Collis gastroplasty: why, when and how?
Collis gastroplasty was originally designed to deal with the increasing incidence of short esophagus (SE) associated with the new epidemic of gastroesophageal reflux disease (GERD) and hiatal hernias. In following years, a fundoplication was added to the procedure in an attempt to correct the underlying cause of the disease. Nowadays Collis gastroplasty with fundoplication is the standard treatment for patients in whom, even after an extensive surgical dissection of the distal esophagus, the gastroesophageal junction (GEJ) cannot be brought at least 2.5 cm below the diaphragmatic hiatus without tension. The real incidence of SE is controversial in the era of laparoscopic fundoplication, with some groups proposing that all short esophagi can be solved with adequate mediastinal dissection of the esophagus prior to fundoplication, and others advocating frequent use of the Collis. Still others have tried to identify predictive factors linked to the presence of a true SE. However, studies suggest that a significant percentage of failures of primary antireflux surgery might be due to axial tension on the repair from intrinsic shortening of the esophagus that was not properly addressed. With the advent of the laparoscopic era new tools and new approaches were described to asses and to treat this condition. We describe both thoracoscopic/laparoscopic and totally laparoscopic techniques for minimally invasive Collis gastroplasty. While symptomatic results are good, the procedure is non-physiologic and many patients have esophagitis from ectopic gastric mucosa. While the true incidence of SE is unknown, what is undeniable is that chronic reflux disease can lead to foreshortening of the esophagus and, although in the proton pump inhibitor (PPI) era the presence of a SE is a relatively rare finding, the foregut surgeon must be prepared to identify and treat this condition.