The Modified Collis-Nissen Operation for Control of Gastroesophageal Reflux Felix A. Evangelist, M.D., Frederick H. Taylor, M.D., and J . David Alford, M.D. ABSTRACT An operation employing the Nissen fundoplication performed about an undivided 5 cm gastroplasty tube created with a gastrointestinal anastomosing (GIA) stapler that was modified by elimination of the cutting blade has been devised and evaluated in 48 patients over a period ranging from 3 to 52 months (average, 27 months). Seventeen of these patients had severe esophageal strictures. Reflux control, evaluated by clinical appraisal and roentgenograms in all patients and by 24-hour esophageal pH monitoring in some, has been complete in all patients throughout the study. One patient with undetected subclinical achalasia continues to have mild dysphagia and represents the only unsatisfactory result in the series. Normal swallowing has been restored to all patients with strictures, and the others remain free of symptoms. The simplicity, reproducibility, and effectiveness of this operation warrant its continuing evaluation.
Complete and permanent control of gastroesophageal reflux is the ultimate and mandatory goal of any treatment proposed for the altered pathophysiology associated with hiatal hernia and incompetence of the lower esophageal sphincter. It is apparent that the widely accepted procedures, the Belsey [24], Nissen [l, 151, and Hill 1131 operations, can and do achieve this in a majority of patients provided they are performed under favorable anatomical conditions and with precise attention to the details of the operative techniques [2,4, 11, 261. However, the high incidence of recurrent or persistent reflux [17,20,25], especially in patients with complicated forms of hiatal hernia, esophageal strictures, panmural esophagitis, and esophageal shortening, has led to the pursuit of alternative surgical goals. From Mercy Hospital, Charlotte, NC. Presented at the Twenty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Nov 3-5, 1977, Marco Island, FL. Address reprint requests to Dr. Evangelist, 1900 Randolph Rd, Charlotte, NC 28207.
107
Pearson and associates [22] reported that combining the Belsey Mark IV operation with the gastroplasty described by Collis [6, 71 gave unique success in patients with severe esophageal strictures and shortening of the esophagus. In this procedure, a 5 cm gastroplasty tube is created by division and suturing or by stapling and division, and a standard Belsey fundoplication is done [18, 21, 221. Our own efforts in this direction led to a method that utilizes an undivided gastroplasty tube, which is created with a modified GIA stapler, combined with the Nissen fundoplication.
Material and Methods Forty-eight patients, ranging from 11 to 72 years old, underwent combined Collis-Nissen reconstruction between June, 1973, and July, 1977. There were 16 male and 32 female patients. Reconstruction was done in 44 patients because of complications of gastroesophageal reflux (including esophageal strictures in 17). The procedure was performed in 3 patients with achalasia to ensure gastroesophageal competence following esophagomyotomy [231 and in 1 patient with known gastroesophageal reflux as an adjunct to emergency repair of a mptured esophagus. Preoperative symptoms included pyrosis in 25 patients, dysphagia in 20, atypical chest pain in 12, spontaneous and troublesome vomiting in 7 (in 3 of whom it was the only symptom present), and major pulmonary complications in 4 patients. All patients underwent preoperative roentgenographic and endoscopic evaluation. Roentgenographic findings included a hiatal hernia in 39 patients. Fourteen of them had major gastroesophageal reflux, and 17 had moderate to severe stricture, including almost complete obliteration of the lumen in 5. Six patients had moderate to severe gastroesophageal reflux with no hernia visible on roentgenograms. Achalasia was demonstrated roentgeno-
0003-497517810026-0203$01.25@ 1978 by Felix A. Evangelist
108 The Annals of Thoracic Surgery Vol 26
No 2 August 1978
interspace thoracotomy, and the esophagogastric junction is mobilized in the same manner as in the Mark IV operation. The free portion of the cardia of the stomach is drawn upward through the intact hiatus. At no time is it necessary to divide either short gastric vessels or the graphically in 3 patients. Endoscopic findings gastrohepatic omentum. A 52F Hurst mercurywere moderate to severe peptic esophagitis in filled bougie is passed from above and caused 34 patients, including stricture in 17, and gross to lie across the esophagogastric junction along the lesser curvature of the stomach. A standard reflux in 17 patients. During the last 6 months of this study, 24- GIA stapling instrument is then applied lonhour esophageal pH monitoring became avail- gitudinally to the gastric wall, parallel to and able and was carried out in 12 patients before gently but firmly abutted against the indwellthe procedure was done. All 12 showed moder- ing bougie (Fig 1A). The staples are driven ate to severe degrees of reflux during the 24- home and the stapler removed, thereby creating a 5 cm gastroplasty tube (Fig lB), which is still hour period. Operation is carried out through a left sixth attached to the remainder of the fundus. This is
Operatzve technique for the combined Collis-Nissen procedure. (A) The GlA stapler without a cutting blade is applied to the cardia so that it lies against an indwelling bougie. (B)An undivided 5 cm gastroplasty tube is made. (C, D ) The Nissen fundoplication is done with three horizontal mattress sutures.
109
Evangelist, Taylor, and Alford: Modified Cobs-Nissen Operation
wrapped around the newly created tube and is showed evidence of gastroesophageal reflux by held in place with three horizontal mattress su- the monitoring technique. All but 1 of the 20 patients with strictures tures of nonabsorbable material (Fig lC, D). Then the bougie is partially withdrawn into have had normal swallowing restored throughthe thoracic esophagus to facilitate reduction of out the period of study. Four patients did rethe newly constructed gastroesophageal junc- quire bougienage once or twice in the first 3 tion below the diaphragm. Once reduction is months after operation, but since then have accomplished, the bougie is reinserted into the remained well. One woman did well for 6 stomach to aid in calibration of the hiatus while months after repair of a severe distal esophageal three previously placed crural sutures are tied stricture. Then she swallowed lye in a suicide posterior to the hiatus. attempt, and a stricture developed in the upper Attempts were made to achieve preoperative thoracic esophagus. One man had achalasia esophageal dilation to a diameter of 60F in all that was not suspected preoperatively and conadult patients with strictures. This could not be sequently was not treated. It became clinically done safely in 6 of them. Three of the 6 were more important and bothersome in the postsuccessfully brought to this level intraopera- operative period. He represents the only untively under direct control, and the remainder satisfactory result in this series. Thus 47 of 48 were dilated to diameters of 44 to 50F intraoper- patients are now able to swallow normally, eat all foods without difficulty, and require no speatively. cific medications or anatomical maneuvers to Results maintain comfort. There were no surgical deaths in this series and no complications related to the fundoplication Comment or gastroplasty. An esophageal leak developed The control of gastroesophageal reflux has repon the seventh day after operation in an 11- resented a major surgical challenge for some year-old girl who had a combined esopha- time. Many excellent procedures have been degomyotomy and fundoplication. It was a vised and vigorously championed. All too fre0.5 cm perforation in the upper one-third of the quently, however, dissatisfaction has arisen myotomized segment related to a small area of due to either inadequate control of reflux inilate necrosis in the mucosa, and was controlled tially or late recurrence of this disastrous entity. by T-tube drainage. The child did well and in 7 In 1977, Henderson [12] and Orringer [16] remonths after the operation had gained 10 kg ported failure rates of 44.6% and 1670, respectively, with the Collis-Belsey procedure. Both over her preoperative weight of 21.3 kg. At the time of writing, the entire group had have since abandoned this procedure in favor been followed for from 3 to 52 months (average, of a Nissen-type fundoplication about the di27 months). All 48 patients have had complete vided gastric tube, with improved results [12, clinical control of reflux, and roentgenographic 19].* analysis has failed to show recurrence of reflux Bingham [3] in 1974 reported a series of cliniin any. cal techniques designed to create an antireflux Six patients have had postoperative 24-hour valve that would function permanently. Each of pH monitoring in the distal esophagus [5,8,141 the three methods was tried in 50 patients over at periods ranging from 3 to 42 months follow- several years. The work culminated in the adoping operation. (Three of these patients are in tion of an undivided gastric tube, created with the group of 12 who had preoperative the TA-55 stapling device, combined with a esophageal pH monitoring that indicated se- Nissen fundoplication. Control of reflux has vere gastroesophageal reflux. The other 3 been complete through the two-year period of underwent the procedure before this test was follow-up in the 59 patients in whom this available; reflux was demonstrated preopera- method was used. Demos and associates 19, 101 tively by roentgenographic, clinical, and endoscopic methods.) None of the 6 patients *Orringer MB: Personal communication, 1977.
110 The Annals of Thoracic Surgery Vol 26
No 2
August 1978
independently devised the same procedure and achieved similar results. Their operation differs from the one reported here only in the use of a different stapling device and the need to mobilize somewhat less of the gastric fundus. The Collis-Nissen approach was utilized initially only for patients with esophageal shortening and strictures. The early good results in these difficult cases combined with the simplicity and reproducibility of the procedure soon led us to adopt it for the more common and less demanding problems associated with gastroesophageal reflux. We realize that only a longer period of observation can demonstrate the true merit of this operation. However, the favorable results we have obtained during the four years the procedure has been in use encourage us to recommend its continuing application and evaluation.
Addendum Since the submission of this paper for publication, the I patient with an unsatisfactory result because of unsuspected achalasia underwent a standard Heller esophagomyotomy on December 22, 1977. This was readily accomplished by carrying the myotomy just below the original gastroesophageal junction and without needing to disrupt the earlier Collis-Nissen procedure. Normal swallowing function was restored, and the patient has no reflux either symptomatically or roentgenographically or by pH monitoring.
References Battle WS, Nyhus LM, Bombeck CT: Nissen fundoplication and esophagitis secondary to gastroesophageal reflux. Arch Surg 106:588, 1973 Baue Ah, Belsey RHR: The treatment of sliding hiatus hernia and reflux esophagitis by the Mark 1V technique. Surgery 62:396, 1967 Bingham JAW: Evolution and early results of constructing an anti-reflux valve in the stomach. Proc R SOCMed 67:4, 1974 Bushkin FL, Neustein CL, Parker TH, et al: Nissen fundoplication for reflux esophagitis. Ann Surg 185:672, 1977 Clark J , DeMeester TR, Johnson LF, et al: Twenty-four hour lower esophageal pH monitoring and the lower esophageal sphincter. Surg Forum 26:362, 1975
6. Collis JL: Gastroplasty. Thorax 16:197, 1961 7. Collis JL: An operation for hiatus hernia with short esophagus. J Thorac Cardiovasc Surg 34:768, 1967 8. DeMeester TR, Johnson LF, Kent AH: Evaluation of current operations for the prevention of gastroesophageal reflux. Ann Surg 180:511, 1974 9. Demos NJ: A simplified improved technique for the Collis gastroplasty for dilatable esophageal strictures. Surg Gynecol Obstet 143:591, 1976 10. Demos NJ, Smith N, Williams D: A gastroplasty for short esophagus and reflux esophagitis. Ann Surg 181:178, 1975 11. Ellis FH, El-Kurd MFA, Gibb SP: The effect of fundoplication on the lower esophageal sphincter. Surg Gynecol Obstet 143:1, 1976 12. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206, 1977 13. Hill LD, Gelfand M, Bauermeister DL: Simplified management of reflux esophagitis with stricture. Ann Surg 172:638, 1970 14. JohnsonLF, DeMeester TR: Twenty-four hour pH monitoring of the distal esophagus: a quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325, 1974 15. Nissen R: Reminiscences-reflux esophagi tis and hiatal hernia. Rev Surg 27:307, 1970 16. Orringer MB: Discussion of Henderson [12] 17. Orringer MB, Skinner DB, Belsey RHR: Longterm results of the Mark 1V operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 63:35, 1972 18. Orringer MB, Sloan HE: An improved technique for the combined Collis-Belsey approach to dilatable esophageal strictures. J Thorac Cardiovasc Surg 68:298, 1974 19. Orringer MB, Sloan HE: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 25:16, 1978 20. Pearson FG, Henderson RD: Experimental and clinical studies of gastroplasty in the management of acquired short esophagus. Surg Gynecol Obstet 136:737, 1973 21. Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty and Belsey hiatus hernia repair. Surgery 80:396, 1976 22. Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus hernia repair; an operation for the management of peptic stricture and acquired short esophagus. J Thorac Cardiovasc Surg 61:50, 1971 23. Peyton MD, Greenfield LJ, Elkins RC: Combined myotomy and hiatal hemiorrhaphy: a new approach to achalasia. Am J Surg 128:786, 1974 24. Skinner DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 53:33, 1967
111 Evangelist, Taylor, and Alford: Modified Collis-Nissen Operation
25. Urschel HC, Razzuk MA, Wood RE, et al: A n improved surgical technique for the complicated hiatal hernia with gastroesophageal reflux. Ann Thorac Surg 15:443, 1973 26. Woodward ER, Thomas HF, McAlhany JC: Comparison of crural repair and Nissen fundoplication in the treatment of esophageal hiatus hernia with peptic esophagitis. Ann Surg 173:782, 1971
Editor's Note The authors have achieved excellent results in relieving the symptoms of esophageal reflux and are to be congratulated. However, it is not possible to compare these results with reports in which the control of reflux has been determined by more sophisticated manometric and pH studies.
Notice from The Society of Thoracic Surgeons Call for Surgical Films (Deadline: August 37, 7978) The popular surgical movie program will again be presented at the Phoenix meeting. The ProAbstracts for papers to be presented at the 1979 gram Committee hereby solicits the submission Annual Meeting of The Society of Thoracic Sur- of surgical films, which may portray a surgical geons are now being accepted. The meeting is procedure or simply a technical maneuver that to be held at the Phoenix Civic Plaza, Phoenix, the surgeon thinks will be of interest to the SoAZ,January 15-17, 1979. ciety. The film may not exceed 10 minutes in The deadline for receipt of abstracts is August length. Sound movies are acceptable but not 31,1978. An original and eight copies should be necessary, and live narration by the principal submitted on the official society abstract form surgeon is a requirement for participation in to Robert L. Replogle, M.D., Chairman, Pro- the movie night program. The movies may be gram Committee (Abstracts), The Society of on Super-8 or 16-mm film. The deadline for Thoracic Surgeons, 111 E Wacker Dr, Chicago, submission of films is August 31, 1978. Films IL 60601. The forms are available upon request also should be sent to Robert L. Replogle, M.D., from The Society. Abstracts must summarize an Chairman, Program Committee, at The Society original contribution not presented or submit- office, 111 E Wacker Dr, Chicago, IL 60601. ted elsewhere. Abstracts received after the Application for Membership deadline will not be considered. It is requested (Deadline: September 7 , 7978) that the covering letter indicate the author who Requests for membership application forms is to receive notice of acceptance or rejection should be addressed to Quentin R. Stiles, M.D., and the author who will present the paper. Chairman, Membership Committee, The SociThe Program Committee reserves the right to ety of Thoracic Surgeons, 111 E Wacker Dr, select papers for either regular or forum-type Chicago, IL 60601. presentation. The author may also designate his The completed application forms and suppreference for presentation in the forum. Esporting letters must be in the hands of the sayists are reminded that the complete manuMembership Committee by September 1,1978, script must be submitted in duplicate either to for the applicant to be considered for election at the Editor of The Annals of Thoracic Surgery bethe Phoenix meeting next January. fore the meeting or to the Secretary of The Society at the meeting, immediately prior to presen- Thomas D. Bartley, M . D . Secretary tation.
Call for Abstracts-7979 Meeting (Deadline: August 31, 7978)
Complete and permanent control of gastroesophageal reflux is the ultimate and mandatory goal of any treatment proposed for the altered pathophysiology associated with hiatal hernia and incompetence of the lower esophageal sphincter. It is apparent that the widely accepted procedures, the Belsey [24], Nissen [l, 151, and Hill 1131 operations, can and do achieve this in a majority of patients provided they are performed under favorable anatomical conditions and with precise attention to the details of the operative techniques [2,4, 11, 261. However, the high incidence of recurrent or persistent reflux [17,20,25], especially in patients with complicated forms of hiatal hernia, esophageal strictures, panmural esophagitis, and esophageal shortening, has led to the pursuit of alternative surgical goals. From Mercy Hospital, Charlotte, NC. Presented at the Twenty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Nov 3-5, 1977, Marco Island, FL. Address reprint requests to Dr. Evangelist, 1900 Randolph Rd, Charlotte, NC 28207.
107
Pearson and associates [22] reported that combining the Belsey Mark IV operation with the gastroplasty described by Collis [6, 71 gave unique success in patients with severe esophageal strictures and shortening of the esophagus. In this procedure, a 5 cm gastroplasty tube is created by division and suturing or by stapling and division, and a standard Belsey fundoplication is done [18, 21, 221. Our own efforts in this direction led to a method that utilizes an undivided gastroplasty tube, which is created with a modified GIA stapler, combined with the Nissen fundoplication.
Material and Methods Forty-eight patients, ranging from 11 to 72 years old, underwent combined Collis-Nissen reconstruction between June, 1973, and July, 1977. There were 16 male and 32 female patients. Reconstruction was done in 44 patients because of complications of gastroesophageal reflux (including esophageal strictures in 17). The procedure was performed in 3 patients with achalasia to ensure gastroesophageal competence following esophagomyotomy [231 and in 1 patient with known gastroesophageal reflux as an adjunct to emergency repair of a mptured esophagus. Preoperative symptoms included pyrosis in 25 patients, dysphagia in 20, atypical chest pain in 12, spontaneous and troublesome vomiting in 7 (in 3 of whom it was the only symptom present), and major pulmonary complications in 4 patients. All patients underwent preoperative roentgenographic and endoscopic evaluation. Roentgenographic findings included a hiatal hernia in 39 patients. Fourteen of them had major gastroesophageal reflux, and 17 had moderate to severe stricture, including almost complete obliteration of the lumen in 5. Six patients had moderate to severe gastroesophageal reflux with no hernia visible on roentgenograms. Achalasia was demonstrated roentgeno-
0003-497517810026-0203$01.25@ 1978 by Felix A. Evangelist
108 The Annals of Thoracic Surgery Vol 26
No 2 August 1978
interspace thoracotomy, and the esophagogastric junction is mobilized in the same manner as in the Mark IV operation. The free portion of the cardia of the stomach is drawn upward through the intact hiatus. At no time is it necessary to divide either short gastric vessels or the graphically in 3 patients. Endoscopic findings gastrohepatic omentum. A 52F Hurst mercurywere moderate to severe peptic esophagitis in filled bougie is passed from above and caused 34 patients, including stricture in 17, and gross to lie across the esophagogastric junction along the lesser curvature of the stomach. A standard reflux in 17 patients. During the last 6 months of this study, 24- GIA stapling instrument is then applied lonhour esophageal pH monitoring became avail- gitudinally to the gastric wall, parallel to and able and was carried out in 12 patients before gently but firmly abutted against the indwellthe procedure was done. All 12 showed moder- ing bougie (Fig 1A). The staples are driven ate to severe degrees of reflux during the 24- home and the stapler removed, thereby creating a 5 cm gastroplasty tube (Fig lB), which is still hour period. Operation is carried out through a left sixth attached to the remainder of the fundus. This is
Operatzve technique for the combined Collis-Nissen procedure. (A) The GlA stapler without a cutting blade is applied to the cardia so that it lies against an indwelling bougie. (B)An undivided 5 cm gastroplasty tube is made. (C, D ) The Nissen fundoplication is done with three horizontal mattress sutures.
109
Evangelist, Taylor, and Alford: Modified Cobs-Nissen Operation
wrapped around the newly created tube and is showed evidence of gastroesophageal reflux by held in place with three horizontal mattress su- the monitoring technique. All but 1 of the 20 patients with strictures tures of nonabsorbable material (Fig lC, D). Then the bougie is partially withdrawn into have had normal swallowing restored throughthe thoracic esophagus to facilitate reduction of out the period of study. Four patients did rethe newly constructed gastroesophageal junc- quire bougienage once or twice in the first 3 tion below the diaphragm. Once reduction is months after operation, but since then have accomplished, the bougie is reinserted into the remained well. One woman did well for 6 stomach to aid in calibration of the hiatus while months after repair of a severe distal esophageal three previously placed crural sutures are tied stricture. Then she swallowed lye in a suicide posterior to the hiatus. attempt, and a stricture developed in the upper Attempts were made to achieve preoperative thoracic esophagus. One man had achalasia esophageal dilation to a diameter of 60F in all that was not suspected preoperatively and conadult patients with strictures. This could not be sequently was not treated. It became clinically done safely in 6 of them. Three of the 6 were more important and bothersome in the postsuccessfully brought to this level intraopera- operative period. He represents the only untively under direct control, and the remainder satisfactory result in this series. Thus 47 of 48 were dilated to diameters of 44 to 50F intraoper- patients are now able to swallow normally, eat all foods without difficulty, and require no speatively. cific medications or anatomical maneuvers to Results maintain comfort. There were no surgical deaths in this series and no complications related to the fundoplication Comment or gastroplasty. An esophageal leak developed The control of gastroesophageal reflux has repon the seventh day after operation in an 11- resented a major surgical challenge for some year-old girl who had a combined esopha- time. Many excellent procedures have been degomyotomy and fundoplication. It was a vised and vigorously championed. All too fre0.5 cm perforation in the upper one-third of the quently, however, dissatisfaction has arisen myotomized segment related to a small area of due to either inadequate control of reflux inilate necrosis in the mucosa, and was controlled tially or late recurrence of this disastrous entity. by T-tube drainage. The child did well and in 7 In 1977, Henderson [12] and Orringer [16] remonths after the operation had gained 10 kg ported failure rates of 44.6% and 1670, respectively, with the Collis-Belsey procedure. Both over her preoperative weight of 21.3 kg. At the time of writing, the entire group had have since abandoned this procedure in favor been followed for from 3 to 52 months (average, of a Nissen-type fundoplication about the di27 months). All 48 patients have had complete vided gastric tube, with improved results [12, clinical control of reflux, and roentgenographic 19].* analysis has failed to show recurrence of reflux Bingham [3] in 1974 reported a series of cliniin any. cal techniques designed to create an antireflux Six patients have had postoperative 24-hour valve that would function permanently. Each of pH monitoring in the distal esophagus [5,8,141 the three methods was tried in 50 patients over at periods ranging from 3 to 42 months follow- several years. The work culminated in the adoping operation. (Three of these patients are in tion of an undivided gastric tube, created with the group of 12 who had preoperative the TA-55 stapling device, combined with a esophageal pH monitoring that indicated se- Nissen fundoplication. Control of reflux has vere gastroesophageal reflux. The other 3 been complete through the two-year period of underwent the procedure before this test was follow-up in the 59 patients in whom this available; reflux was demonstrated preopera- method was used. Demos and associates 19, 101 tively by roentgenographic, clinical, and endoscopic methods.) None of the 6 patients *Orringer MB: Personal communication, 1977.
110 The Annals of Thoracic Surgery Vol 26
No 2
August 1978
independently devised the same procedure and achieved similar results. Their operation differs from the one reported here only in the use of a different stapling device and the need to mobilize somewhat less of the gastric fundus. The Collis-Nissen approach was utilized initially only for patients with esophageal shortening and strictures. The early good results in these difficult cases combined with the simplicity and reproducibility of the procedure soon led us to adopt it for the more common and less demanding problems associated with gastroesophageal reflux. We realize that only a longer period of observation can demonstrate the true merit of this operation. However, the favorable results we have obtained during the four years the procedure has been in use encourage us to recommend its continuing application and evaluation.
Addendum Since the submission of this paper for publication, the I patient with an unsatisfactory result because of unsuspected achalasia underwent a standard Heller esophagomyotomy on December 22, 1977. This was readily accomplished by carrying the myotomy just below the original gastroesophageal junction and without needing to disrupt the earlier Collis-Nissen procedure. Normal swallowing function was restored, and the patient has no reflux either symptomatically or roentgenographically or by pH monitoring.
References Battle WS, Nyhus LM, Bombeck CT: Nissen fundoplication and esophagitis secondary to gastroesophageal reflux. Arch Surg 106:588, 1973 Baue Ah, Belsey RHR: The treatment of sliding hiatus hernia and reflux esophagitis by the Mark 1V technique. Surgery 62:396, 1967 Bingham JAW: Evolution and early results of constructing an anti-reflux valve in the stomach. Proc R SOCMed 67:4, 1974 Bushkin FL, Neustein CL, Parker TH, et al: Nissen fundoplication for reflux esophagitis. Ann Surg 185:672, 1977 Clark J , DeMeester TR, Johnson LF, et al: Twenty-four hour lower esophageal pH monitoring and the lower esophageal sphincter. Surg Forum 26:362, 1975
6. Collis JL: Gastroplasty. Thorax 16:197, 1961 7. Collis JL: An operation for hiatus hernia with short esophagus. J Thorac Cardiovasc Surg 34:768, 1967 8. DeMeester TR, Johnson LF, Kent AH: Evaluation of current operations for the prevention of gastroesophageal reflux. Ann Surg 180:511, 1974 9. Demos NJ: A simplified improved technique for the Collis gastroplasty for dilatable esophageal strictures. Surg Gynecol Obstet 143:591, 1976 10. Demos NJ, Smith N, Williams D: A gastroplasty for short esophagus and reflux esophagitis. Ann Surg 181:178, 1975 11. Ellis FH, El-Kurd MFA, Gibb SP: The effect of fundoplication on the lower esophageal sphincter. Surg Gynecol Obstet 143:1, 1976 12. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206, 1977 13. Hill LD, Gelfand M, Bauermeister DL: Simplified management of reflux esophagitis with stricture. Ann Surg 172:638, 1970 14. JohnsonLF, DeMeester TR: Twenty-four hour pH monitoring of the distal esophagus: a quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325, 1974 15. Nissen R: Reminiscences-reflux esophagi tis and hiatal hernia. Rev Surg 27:307, 1970 16. Orringer MB: Discussion of Henderson [12] 17. Orringer MB, Skinner DB, Belsey RHR: Longterm results of the Mark 1V operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 63:35, 1972 18. Orringer MB, Sloan HE: An improved technique for the combined Collis-Belsey approach to dilatable esophageal strictures. J Thorac Cardiovasc Surg 68:298, 1974 19. Orringer MB, Sloan HE: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 25:16, 1978 20. Pearson FG, Henderson RD: Experimental and clinical studies of gastroplasty in the management of acquired short esophagus. Surg Gynecol Obstet 136:737, 1973 21. Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty and Belsey hiatus hernia repair. Surgery 80:396, 1976 22. Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus hernia repair; an operation for the management of peptic stricture and acquired short esophagus. J Thorac Cardiovasc Surg 61:50, 1971 23. Peyton MD, Greenfield LJ, Elkins RC: Combined myotomy and hiatal hemiorrhaphy: a new approach to achalasia. Am J Surg 128:786, 1974 24. Skinner DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 53:33, 1967
111 Evangelist, Taylor, and Alford: Modified Collis-Nissen Operation
25. Urschel HC, Razzuk MA, Wood RE, et al: A n improved surgical technique for the complicated hiatal hernia with gastroesophageal reflux. Ann Thorac Surg 15:443, 1973 26. Woodward ER, Thomas HF, McAlhany JC: Comparison of crural repair and Nissen fundoplication in the treatment of esophageal hiatus hernia with peptic esophagitis. Ann Surg 173:782, 1971
Editor's Note The authors have achieved excellent results in relieving the symptoms of esophageal reflux and are to be congratulated. However, it is not possible to compare these results with reports in which the control of reflux has been determined by more sophisticated manometric and pH studies.
Notice from The Society of Thoracic Surgeons Call for Surgical Films (Deadline: August 37, 7978) The popular surgical movie program will again be presented at the Phoenix meeting. The ProAbstracts for papers to be presented at the 1979 gram Committee hereby solicits the submission Annual Meeting of The Society of Thoracic Sur- of surgical films, which may portray a surgical geons are now being accepted. The meeting is procedure or simply a technical maneuver that to be held at the Phoenix Civic Plaza, Phoenix, the surgeon thinks will be of interest to the SoAZ,January 15-17, 1979. ciety. The film may not exceed 10 minutes in The deadline for receipt of abstracts is August length. Sound movies are acceptable but not 31,1978. An original and eight copies should be necessary, and live narration by the principal submitted on the official society abstract form surgeon is a requirement for participation in to Robert L. Replogle, M.D., Chairman, Pro- the movie night program. The movies may be gram Committee (Abstracts), The Society of on Super-8 or 16-mm film. The deadline for Thoracic Surgeons, 111 E Wacker Dr, Chicago, submission of films is August 31, 1978. Films IL 60601. The forms are available upon request also should be sent to Robert L. Replogle, M.D., from The Society. Abstracts must summarize an Chairman, Program Committee, at The Society original contribution not presented or submit- office, 111 E Wacker Dr, Chicago, IL 60601. ted elsewhere. Abstracts received after the Application for Membership deadline will not be considered. It is requested (Deadline: September 7 , 7978) that the covering letter indicate the author who Requests for membership application forms is to receive notice of acceptance or rejection should be addressed to Quentin R. Stiles, M.D., and the author who will present the paper. Chairman, Membership Committee, The SociThe Program Committee reserves the right to ety of Thoracic Surgeons, 111 E Wacker Dr, select papers for either regular or forum-type Chicago, IL 60601. presentation. The author may also designate his The completed application forms and suppreference for presentation in the forum. Esporting letters must be in the hands of the sayists are reminded that the complete manuMembership Committee by September 1,1978, script must be submitted in duplicate either to for the applicant to be considered for election at the Editor of The Annals of Thoracic Surgery bethe Phoenix meeting next January. fore the meeting or to the Secretary of The Society at the meeting, immediately prior to presen- Thomas D. Bartley, M . D . Secretary tation.
Call for Abstracts-7979 Meeting (Deadline: August 31, 7978)
