11 including 3 patients
with associated peptic stricture, linear esophagitis with
and without stricture in 1 and 5 patients, respectively,
and gastroesophageal reflux without esophagitis p r o d u c -
in~ s y m p t o m s refracto D' to medical m a n a g e m e n t in I
0003-4975195159.50
SSDI 0003-4975(95)00597-E
916 PERA ET ~%L Ann Thorac Surg
U N C U T COLLIS-NISSEN (;-\'-; [RO['I kS [h 1995;60:915-21

I
il iii
Ill
I,I I
/ Mucosal lesions were classified using the MUSE system
A B
Fig 1. (A) A 3-cnl linear stapler is applied ,dmt x, the smaller curv~¢-
ture of the stonlach whih" a i1o. 50 mcrcltfy bolG,ic protects the in-
tegrity of the esophagogastri~ /uuctiolt. The pin of the staph'r is
pushed through both walls o! the ~nh'rior L~/hl ]~o~tcrior.htndus be-
fore the stapler is fired. (B) Once the ~-c m ~x,,lstpx~ptasty is ~reatcd,
the remaining fundus, a,hiUz has bee~l extcllsivclv mobilized, is
wrapped around the ,\,astroplasO/ tube whih' tit,' m,. 50 bou\,ic is still
in place. The greater t'ttrvatltrc part 0¢ the Cumtus iS tied alon X ,1 lira'
immediately anterior to the n~w q[ staples c;,vcrm,¢ t,~th staple; mid
the repair site qfi the pinhoh'.
patient) and hiatal hernias in 9 patients (8 type 1II and 1
pure p a r a e s o p h a g e a l hernia atter a previous antircflux
procedure). None of the patients had evidence of a
p r i m a r y esophageal motor disorder, collagen vascular
disease, n e u r o m u s c u l a r disease, or chronic alcoholism.
Two patients had diabetes.
Operative Technique
All patients u n d e r w e n t an uncut Coltis-Nissen gastro-
plasty through a left thoracotomv above the eighth rib.
The e s o p h a g u s is dissected from the aortic arch to the
d i a p h r a g m a t i c hiatus. The proximal sttmaach is dissected
free through the hiatus when a large hernia exists or it is
dissected through a peripheral d i a p h r a g m a t i c incision
when no hernia or a small hiatus is present. The whole
esophagogastric junction is delivered into the chest.
Meticulous dissection of the junction as for a supraselec-
Radiology
S t a n d a r d barium e s o p h a g o g r a m s were o b t a i n e d u n d e r
fluoroscopic control with four to six frames p r i n t e d p e r
second. The presence of a hiatal hernia (types I, II, a n d
liB, s p o n t a n e o u s gastroesophageal reflux, stricture, m u -
cosal changes, and stasis were recorded.
Endoscop,tt
A standard fiberoptic system (Pentax FG34JH) was u s e d
to assess the e s o p h a g u s and gastroesophageal junction.
Imetaplasia, ulcer, stricture, erosion) as p r o p o s e d by
Armstrong and colleagues [18]. Mucosal d a m a g e was
graded according to the increasing severity of metaplasia,
ulcers, stricture, and erosion, with a score of from 0 to 3
assigned for each of these aspects (Fig 2). A single patient
refused to have the postoperative endoscopic evaluation.
Barrett's e s o p h a g u s was defined as the presence of 3 cm
or more of columnar epithelium in the distal e s o p h a g u s
or any biopsy showing incomplete intestinal metaplasia
(specialized epithelium) in the distal e s o p h a g u s despite
its length.
Manomet~/
Esophageal motility studies were p e r f o r m e d using a
four-lumen perfused system (R4 A 5-5-5; MUI Scientific,
Mississauga, Ont, Canada). Each l u m e n e n d e d 5 cm
apart, and all were oriented at 90 degrees to each other.
Perfusion was p e r f o r m e d at a rate of 0.7 m L / m i n using a
low-compliance A r n d o r f e r - M U l - t y p e p n e u m o h y d r a u l i c
p u m p (PlP-3; MUI Scientific) generating 15 psi of pres-
sure. Pressures were recorded on a four-channel physi-
o g r a p h ( H e w l e t t - P a c k a r d 7754A) after a m p l i f i c a t i o n
(Hewlett-Packard 8805D).
Ten swallows of a 2-mL water bolus were recorded in
the proximal and distal half of the esophagus. The
esophageal resting pressure, the peak of contraction, and
the type of contractions (primary peristalsis or tertiary
~aves) were assessed in both the proximal a n d distal
esophagus. The lower esophageal sphincter resting pres-
Degree of Metaplasia Ulcer Stricture Erosions
severity
0 Absenl Absent Absent Absent
r =--..~

tire vagotomy is performed. The fat pad is removed. The

anterior a n d posterior vagi are left intact but away from 1

the gastric wall. A no. 50 Mahmev bougie is passed into

9 mm one told
the stomach and held in place ahmg the smaller curva-
ture. A 3-cm stapler (Linear stapler 30 Proximate; Ethi- F ......
00
con, Inc, Somerville, NJ) is then used, pushing the pin ,P
through the anterior and posterior gastric walls to ensure
: two folds earretl's ulcer • 9 mm ~>t w o f o l d s
linear stapling. Both the anterior and posterior wall of the
r e m a i n i n g fundus are brought around the created gas-
troplasty tube and fixed with four sutures in front of the
staple line to cover it. The repair is reduced u n d e r the short
Stricture +
c=rcumferential oesophagus circumferential
d i a p h r a g m and fixed in place b ; three sutures passing
through esophageal wall, apex o ( t h e fundoplication, and f G' 2. F/to .~1Ll~[ s~stem (tnetaphlsia, ulcer, stricture; erosion) as
diaphragm. The right and left crus ot the d i a p h r a g m art, proposed b q Armstrfm~, and associates [78] to classify mucosal le-
r e a p p r o x i m a t e d behind the e s o p h a g u s (Fig 1). sions ill t/fc esot,]la~u5.
Ann Thorac Surg PERA ET AL 917
1995;60:915-21 UNCUTCOLLIS-NISSENGASTROPLASTY

sure, closing pressure, and percentage of relaxation were Table 2. Radiolo%icFindings

assessed in the same fashion using a station pull-through
Preop Postop
technique in the high-pressure zone. When the intragas- Characteristic (n 27) (n - 27)
tric pressures are substracted from the intrasphincteric
pressures, this yields lower esophageal sphincter gradi- Hiatal hernia
ent pressures between esophagus and the stomach. Type 1 10 0
Type II 1 0
24-Hour pH Recording lype lll 8 O
A Sandhill ambulatoD, pH recorder (Sandhill, Littleton, Strictu re 4"~ 2
CO) was used to register reflux events during 24-hour Stasis 1 8
periods. An a n t i m o n y electrode was placed 5 cm above Gastroe~ophageal reflux 15 2
the gastroesophageal junction, which had been identified Mucosal changes
manometrically. The total n u m b e r of reflux episodes, the Erosion 8 0

n u m b e r of reflux episodes lasting more than 5 minutes, Ulcer 5 0

the n u m b e r of m i n u t e s of reflux, and the percentage of "' Fhrer ~a,,es ~ith associated Barrett's esophagus.
time of exposure to acid were computed. Recordings
were obtained in 26 patients before and in all 27 patients
after their operation.
pharyngeal dysphagia and substernal chest pain were
Statistical Analysis relieved in all patients. Odynophagia was relieved in 3 of
A two-tailed Student's t test for paired continuous values 4 patients.
and McNemar analysis for discontinuous values were
used w h e n appropriate. A p value of less than 0.05 was
considered statistically significant. Operative Morbidihj and Mortali~
Tvxo patients showed lobar atelectasis requiring bron-
Results choscopy. Atrial fibrillation was seen in 2 patients. A
severe diabetic patient had a prolonged paralytic ileus,
Clinical Presentation which required colonoscopic decompression. There were
The clinical findings are summarized in Table 1. Nine- no postoperative deaths. The m e a n hospital stay from
teen patients presented with sour-tasting regurgitation operation to discharge was 9.1 days (range, 6 to 16 days).
and 17 patients complained initially of heartburn. These
symptoms subsided postoperatively in all patients. Eight
patients complained of substernal dysphagia, whereas 5 Rmtioh)g~y
patients presented initially with oropharyngeal dyspha- The radiologic observations are described in Table 2.
gia. After the operation, 3 patients describe occasional Hiatal hernias were observed in 19 patients. Ten were
frank episodes of dysphagia, none requiring dilation. type I hernias. There was one paraesophageal hernia
One type lll hernia patient reports after her operation through the hiatus occurring after a Nissen fundoplica-
occasional fresh food regurgitations when eating rapidly. tion. Eight patients showed a type III hernia. Barrett's
A slow emptying sensation is described by 8 patients esophagus was later confirmed in 6 of 10 type I hernias
during the follow-up period. Six of these 8 patients and in one type III hernia, and had already been docu-
described this as a new symptom that is still present at 12 mented in the only iatrogenic paraesophageal hiatal
months after the operation. The presence of either slow hernia.
emptying or dysphagia was recorded as dysphagia. Oro- Four patients showed preoperative strictures, 1 requir-
ing prolonged dilation sessions. In 2 of them complete
radiologic regression of the stricture has been observed
during the follow-up.
Table 1. Clinical l)rcsentatioH Initially 1 patient with a type I hernia showed esoph-
Preop Postop ageal stasis. After the operation 8 patients showed evi-
Symptom (n 27) (n 271 dence of delayed b a r i u m emptying on the esophago-
Heartburn 17 (I gram. In 15 patients s p o n t a n e o u s gastroesophageal reflux
Regurgitation 19 I was observed during the preoperative examination. In 2
Dysphagia patients gastroesophageal reflux was seen radiologically
Frank dysphagia 8 3 after the operation. Neither of these 2 patients had
Slow emptying sensation 0 S~' objective evidence of reflux.
Odynophagia 4 I Mucusal damage such as erosions a n d ulcers were
Retrosternal chest pain 4 (!
suggested in 8 and 5 patients, respectively. Endoscopy
Anemia I 0 confirmed the erosions in 4 of 8 patients, whereas ulcers
Oropharyngeal dysphagia 5 ~1 were confirmed in 2 of 5 patients. Barrett's esophagus
was suspected in 3 patients (1 with radiologically short
'~Two palientswithout this svmphml attcr 12 mtmth~. esophagus plus a fine ulcer a n d 2 patients with short
918 PERA E'I AL Ann Thorac Surg
UNCU1 COLLIS-NISSEN GASI ROI'I ASTY 1995;60:915~21

Table 3. Endoscopy Fimiings Class{fled by MUSE System g r e a t e r t h a n 9.5 m m as m e a s u r e d b y free p a s s a g e of t h e

endoscope. The three other strictures have regressed.
Preop Postop
Grade of Findings (n 271 (n : 26 '~) In 1 p a t i e n t p a r t i a l d e h i s c e n c e of t h e p r o x i m a l g a s t r o -
p l a s t y t u b e w a s d o c u m e n t e d at t h e first e n d o s c o p i c
Metaplasia r e a s s e s s m e n t a f t e r 15 m o n t h s . H e r e m a i n s a s y m p t o m a t i c
3 I1 12 a n d w i t h o u t o b j e c t i v e e v i d e n c e of reflux.
2 1 2
1 Manomet~
0 15 12
Fable 4 details the preoperative and postoperative man-
Ulcer
o m e t r i c v a l u e s . T h e e s o p h a g e a l r e s t i n g p r e s s u r e s in t h e
3
p r o x i m a l a n d distal e s o p h a g u s d i d n o t c h a n g e a f t e r t h e
2
operation. The peak contraction pressures were similar
1
in t h e p r o x i m a l a n d d i s t a l e s o p h a g u s a n d d i d n o t c h a n g e
0 22 26
a f t e r t h e total f u n d o p l i c a t i o n u n c u t g a s t r o p l a s t y . B o t h in
Stricture
t h e p r o x i m a l a n d d i s t a l e s o p h a g u s , t h e r e is a n i n c r e a s e in
3 3 1
t e r t i a r y activity a f t e r v o l u n t a r y s w a l l o w s . T h i s w a s c o n -
2
sidered nonsignificant.
1
The absolute lower esophageal sphincter resting pres-
0 23 25
s u r e w a s i n c r e a s e d b y t h e o p e r a t i o n f r o m 20.9 to
Erosions
27.2 m m H g (p - 0.0007). T h e i n t r a g a s t r i c p r e s s u r e s
3 7~ ...
remained unchanged. The lower esophageal sphincter
2 3 2
gradient pressure between esophagus and stomach was
1
8.3 m m H g p r e o p e r a t i v e l y . T h e o p e r a t i o n i n c r e a s e d t h i s
0 16 24
g r a d i e n t v a l u e to 14.6 m m H g (p - 0.0001). T h e c l o s i n g
One patient without postuperatixc endl~s~np\ p r e s s u r e i n c r e a s e d f r o m 35.2 m m H g to 44.8 m m H g (p =
0.005). C o m p l e t e r e l a x a t i o n in t h e h i g h - p r e s s u r e z o n e
d e c r e a s e d f r o m 97.4% to 90.9% (p 0.04).

e s o p h a g u s a n d stricture). B a r r e t t ' s e s o p h a g u s w a s e n d o - 24-Hour pH Recordings

s c o p i c a l l y c o n f i r m e d in t h e 2 p a t i e n t s w i t h a s h o r t e s o p h -
Details of t h e p H r e c o r d i n g s are g i v e n in T a b l e 5. In t h e
a g u s a n d s t r i c t u r e a n d in 12 a d d i t i o n a l p a t i e n t s .
27 p a t i e n t s w h o u n d e r w e n t 2 4 - h o u r p H a s s e s s m e n t a f t e r

Endoscopy
T h e e n d o s c o p i c f i n d i n g s are o u t l i n e d in g a b l e 3. T w e l v e Tabh' 4. Manometric Data"
of t h e 27 p a t i e n t s e x h i b i t e d p r e o p e r a t i v e l y a c o l u m n a r - Preop Postop p
l i n e d m u c o s a (11 c i r c u m f e r e n t i a l a n d 1 w i t h f i n g e r - l i k e Esophagus (n - 27) (n = 27) Value
p r o j e c t i o n s ) . P o s t o p e r a t i v e e n d o s c o p i c a s s e s s m e n t re-
v e a l e d t h a t 14 of t h e 27 p a t i e n t s h a d B a r r e t t ' s m e t a p l a s i a . Proximal
These 2 additional patients were underassessed, being Resting pressure 5.4 - 2.4 6.6 + 5.4 NS
(mm Hg)
i n t e r p r e t e d as h a v i n g a t y p e Ill hiatal h e r n i a for 1 a n d
Peak pressure 54.0 + 16.9 54.0 + 20.7 NS
c i r c u m f e r e n t i a l e r o s i o n s in t h e s e c o n d . B i o p s i e s in all 14 (mm Hg}
patients showed fundic and specialized type epithelium Primary waves (%) 87.2 + 17.2 81.6 + 29.2 NS
w i t h o u t a n y e v i d e n c e of e p i t h e l i a l d y s p l a s i a . T h e p r e o p - Distal
erative columnar metaplasia zone showed a mean length Resting pressure 6.1 ~ 2.6 6.3 + 4.9 NS
of 6.16 cm. T h e first e n d o s c o p i c a s s e s s m e n t a f t e r t h e (ram Hg)
o p e r a t i o n s h o w e d a m e a n l e n g t h of 4.57 cm. All t h e s e Peak presstire 50.3 + 19.6 52.7 = 22.4 NS
p a t i e n t s are b e i n g f o l l o w e d u p in a s u r v e i l l a n c e p r o g r a m . (ram Hg)
U l c e r s a n d e r o s i o n s h e a l e d in all p a t i e n t s d u r i n g t h e Primary waves (%) 87.2 + 20.1 79.0 ~+ 32.1 NS
f o l l o w - u p p e r i o d . H o w e v e r , E2 e r o s i o n s r e a p p e a r e d in 2 I~ES
p a t i e n t s at 36 a n d 21 m o n t h s of f o l l o w - u p . Both p a t i e n t s Resting pressure 20.9 ; 6.7 27.2 +- 8.0 0.0007
have extensive Barrett's esophagus and remain asymp- (ram Hg)
t o m a t i c . O n e of t h e s e 2 p a t i e n t s s h o w s a n a b n o r m a l lntragastric pressure 13.0 ÷ 3.5 13.2 + 4.4 NS
(ram Hg)
2 4 - h o u r p H r e c o r d i n g (10% of acid e x p o s u r e ) .
Gradient (mm Hg) 8.3 - 6.5 14.6 + 6.9 0.0001
T h e r e w e r e f o u r s t r i c t u r e s . T h r e e of t h e four s t r i c t u r e s
Closing pressure 35.2 - 15.2 44.8 + 12.9 0.005
showed associated Barrett's metaplasia. One patient with
(rnm Hg)
a 5-mm-diameter stricture required repeated prenpera- Relaxation (",) 97.4 + 9.0 90.9 +- 13.8 0.04
tive g u i d e w i r e d i l a t i o n s o v e r a p e r i o d of 1 year. P o s t o p -
eratively, t h r e e m o r e d i l a t i o n s e s s i o n s w e r e r e q u i r e d . Data a r e given as mean plus or minus standard deviation.
C u r r e n t l y , t h e s t r i c t u r e h a s i m p r o v e d to a d i a m e t e r I tS lower esophageal sphincter; NS = not significant.
Ann Thorac Surg
1995;60:915-21
Table 5. Preoperative and Postoperative 24-Hour td-1
Recordin S
Preop Postop
Variable (n 26j (n 27)
Episodes (ff r e f l u x 1(16.7 • 105.4 2 2 2 . 6 ~ 37.2
Episodes of reflux 6.1 " 10.3 0.8 + 2.0
- 5 rain
Minutes of acid exposure 109.5 ~ 154.0 22.6 • 37.2 0.004
Total % of acid exposure S.(I ~ 10.~ 1.7 ~ 2.9 0.003
"~D a t a are g i v e n as m e a n plus or m i ] l u , s t a n d a r d dcxiation.
their total fundoplication gastroplasty, the n u m b e r of
reflux episodes, the n u m b e r of episodes lasting more
than 5 minutes, the minutes of acid exposure, and the
percentage of exposure time to acid were all found to be
significantly decreased.
Three patients still show acid exposure after their
operation (12%, 10%, and 6"¢,). The first patient is a s y m p -
tomatic, and his last endoscopic examination showed
complete healing of preoperative circumferential ero-
sions (E3). The remaining 2 patients have Barrett's esoph-
agus with fundic and specialized epithelium. The first of
these 2 patients remains a s y m p t o m a t i c 36 months after
the operation, and his most recent endoscopic evaluation
shows two linear erosions (E2). The second patient re-
ports occasional dysphagia with an improving stricture
(>9.5 mm). No erosions were observed at endoscopy 20
months after the operation despite the 6% acid exposure.
Comment
Since 1971 Bingham [9] has used a modification of the
Collis gastroplasty as a s t a n d a r d hiatal hernia and anti-
reflux repair. The uncut Collis-Nissen gastroplasty was
popularized in North America mostly bv Demos [11, 12]
and Evangelist and associates [13]. Piehler and Payne [16,
17], with their associates at the May(} Clinic, reported
their experience with a large group of patients. They use
this operation as the procedure of choice to treat patients
with gastroesophagea] reflux disease complications or
with large hernias. Their experience shows control ot
s y m p t o m s in 85'~i, to 95% of the patients operated on.
The technique has the c o m b i n e d advantages of length-
ening the distal e s o p h a g u s while providing an " a n c h o r "
for the fundoplication to reduce the incidence of ana-
tomic hernia recurrence or slipping nf the esophagus out
of the wrap [16]. Mucosal apposition using the uncut
technique raises the potential of dehiscence of the gas-
troplasty. Because mucosal apposition results in a non-
healing process, the sutures of the stapled line, either bv
progressively working their ~¢,ay through the gastric wall
or by becoming undone, would result in the loss of
anterior and posterior wall apposition. The d i s a p p e a r -
ance of the gastroplasty could lead theoreticallv to an
increased incidence of recurrent hernia or reflux. This in
practice has not been a significant problem. Of 80 pa-
tients operated on for an intrathoracic stomach using a
transthoracic uncut Collis-Nissen ]19], only 1 patient
P E R A ET A L 919
UNCU 1 COLLIS-NISSEN GASTROPLASTY
(1.3%) required reoperation for a recurrent hernia 86
months postoperatively. In a n o t h e r series of 101 reflux-
induced e s o p h a g e a l stenoses [17], Payne r e p o r t e d excel-
p Value lent to good functional results in 85% of a group of 55
patients treated with a transthoracic uncut Collis-Nissen.
0.(1003
Leak at the staple line is another potential area of
0.006
concern. A confined extravasation of contrast m e d i u m
occurred in 3.9% in the intrathoracic stomach group [19]
and 5% in the reflux-induced esophageal stenoses group
117[. All did heal well with conservative m e a s u r e s a n d
r e s u m e d oral diet by the time of hospital dismissal.
Bingham [10] in 1977 r e p o r t e d his personal experience
with 138 patients. Clinical and radiographic follow-up
r a n g e d from 1 to 3 years for 110 patients. Three patients
were interpreted as presenting s y m p t o m s of recurrent
reflux. Disruption of the gastroplasty was o b s e r v e d in 8
patients (7%). In 18 additional patients the complete
plication w r a p p e d a r o u n d the gastroplasty lost its radio-
logic appearance. One of our patients showed a partial
dehiscence of the proximal gastroplasty at e n d o s c o p y 14
months after the operation. He r e m a i n s a s y m p t o m a t i c
with d i s a p p e a r a n c e of esophagitis a n d objective evidence
of reflux control. This was due to a technical p r o b l e m
resulting from misalignment of the linear stapler w h e n
the pin was not p u s h e d through the stomach wall. This
complication has not been r e p o r t e d by other authors
using this technique.
Demos [121 reported on 82 patients, 80 of w h o m were
followed up for a period of 2 to 12 years. There were no
deaths. The patients r e m a i n e d a s y m p t o m a t i c a n d there
was no anatomic recurrence.
Paris and associates [14] r e p o r t e d on 48 patients who
had total fundoplication gastroplasties. Thirty-three had
uncut Collis-Nissen gastroplasties and 15 h a d a cut
Collis-Nissen operation as described by Orringer and
Sloan [8]. Without c o m p a r i n g the results of these two
techniques, they have reported excellent s y m p t o m con-
trol for the total group.
Piehler and colleagues [16] reported the Mayo Clinic
experience in the evaluation of 136 patients over a 4.5-
year period. During the follow-up 56.8% of the patients
had esophagograms, 23.1% had endoscopy, a n d 25.4%
had e s o p h a g e a l motility studies. S y m p t o m s of gastro-
esophageal reflux disease d i s s a p e a r e d in 85.5%. The
results were considered highly acceptable for 94% of the
group. Evangelist and associates [13] r e p o r t e d on 48
patients with an u n d i v i d e d gastroplasty tube with a d d e d
total fundoplication created by using a modified GIA
stapler. Their average follow-up was 27 months. All
patients are reported as having complete clinical control
of reflux symptoms.
Poor results after an antireflux operation are due either
to i n a d e q u a t e reflux control or to side effects resulting
from the technique. Dysphagia is the most frequently
r e p o r t e d side effect of both the cut and uncut forms of
Cnllis-Nissen gastroplasty. The grading of d y s p h a g i a
remains difficult to establish from the existing literature.
Demos [12] and Paris and associates [14] found "transient
mild d y s p h a g i a " to be the most frequent i m m e d i a t e
postoperative complication, although it usually s u b s i d e d
920 PERA ET AL
UNCUT COI.I.IS-NISSEN(;AS1ROI'I\STY
by the seventh or eighth week after the operation. Bing-
h am [101 and Evangelist and associates [13] did not report
the exact prevalence of dysphagia during the postopera-
tive follow-up. Piehler and colleagues [16] r e p o r t e d
dysphagia in 40°,,i, of their patients (sporadic in 29%, at
least once a week in 6.9%, and daily in 3.8°/,). This
observation led them to reduce the length of the gastro-
plasty from 5 to 3 cm.
Stirling and Orringer [201, reporting on 261 patients
who had a cut Collis-Nissen gastroplasty, reported
dysphagia in 17% of their patient population. These
patients r e q u i r e d regular (9%) or occasional (8%) dila-
tions. Persistent dysphagia was more c o m m o n in patients
with a complicated hernia or reflux problem (type Ill
hernias, stricture, p r e v i o u s operation, scleroderma).
Stirling and Orringer also reported mild dysphagia not
requiring dilation in an additional 25% of their patients.
This led them to reduce their total fundoplication from 6
to 3 cm around their gastroplasty.
After creating a total fundoplication of 3 cm around an
uncut gastroplasty we observed 11 patients retaining
some form of dysphagia. For 8 patients this was a slow
emptying sensation; this was evident in 6 patients after 12
months. One patient had a hard stricture, which im-
proved slowly after postoperative dilations. Two more
patients have intermittent episodes of dysphagia. These
observations led us to conclude that an uncut Collis-
Nissen gastroplasty creates significant resistance to emp-
tying at the distal end of the esophagus at least during
the initial vear after the operation.
As for other antireflux repairs, our manometric studies
show a significant increase in the high-pressure zone of
the esophagogastric iunction after the uncut Collis-
Nissen operation. There was no change observed in the
contraction amplitude of the esophageal bodv. Demos
[12] reported a reduction in the incidence of tertiary
esophageal contractions from 74% before the operation
to 18% after operation. We observed a slight increase in
tertiary, waves, although it was not considered significant.
This might be explained bv increased resistance to
esophageal emptying by the operation.
Endoscopy and 24-hour pH recordings showed definite
i m p r o v e m e n t s in mucosal damage, whereas a significant
decrease in acid exposure was recorded. Still, 2 patients
showed recurrent linear erosions on their esophageal
mucosa, 1 of them with an abnormal 24-hour pH study
(10%). Two patients revealed abnormal acid exposure
(12% and 6%) without s y m p t o m s and without mucosal
lesions. Barrett's esophagus remains u n d e r d i a g n o s e d in
the initial assessment of hiatal hernias and esophagitis
patients [21, 22]. This metaplasia is possibly reduced in
length by effects of the operation itself. Otherwise it is not
modified by the disappearance of reflux.
In conclusion, we think it is well established that on
short-term follow-up the uncut Collis-Nissen gastro-
plasty affords good protection against reflux disease and
allows complete healing of ulcerative and erosive lesions
in the esophagus. W h e n present, a c o l u m n a r - l i n e d
esophagus remains unchanged.
Ann Thorac Surg
1995;60:915-21
Doctor Manuel Pera was supported by the Foundation pour la
Recherche en Chirurgie de Montr6al, D6partement de Chirur-
gie, H6tel-Dieu de Montr6al, and the Fondo de Investigaciones
Sanitarias (FIS 93-5558), Spain.
References
1. Jamieson GG, Duranceau A. The development of surgery for
gastroesophageal reflux disease. In: Jamieson GG, ed. Sur-
gery, of the oesophagus. New York: Churchill Livingstone,
1988:233-45.
2. Orringer MB, Skinner DB, Belsey RHR. Long-term results of
the Mark IV operation for hiatal hernia and analyses of
recurrences and their treatment. J Thorac Cardiovasc Surg
1972;63:25-33.
3. Collis JL. An operation for hiatus hernia with short esopha-
gus. J Thorac Cardiovasc Surg 1957;34:768-73.
4. Collis JL. Gastroplasty. Thorax 1961;16:197-206.
5. Pearson FG, Langer B, Henderson RD. Gastroplasty and
Belsey hiatus repair: an operation for the management of
peptic stricture with acquired short esophagus. J Thorac
Cardiovasc Surg 1971;61:50-63.
6. Henderson RD. Reflux control following gastroplasty. Ann
Thorac Surg 1977;24:206-14.
7. Henderson RD, Marryatt G. Total fundoplication gastro-
plasty. J Thorac Cardiovasc Surg 1983;85:81-7.
8. Orringer MB, Sloan H. Combined Collis-Nissen reconstruc-
tion of the esophagogastric junction. Ann Thorac Surg 1978;
25:16-21.
9. Bingham JAW. Evolution and early results of constructing an
antireflux valve in the stomach. Proc R Soc Med 1974;67:4-8.
If). Bingham lAW. Hiatus hernia repair combined with the
construction of an anti-reflux valve in the stomach. Br J Surg
1977;64:460 -5.
11. Demos NJ, Smith N, Williams D. New gastroplasty for
strictured short esophagus. N Y State J Med 1975;75:57-9.
12. Demos NJ. Stapled, uncut gastroplasty for hiatal hernia:
12-year follow-up. Ann Thorac Surg 1984;38:393-400.
13. Evangelist FA, Taylor FH, Alford JD. The modified Collis-
Nissen operation for control of gastroesophageal reflux. Ann
Thorac Surg 1978;26:107-11.
14. Paris F, Tomais-Ridocci M, Benages A, et al. Gastroplasty
with partial or total plication for gastroesophageal reflux:
manometric and pH-rnetric postoperative studies. Ann Tho-
rac Surg 1981;33:540-8.
15. Van Kemmel M, Francke-Mauroy B. Cardioplastie antireflux
par suture m6canique: bases physio-pathologiques et r6sul-
tats. Ann Chir 1982;36:459-67.
16. Piehler JM, Payne WS, Cameron AJ, Pairolero PC. The uncut
Collis-Nissen procedure for esophageal hiatal hernia and its
complications. Probl Gen Surg 1984;1:1-14.
17. Payne WS. Surgical management of reflux-induced oesoph-
ageal stenoses: results in 101 patients. Br J Surg 1984;71:
971-3.
18. Armstrong D, Monnier PH, Nicolet M, et al. Endoscopic
assessment of oesophagitis. Gullet 1991;1:63-7.
19. Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intratho-
racic stomach. Presentation and results of operation. J Tho-
rac Cardiovasc Surg 1993;105:253-9.
20. Stirling MC, Orringer MB. Continued assessment of the
combined Collis-Nissen operation. Ann Thorac Surg 1989;
47:224 -30.
21. Kim SL, Waring JP, Spechler SJ, et al. Diagnostic inconsis-
tencies in Barrett's esophagus. Gastroenterology 1994;107:
945-9.
22. Schnell T, Sontag S, Cheifec G, Kurucar C, et al. An attempt
to define the incidence of development of Barrett's esopha-
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Ann rhorac Surg
1995;60:915-21
DISCUSSION
D R N I C H O L A S J. D E M O S (Jersey City, NJ): I was d e l i g h t e d to
hear the outstanding work nf l)rs Pera, Duranceau, and associ-
ates.
In 1974 at the New York S(~cietx for Thoracic Surgery l
p r e s e n t e d the e x p e r i m e n t a l basis ot this p r o c e d u r e a n d the first
c a u t i o u s clinical application. Since then I h a v e p e r f o r m e d 145
s t a p l e d u n c u t g a s t r o p l a s t i e s a n d t u n d u p l i c a t i o n with onh, two
p o s s i b l e recurrences.
T h e p r o c e d u r e we are d i s c u s s i n g now m a y also be p e r f o r m e d
for short e s o p h a g u s . The s t o m a c h can be s t a p l e d 5 or 6 cm below
the cardia a n d the plication d o n e a n d c o m f o r t a b l y s u t u r e d
u n d e r the d i a p h r a g m . Moreover, in the aperistaltic or dvskinetic
e s o p h a g u s a partial plication is p e r t o r m e d after the stapling, a n d
the s u t u r e s are taken only on the gastric wall. No s u t u r e s are
taken on the fragile e s o p h a g e a l wall.
In the last t h r e e y e a r s I have p e r f o r m e d this p r o c e d u r e
thoracoscopically with the \ i d e o - a s s i s t e d thoracoscopic surgical
t e c h n i q u e , to the d i s m a y of s o m e m e m b e r s here todav. You n e e d
only four portals to do the operation: o n e for the camera, o n e for
the l u n g retractor, a n d two w o r k i n g c h a n n e l s . You n e e d only one
a s s i s t a n t to hold the thoracuscopic camera, a n d of c o u r s e you dl)
not h a v e to u s e C O , insuffiati~m in the chest as people do in the
abdomen.
DR V I C T O R F. T R A S T E K (Rt}cllester, MN): 1 c o m n l e n d Dr Pera
a n d Dr D u r a n c e a u for an excellent p r e s e n t a t i o n . In particular,
t h e s t r e n g t h of this p r e s e n t a t i o n was the rigorous preoperative
a n d p o s t o p e r a t i v e testing of this o n e particular procedure, the
u o c u t C o l l i s - N i s s e n gastroplast,.,. Certainly your restllts were
s u p e r b . You h a d s v m p t o m a t i c or subjective i m p r t w e m e n t in all
patients a n d objective i m p r o v e m e n t by testing in a l m o s t all, as
t h e r e were a few w h o h a d p e r s i s t e n t acid reflux a n d s o m e with
linear erosions. T h e r e w a s no mortality a n d m i n i m a l murbiditv.
I t h i n k this is an operation that c e r t a i n h can be u s e d for this
d i s e a s e process. As you knox¢, we have u s e d this p r o c e d u r e at
o u r institution n o w for nearl~ 20 y e a r s a n d h a v e h a d m a n y
patients with e q u a l l y good results. It is an operation that is
teachable, reproducible, a n d effective. A point of caution is that
p o s t o p e r a t i v e d y s p h a g i a is a p r o b l e m with f u n d o p l i c a t i n n s of all
types, a n d this p r o c e d u r e i~ nut excluded, as was s h o w n b \ Dr
Pera.
I would like to nlake o n e t u r t h e r point w h e n talking a b o u t
antireflux p r o c e d u r e s . That is, w h a t is a success? T o d a y we have
m a n y o p e r a t i o n s to treat this disease, even m o r e so no~% with tilt'
addition of laparoscopic N i s s e n tundoplication. I t h i n k we need
to better clarify h o ~ we d e t e r n f i n e ~ h a t is a successful outconlc.
H o ~ long s h o u l d fullo~x-up be, a n d what criteria shotlld we u s e
to d e t e r m i n e a successful antireflux nperation? A l o n g this line, I
w o u l d like to ask Dr Pera t~. c n m n l e n t on w h a t he think~ a
successful operation is.
DR F. GRIFFITH P E A R S O N I l o n l n t o , Ont, Canada): I just
w a n t e d to raise the issue ot the potential for an u n c u t stapled
line w h e r e you staple two nTucosa] surfaces t o g e t h e r to s e p a r a t e
with time. indeed, the next p a p e r is on a stapling t e c h n i q u e that
PERA ET AL 921
UNCUT COLLIS-NISSEN GASTROPLASTY
within 25 d a y s h a s dissolved, to u s e their term, in a majority of
cases.
M a n y 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
tip 12 of those patients 5 or more years later, and there was a
p r o p o r t i o n in w h o m it had reopened. Now, maybe the technique
you use for stapling prevents that reopening from occurring. But
I recall very well some years ago w h e n M a r k Ravitch was visiting
our service and I had just used a stapling device, a TA-30, to
exclude a main bronchus in a broncbopleural fistula using a
transsternal approach. A b o u t 10 days later it just opened up, we
w a t c h e d it o p e n up, a n d w h e n I told h i m a b o u t it h e r e m i n d e d
m e that H a l s t e d h a d d e f i n e d t h e principles of healing, if I h a d
only read his p a p e r s , a n d if I t h o u g h t that by k e e p i n g m y m o u t h
s h u t a n d m y lips t o g e t h e r for a year that t h e y w o u l d seal a n d
heal, I h a d s o m e l e a r n i n g to do. I still t h i n k that q u e s t i o n is
raised with t h e u n c u t gastroplasty. Also, t h e r e is an occasional
p a t i e n t with s u c h a d e g r e e of s h o r t e n i n g that t h e u n c u t g a s t r o -
plasty will not allow y o u to r e d u c e t h e h e r n i a or to r e d u c e y o u r
repair. 1 t h i n k it is ve D, rare, 1 w o u l d p u t that at a tiny percent,
b u t it is worth noting.
DR PERA: R e g a r d i n g Dr T r a s t e k ' s q u e s t i o n , this t e c h n i q u e h a s
b e e n u s e d at H o t e l - D i e u de M o n t r e a l over t h e last 5 years. In
patients with s c l e r o d e r m a , a short total f u n d o p l i c a t i o n t h r o u g h
the a b d o m e n is the c u r r e n t operation of choice. In p a t i e n t s with
achalasia, the Belsey partial f u n d o p l i c a t i o n is the p r o c e d u r e we
u s e as a d d e d antireflux protection after t h e m y o t o m y .
We c o n s i d e r a n y type of antireflux o p e r a t i o n as s u c c e s s f u l
w h e n on a l o n g - t e r m basis ( m o r e t h a n 10 years) it p r o v i d e s
control of d o c u m e n t e d reflux d i s e a s e or offers protection a g a i n s t
potential reflux. Objective d o c u m e n t a t i o n of s u c c e s s c a n n o t be
m e a s u r e d from s y m p t o m s or radiologic o b s e r v a t i o n s . A s u c c e s s -
ful operation s h o u l d be q u a n t i t a t e d from e n d o s c o p i c findings,
biopsies, e s o p h a g e a l mobility studies, 2 4 - h o u r p H r e c o r d i n g s ,
a n d scintigraphic e m p t y i n g studies.
hi a n s w e r to Dr P e a r s o n ' s q u e s t i o n , we realize that t h e
c o n c e p t of m u c o s a l a p p o s i t i o n to create an u n c u t C o l l i s - N i s s e n
repair is a point o p e n to criticism. In this initial e x p e r i e n c e on 27
patients, in only 1 patient did we o b s e r v e a partial d i s r u p t i o n of
the gastroplasty. This w a s o b s e r v e d 14 m o n t h s after t h e o p e r a -
tion d u r i n g the first e n d o s c o p i c r e a s s e s s m e n t .
T h e d i s r u p t i o n w a s traced back to a technical p r o b l e m d u r i n g
the operation w h e r e m i s a l i g n m e n t of t h e lineal stapler line
occurred b e c a u s e the pin of the stapler w a s n o t p u s h e d t h r o u g h
the gastric wall. W e accept t h e fact that m u c o s a l opposition, by
n o t offering h e a l i n g a l o n g the g a s t r o p l a s t y line, is a p o i n t for
criticism. H o w e v e r o u r s h o r t - t e r m follow-up o b s e r v a t i o n s h o w s
that in all patients in w h o m the g a s t r o p l a s t y w a s c o n s t r u c t e d
properly, t h e f u n d o p l i c a t i o n s e e m s to protect t h e stapler line
from b e i n g d i s r u p t e d . In patients in w h o m a s h o r t e s o p h a g u s is
d o c u m e n t e d with an e s o p h a g o g a s t r i c junction that c a n n o t be
r e d u c e d below t h e d i a p h r a g m , we do n o t hesitate to p e r f o r m a
cut Collis-Niessen gastroplasty.