A Gastroplasty for Short Esophagus
and Reflux Esophagitis: Experimental and Clinical Studies NICHOLAS J. DEMOS, M.D., NORMAN SMITH, Ph.D.,* DAVID WILLIAMS, B.S. A safe, simple, effective gastroplasty for short esophagus with reflux esophagitis is described. It has been evaluated in dogs for up to three years with flexible fiberesophagoscopy, esophagrams and intraluminal pressure studies. Successful clinical experience has been encouraging.
From the Departments of Surgery of the New Jersey Medical School, Newark and Christ Hospital, Jersey City, New Jersey
TIIE 'I'TIEA'T'NIENTI' of reflux esophagitis in the presence of a short esophagus has two objectives: 1) the mechanical restoration of a one-way valve mechanism; and 2) infradiaphragmatic placement of the valve. In the presence of short esophagus the Collis gastroplasty corrects the shortening by using the lesser curvatuire of the stomach for extra length. Long term results have been excellent with the initial Collis procedure"2 or the addition of Belsey repair to the Collis technique.4'5 In the original Collis procedure, the stomach is divided 6-10 cm parallel to the lesser curvature, and a prolongation of the esophaguis is achieved. In doing so a 12-20 cm sututre line is created, which takes 45-60 minutes to accomplish. This technique inherently carries the possibility of a leak. A modification of the Collis technique has been worked ouit in the dog and successfuilly applied clinically. The new techniquie has been fouind safer, simpler and effective. Moreover it reduices the operating time by 45 minuites. Technique A simple cartridge of two rows of staples is placed with the TA-55 stapler on the funduis of the stomach parallel to the lesser cuirvatuire. The lumen of the esophagus and of the new lesser cuirvatuire segment is held open by a perorally in-
troduced esophageal dilator of French 44 to 55 size. An additional 6 cm of esophageal length is thus obtained (Fig.
Suibmitted for puiblication Juily 1, 1974. Aided by the James Nicholas Sturgical Research Fund. ° Dr. Smith is a medical sttudent whose research fellowship was ported by the New Jersey Medical School Class of 1972.
IA). This proceduire takes one minute to perform. Next, the remaining gastric funduis is wrapped either totally or subtotally around the newly created tubular prolongation of the esophagus. Frequently, this entire valvular mechanism can be suitured in its entirety below the diaphragm (Fig. 1D).
Experiment Esophagogastric incompetence was produced in a group of 8 dogs by either esophagogastrostomy or esophagogastromyectomy.3'6 In a second operation esophageal lengthening and fundoplication was performed as described above. In an additional 10 dogs the above two stages were performed simultaneouisly. The effectiveness of this new gastroplasty was tested by pre- and postoperative photographic flexible fiberesophagoscopy, esophagrams, fluoroscopy and by gastroesophageal pressure studies.
Experimental Results
Two of the Group I dogs died, one of pneumonia and one of too narrow lesser curvatuire channel. The adequacy of the new channel was subsequiently ensured by the insertion of suip- the esophageal bouigie during the stapling and fundoplication. 178
GASTROPLASTY
Vol. 181 * No. 2
179
Fi(;. 2. Lower esophageal petence.
com-
i(~~~~~~~~~~~~~~~~~~~i B t
Fi(;. 3. Adequiate Ilmen of new lower esophageal segment.
Fi(;. 1. A. Stapling parallel to the lesser curvatuire to lengthen short esophagus. B. Ftundoplication. C. Suitture of the hiatus: part of the plicated
segment remains above the diaphragm. D. Frequently, the entire plicated segment can be suittured below the diaphragm, even if the truie cardia is preoperatively at or above the level of the hiatuis.
Complete healing of the hemorrhagic and/or ulcerating esophagitis was observed in the remaining six dogs of Group I. The Grouip II dogs never showed esophagitis. All stirviving dogs maintained competence (Fig. 2) and a good size lutmen (Fig. 3) during a three- year followup. Pressuire competence of the new sphincteric mechanism was rouitinely observed (Fig. 4). Barium studies revealed a 5-6 cm competent lower esophageal segment (Fig. 5). Case Reports
was seen on fiberesophagoscopy. Bariuim swallow revealed a large sliding hiatal hernia (Fig. 6). The new gastroplasty and fuindoplication was performed through the left seventh intercostal space. Postoperative esophagram revealed sphincteric competence and an infradiaphragmatic lower esophageal segment (Fig. 7). She has remained asymptomatic for over nine months, and fiberesophagoscopy has revealed healing of the
esophageal erosions. Case 2. A 65-year-old man had several episodes of dysphagia over the past few years. X-rays demonstrated a large hiatal hernia with abouit onethird of his stomach displaced in the chest. At operation a short esophagus was also fouind. A gastroplasty and fuindoplication were performed throuigh the left seventh intercostal space. He made an uneventfuil recovery and has remained free of dysphagia over several months. Case 3. A 60-year-old woman has had severe epigastric pain and substernal buirning recuirring shortly after a hiatal hernioplasty performed 4 years previotisly elsewhere. Fiberesophagoscopy revealed free gastroesophageal reflux. Biopsies of the cardia revealed acute and chronic inflammation. Throuigh the left seventh intercostal space, a gastroplasty and fundoplicaCase 1. A 56-year-old woman had two episodes of subacuite but massive tion were performed. A short esophagus was present. The entire plicated tupper gastrointestinal bleeding. Lower esophageal hemorrhagic erosion segment was sututred at an infradiaphragmatic position, even thouigh the
NJ1
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Fi(;. 4. Manometric stuidy of uipper GI tract in preparation with myectomy and gastroplasty. See high pressuire zone at the cardia after the gastroplasty.
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DEMOS, SMITH AND WILLIAMS
180
1I(;. 5. Competent lower esophageal
segment in
Ann.
Stirg. Febriiary 1975 -
the dog.
Fi(;. 7. Case 1. Competence of the lower esophageal. intra-abdominal ment
seg-
after gastroplasty and fundoplication.
cardia cotild be puilled down only to the level of the diaphragm. She has remained free of pain for several months.
Comment
Fi(;. 6. Case 1. Large hiatal hernia.
Great advances have been recently made in the treatment of refliux esophagitis. In the absence of esophageal shortening, simple transabdominal or transthoracic repair restores an intra-abdominal esophageal segment and transfixes the cardia below the diaphragm. Long-standing esophagitis may produce not only circular intraluiminal stricture but longitudinal shortening. The presently described technique produces a prolongation of the esophaguis and fixation of the last few centimeters under the diaphragm. The gastroplasty produced by stapling is quiick, safe and effective. The addition of the fundic wrapping effects a soft, cushioned but distensible collapse of the new esophageal segment. Moreover, it maintains the desired angle between the-esophagus and the stomach and helps by its builk to transfix the last several centimeters intra-abdominally. Duiring the creation of the additional length, the gastric Ilumen is not entered, and leakage with its attendant morbidity and mortality is obviated. Long term stuidies up to three years with fiberoptic
VoI 181 * No 2
GASTROPLASTY
photography, esophagrams, and intraluminal pressure stuidies have confirmed the souindness of the experimental proceduire.
Recent clinical experiences have encouraged uis to regard the proceduire as applicable and curative. The first patient has had no dysphagia or recurrence of her esophageal hemorrhage. Postoperative fiberesophagoscopy has revealed complete healing of the lower esophageal erosions. The other two patients have remained asymptomatic for many months. We will continue to follow these cases for long term resuilts. Acknowledgment we wish to thanik Dr. Benjamin F. Rtush, Jr., Professor and Chairman of the Department of Surgery, New Jersey Medical School, for his most welcomed help arnd encouragement.
References 1. Collis, J. S.: An Operation for Hiatuis Hernia with Short Esophaguis. Thorax, 12:181, 1957. 2. Collis, J. L.: Gastroplasty, Thoraxchiruirgie, 11:57, 1963. 3. Demos, N. J., Timmes, J. J. and DiBianco, J.: Experimental Stuidy of a New Operation for the Treatment of Refltux Esophagitis. J. Thorac., Cardiovas. Sturg., 54:832, 1967. 4. Pearson, F. G.: Discuission of Paper by Orringer, M. B. et al. Long-term Resuilts of the Mark IV Operation for Hiatal Hernia and Analysis of Recuirrences and Their Treatment. J. Thorac. Cardiovas. Suirg. 63:31, 1972. 5. Urschel, H. C., Razzuik, M. A., Wood, R. E., et al.: A Imporved Surgical Techniquie for the Complicated Hiatal Hernia with Gastroesophageal Reflux. Ann. Thorac. Sturg., 15:443, 1973. 6. Vandertoll, D. J., Ellis, F. H., Jr., Schlegel, J. F. and Code, C. F.: An Experimental Sttudy of the Role of Gastric and Esophageal Mutscle in Gastroesophageal Competence. Sturg., Gynecol. Obstet, 122:579, 1966.
and Reflux Esophagitis: Experimental and Clinical Studies NICHOLAS J. DEMOS, M.D., NORMAN SMITH, Ph.D.,* DAVID WILLIAMS, B.S. A safe, simple, effective gastroplasty for short esophagus with reflux esophagitis is described. It has been evaluated in dogs for up to three years with flexible fiberesophagoscopy, esophagrams and intraluminal pressure studies. Successful clinical experience has been encouraging.
From the Departments of Surgery of the New Jersey Medical School, Newark and Christ Hospital, Jersey City, New Jersey
TIIE 'I'TIEA'T'NIENTI' of reflux esophagitis in the presence of a short esophagus has two objectives: 1) the mechanical restoration of a one-way valve mechanism; and 2) infradiaphragmatic placement of the valve. In the presence of short esophagus the Collis gastroplasty corrects the shortening by using the lesser curvatuire of the stomach for extra length. Long term results have been excellent with the initial Collis procedure"2 or the addition of Belsey repair to the Collis technique.4'5 In the original Collis procedure, the stomach is divided 6-10 cm parallel to the lesser curvature, and a prolongation of the esophaguis is achieved. In doing so a 12-20 cm sututre line is created, which takes 45-60 minutes to accomplish. This technique inherently carries the possibility of a leak. A modification of the Collis technique has been worked ouit in the dog and successfuilly applied clinically. The new techniquie has been fouind safer, simpler and effective. Moreover it reduices the operating time by 45 minuites. Technique A simple cartridge of two rows of staples is placed with the TA-55 stapler on the funduis of the stomach parallel to the lesser cuirvatuire. The lumen of the esophagus and of the new lesser cuirvatuire segment is held open by a perorally in-
troduced esophageal dilator of French 44 to 55 size. An additional 6 cm of esophageal length is thus obtained (Fig.
Suibmitted for puiblication Juily 1, 1974. Aided by the James Nicholas Sturgical Research Fund. ° Dr. Smith is a medical sttudent whose research fellowship was ported by the New Jersey Medical School Class of 1972.
IA). This proceduire takes one minute to perform. Next, the remaining gastric funduis is wrapped either totally or subtotally around the newly created tubular prolongation of the esophagus. Frequently, this entire valvular mechanism can be suitured in its entirety below the diaphragm (Fig. 1D).
Experiment Esophagogastric incompetence was produced in a group of 8 dogs by either esophagogastrostomy or esophagogastromyectomy.3'6 In a second operation esophageal lengthening and fundoplication was performed as described above. In an additional 10 dogs the above two stages were performed simultaneouisly. The effectiveness of this new gastroplasty was tested by pre- and postoperative photographic flexible fiberesophagoscopy, esophagrams, fluoroscopy and by gastroesophageal pressure studies.
Experimental Results
Two of the Group I dogs died, one of pneumonia and one of too narrow lesser curvatuire channel. The adequacy of the new channel was subsequiently ensured by the insertion of suip- the esophageal bouigie during the stapling and fundoplication. 178
GASTROPLASTY
Vol. 181 * No. 2
179
Fi(;. 2. Lower esophageal petence.
com-
i(~~~~~~~~~~~~~~~~~~~i B t
Fi(;. 3. Adequiate Ilmen of new lower esophageal segment.
Fi(;. 1. A. Stapling parallel to the lesser curvatuire to lengthen short esophagus. B. Ftundoplication. C. Suitture of the hiatus: part of the plicated
segment remains above the diaphragm. D. Frequently, the entire plicated segment can be suittured below the diaphragm, even if the truie cardia is preoperatively at or above the level of the hiatuis.
Complete healing of the hemorrhagic and/or ulcerating esophagitis was observed in the remaining six dogs of Group I. The Grouip II dogs never showed esophagitis. All stirviving dogs maintained competence (Fig. 2) and a good size lutmen (Fig. 3) during a three- year followup. Pressuire competence of the new sphincteric mechanism was rouitinely observed (Fig. 4). Barium studies revealed a 5-6 cm competent lower esophageal segment (Fig. 5). Case Reports
was seen on fiberesophagoscopy. Bariuim swallow revealed a large sliding hiatal hernia (Fig. 6). The new gastroplasty and fuindoplication was performed through the left seventh intercostal space. Postoperative esophagram revealed sphincteric competence and an infradiaphragmatic lower esophageal segment (Fig. 7). She has remained asymptomatic for over nine months, and fiberesophagoscopy has revealed healing of the
esophageal erosions. Case 2. A 65-year-old man had several episodes of dysphagia over the past few years. X-rays demonstrated a large hiatal hernia with abouit onethird of his stomach displaced in the chest. At operation a short esophagus was also fouind. A gastroplasty and fuindoplication were performed throuigh the left seventh intercostal space. He made an uneventfuil recovery and has remained free of dysphagia over several months. Case 3. A 60-year-old woman has had severe epigastric pain and substernal buirning recuirring shortly after a hiatal hernioplasty performed 4 years previotisly elsewhere. Fiberesophagoscopy revealed free gastroesophageal reflux. Biopsies of the cardia revealed acute and chronic inflammation. Throuigh the left seventh intercostal space, a gastroplasty and fundoplicaCase 1. A 56-year-old woman had two episodes of subacuite but massive tion were performed. A short esophagus was present. The entire plicated tupper gastrointestinal bleeding. Lower esophageal hemorrhagic erosion segment was sututred at an infradiaphragmatic position, even thouigh the
NJ1
N W.
Fi(;. 4. Manometric stuidy of uipper GI tract in preparation with myectomy and gastroplasty. See high pressuire zone at the cardia after the gastroplasty.
tn en
:, W
£
0
Eq H
z
- Intra-Abdominal I I
46
40
k
Intrathoracic
-,-
I
a
I
I
I
25
20
DISTANCE OF PROBE FROM INCISORS, CM
I
If
Intra-Oral -e
I
I
o
6
0
0
DEMOS, SMITH AND WILLIAMS
180
1I(;. 5. Competent lower esophageal
segment in
Ann.
Stirg. Febriiary 1975 -
the dog.
Fi(;. 7. Case 1. Competence of the lower esophageal. intra-abdominal ment
seg-
after gastroplasty and fundoplication.
cardia cotild be puilled down only to the level of the diaphragm. She has remained free of pain for several months.
Comment
Fi(;. 6. Case 1. Large hiatal hernia.
Great advances have been recently made in the treatment of refliux esophagitis. In the absence of esophageal shortening, simple transabdominal or transthoracic repair restores an intra-abdominal esophageal segment and transfixes the cardia below the diaphragm. Long-standing esophagitis may produce not only circular intraluiminal stricture but longitudinal shortening. The presently described technique produces a prolongation of the esophaguis and fixation of the last few centimeters under the diaphragm. The gastroplasty produced by stapling is quiick, safe and effective. The addition of the fundic wrapping effects a soft, cushioned but distensible collapse of the new esophageal segment. Moreover, it maintains the desired angle between the-esophagus and the stomach and helps by its builk to transfix the last several centimeters intra-abdominally. Duiring the creation of the additional length, the gastric Ilumen is not entered, and leakage with its attendant morbidity and mortality is obviated. Long term stuidies up to three years with fiberoptic
VoI 181 * No 2
GASTROPLASTY
photography, esophagrams, and intraluminal pressure stuidies have confirmed the souindness of the experimental proceduire.
Recent clinical experiences have encouraged uis to regard the proceduire as applicable and curative. The first patient has had no dysphagia or recurrence of her esophageal hemorrhage. Postoperative fiberesophagoscopy has revealed complete healing of the lower esophageal erosions. The other two patients have remained asymptomatic for many months. We will continue to follow these cases for long term resuilts. Acknowledgment we wish to thanik Dr. Benjamin F. Rtush, Jr., Professor and Chairman of the Department of Surgery, New Jersey Medical School, for his most welcomed help arnd encouragement.
References 1. Collis, J. S.: An Operation for Hiatuis Hernia with Short Esophaguis. Thorax, 12:181, 1957. 2. Collis, J. L.: Gastroplasty, Thoraxchiruirgie, 11:57, 1963. 3. Demos, N. J., Timmes, J. J. and DiBianco, J.: Experimental Stuidy of a New Operation for the Treatment of Refltux Esophagitis. J. Thorac., Cardiovas. Sturg., 54:832, 1967. 4. Pearson, F. G.: Discuission of Paper by Orringer, M. B. et al. Long-term Resuilts of the Mark IV Operation for Hiatal Hernia and Analysis of Recuirrences and Their Treatment. J. Thorac. Cardiovas. Suirg. 63:31, 1972. 5. Urschel, H. C., Razzuik, M. A., Wood, R. E., et al.: A Imporved Surgical Techniquie for the Complicated Hiatal Hernia with Gastroesophageal Reflux. Ann. Thorac. Sturg., 15:443, 1973. 6. Vandertoll, D. J., Ellis, F. H., Jr., Schlegel, J. F. and Code, C. F.: An Experimental Sttudy of the Role of Gastric and Esophageal Mutscle in Gastroesophageal Competence. Sturg., Gynecol. Obstet, 122:579, 1966.
