When should a Collis gastroplasty be performed?
A. Watson (London)
In 1961, Collis described his gastroplasty procedure to enable functional lengthening of the esophagus in cases of esophageal shortening . Although the original description did not incorporate an antireflux procedure, the Collis gastroplasty is currently performed in conjunction with an antireflux procedure, the Nissen or Belsey procedures being more commonly used in this context.
The indications for Collis gastroplasty may be considered as absolute and relative. The principal absolute indication is the presence of esophageal shortening, usually consequent on the presence of an advanced reflux stricture, or ulceration, with trans-mural inflammatory change and fibrosis. In these circumstances, it is unlikely that an adequate length of intra-abdominal esophagus will be achieved without tension and, as a consequence, the results of standard antireflux procedures in these circumstances are inferior to those in the uncomplicated case [2, 3]. Relative indications which have been advocated by some workers encompass circumstances in which there is considered to be an increased risk of recurrence following antireflux surgery [4, 5]. These include recurrence of gastroesophageal reflux following a previous antireflux procedure, the presence of a very large or fixed hiatal hernia and gross obesity.
Objective measurement of esophageal shortening is not easy, but gross degrees are demonstrable on barium contrast studies, endoscopy or manometry. Circumstances in which gross esophageal shortening is likely to occur include dense, fibrotic strictures, ulceration with dense peri-ulcer fibrosis, very large or fixed hiatal hernias with fibrotic peri-hernial adhesions and following failed antireflux procedures, particularly where there is proximal migration. In these circumstances, few would argue that a Collis gastroplasty should be performed. However, in the era of powerful acid-suppression agents and patient referral at an earlier stage of the disease, many strictures are diagnosed when they are relatively soft and before extensive trans-mural fibrosis occurs, when there may be little or no esophageal shortening. Whilst some would advocate the use of a Collis gastroplasty in all cases of reflux stricture [6, 7], others have shown that good results can be obtained with dilation and standard antireflux procedures in around 80% of such cases [8-10]. In a series of 65 patients undergoing dilation and antireflux surgery for reflux stricture reported by Bonavina et al., gastroplasty was perfomed in 10, in whom the results appeared better than in those in whom gastroplasty was not performed .