When is Collis gastroplasty indicated and what does the procedure entail?

Collis Gastroplasty: Indications and Procedure

Collis gastroplasty is indicated when a "true short esophagus" prevents tension-free placement of at least 1.5-2 cm of esophagus below the diaphragm after maximal mediastinal mobilization during antireflux surgery or hiatal hernia repair. 1, 2

Indications

When to Suspect Short Esophagus

• Preoperative barium studies showing the gastroesophageal (GE) junction >5 cm above the hiatus 3
• Large paraesophageal hernias (Type III-IV) 1
• Chronic severe gastroesophageal reflux disease with esophageal foreshortening 4
• Failed previous antireflux procedures 2

Intraoperative Decision Criteria

The definitive determination occurs intraoperatively after complete hiatal dissection and maximal esophageal mediastinal mobilization 1, 5:

• Proceed with Collis gastroplasty if the abdominal esophageal length is ≤1.5 cm measured with intraoperative endoscopy after full mobilization 1
• Standard fundoplication alone is appropriate if >2 cm of esophagus can be positioned below the diaphragm without tension 2, 3

Incidence

• Approximately 14-26% of patients undergoing antireflux surgery are suspected preoperatively to have esophageal foreshortening 5, 3
• Only 4-20% ultimately require Collis gastroplasty after complete dissection 5, 3

The Procedure

Surgical Technique

Laparoscopic Wedge-Fundectomy Approach (preferred modern technique):

• The gastric fundus is mobilized by dividing short gastric vessels 4, 2
• A 46-52 French Maloney bougie is placed in the esophagus to calibrate the neoesophagus 4, 5
• An endoscopic stapler creates a vertical gastroplasty along the lesser curve of the gastric fundus, creating a 3-5 cm neoesophageal segment 2, 5
• The wedge-fundectomy technique removes a triangular portion of fundus, reducing bulk and dysphagia risk 2

Thoracoscopic Approach (alternative):

• Left thoracoscopy in the V-VI intercostal space with 45° left lateral positioning 4
• Allows direct visualization of stapler passage into mediastinum 4
• Particularly useful when combined approach is needed 1

Completing the Antireflux Procedure

• Nissen fundoplication (360° wrap) is performed in 66% of cases, creating a floppy wrap around the neoesophagus 1, 2
• Toupet fundoplication (270° partial wrap) is used in 34% of cases to minimize dysphagia risk 1
• Hiatal closure (hiatoplasty) with sutures to prevent herniation 4
• Nasogastric tube placement and feeding jejunostomy may be considered 6

Clinical Outcomes

Efficacy

• 91-93% of patients achieve freedom from heartburn postoperatively 1, 2
• Excellent or good results in 91% of patients at median 96-month follow-up 1
• Dysphagia significantly decreases (preoperative 58% vs postoperative 16%) 2
• New-onset dysphagia occurs in only 2-16% of patients with modern techniques 2

Complications

• Postoperative esophagitis occurs in 11% on endoscopy 2
• Complication rates improve dramatically with experience: 43% in first 32 cases vs 6% in subsequent cases 1
• Small recurrent hernias (1-2 cm) occur in 2.4% 2
• No staple line leaks or abscesses reported with proper technique 2

Critical Technical Points

Avoiding Common Pitfalls

• Do not attempt standard fundoplication under tension when the esophagus is truly short—this leads to wrap herniation and reflux recurrence 3
• Ensure adequate bougie size (46-52 French) to prevent creating too narrow a neoesophagus 4, 5
• Complete short gastric vessel division is mandatory for adequate fundic mobilization 4
• Liberal use is encouraged when criteria are met, as outcomes match standard fundoplication when appropriately selected 2

Special Consideration for Esophageal Perforation

In abdominal esophageal perforation repair, gastroplasty using gastric fundus to buttress the esophageal suture line is recommended as part of the repair strategy 6