Is Collis gastroplasty likely to prevent failure of partial fundoplications?
L.S. Leonardi, N.A. Andreollo, L.R. Lopes,
N.A. Brandalise (Sao Paulo)
The Collis gastroplasty was described by Collis in 1957  with the objective of lengthening the distal esophagus by providing a healthy tube of the stomac, at the caliber of the esophagus, allowing this segment to stay in the abdomen, thus preventing gastroesophageal reflux (GER). Pearson et al.  in 1971 modified the original operation and proposed the addition of a partial fundoplication to the gastroplasty, to avoid tension on the repair.
The major benefits of the Collis gastroplasty are reduction of hernia recurrence to less than 1% and high reduction of the need to perform esophagectomy or bowel interposition in patients with a short esophagus, with or without esophageal stricture.
However, partial fundoplication presented high incidence of continued reflux, and subsequently Henderson [3, 4] and Orringer and Sloan  proposed the use of total fundoplication to better control the reflux.
The combined Collis-Nissen operation minimized the occurrence of reflux recurrence, particularly in patients with increased risk due to severe esophagitis, reflux stricture, esophageal shortening, periesophageal inflammatory reaction, chronic obstructive pulmonary disease and marked obesity. The disadvantages of the total fundoplication gastroplasty are the overcompetence of the lower esophageal sphincter (LES) pressure, producing "gas bloat syndrome" and dysphagia in the postoperative period.
The original Collis gastroplasty was again modified by Bingham , Demos , Evangelist , Paris , Pera  and others, proposing the uncut Collis-Nissen gastroplasty, creating a mucosal apposition of the anterior and posterior fundic walls by using the stapler and wrapping this gastroplasty with the remaining gastric fundus.
The uncut or cut Collis-Nissen gastroplasty are the favourite procedures in the United States of America and Canada to treat reflux esophagitis or recurrence of reflux esophagitis.
The operation is performed mainly by left thoracotomy. The esophagus is dissected from the aorta near the diaphragmatic hiatus. Then, the proximal stomach is dissected through the hiatus and the whole esophagogastric junction is delivered into the chest. Both vagus nerves are preserved. After the cut or uncut gastroplasty is performed, the remaining gastric fundus is brought around the gastroplasty tube (3-5 cm extension). The repair is then reduced under the diaphragm, sewed in place, and the right and left crus of the diaphragm are reapproximated.
The problem concerning the Collis gastroplasty is that a great number of surgeons treat reflux esophagitis by abdominal approach, the Collis gastroplasty being more difficult to be performed through the abdomen.
The incidence of postoperative dysphagia reported by the authors varies from 3% to 17%, and is about 5-7% for other complications, with small number of deaths (1-2%).
Table I shows the main results of Collis gastroplasty.
Collis gastroplasty is also indicated in patients with failure of previous repair and recurrence of reflux esophagitis, with good results: Orringer : 35 cases ; Paris : 7 cases and Stirling : 75 cases.
Our opinion is that the Collis gastroplasty is indicated in exceptional cases, mainly in short esophagus. Lopes , developed an experimental model in dogs, performing the Collis gastroplasty associated to partial (Lind) or total (Nissen) fundoplication (Figure 1). The results showed that both techniques protect the esophagus against reflux of gastric contents and, in both groups, there were no differences in the pressures measured at the level of the gastroplasty.
Figure 1. Collis gastroplasty.
To conclude, we think that the surgical treatment of GER remains a challenge. The variety of techniques described in the literature suggests that the best technique has yet to be established. This overview showed that the Collis gastroplasty is a technical option that must be kept in mind when treating patients with GER.
2. 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.
9. Paris F, Tomas-Ridocci M, Benages A, Zarza AG, Molina R, Padilha J, Mora F, Borro JM, Moreno E.- Gastroplasty with partial or total plication for gastroesophageal reflux: manometric and pH-metric postoperative studies. Ann Thorac Surg 1981;33:540-548.
15. Lopes LR. The Collis gastroplasty associated to partial (Lind) or total (Nissen) fundoplication. Experimental study in dogs. Thesis, Faculty of Medicine, State University of Campinas, Sao Paulo, Brazil, 1991.