Definition & Overview
The oesophagus is the main pathway of food and liquids from the mouth to the stomach. The stomach then stores food and breaks it down using a mixture of acids. The oesophagus has mechanisms that prevent a condition called gastroesophageal reflux disease (GERD), a condition wherein undigested food goes back up into the oesophagus. Some of the most common symptoms of this condition are heartburn and acid indigestion.
One of the most common causes of GERD is the failure of the lower oesophageal sphincter (LES) to function properly. The LES is a ring made of muscle. Its main purpose is to block the exit point of the oesophagus into the stomach. It relaxes to allow food to pass into the stomach and tightens again to prevent stomach contents from returning to the oesophagus.
Laparoscopic Nissen fundoplication is a common surgical method to treat GERD. The procedure involves wrapping the upper part of the stomach around the lower part of the oesophagus. However, in some cases, the length of the oesophagus may not be enough to complete the procedure. This condition is referred to as a shortened oesophagus.
There have been many scientific and medical discussions concerning shortened oesophagus. Some groups believe that the condition is a myth and have studies as proofs. Other groups believe that such condition exists but is very uncommon. Regardless of belief, oesophageal lengthening procedure is performed to prevent failure of the Nissen fundoplication procedure due to a postoperative condition called slippage. Slippage occurs when the sutures holding the wrap in place fail to penetrate the oesophageal wall.
The most popular oesophageal lengthening procedure used today is called Collis gastroplasty. The procedure involves making an incision in the upper portion of the stomach where the oesophagus is attached. This extends the oesophagus making it possible to perform a normal Nissen fundoplication and reduce the risks of slippage.
Who Should Undergo & Expected Results
Laparoscopic oesophageal lengthening procedures, specifically Collis gastroplasty, is recommended for patients scheduled for Nissen fundoplication but have been diagnosed with a shortened oesophagus. Collis gastroplasty, in conjunction with Nissen fundoplication, has been proven to reduce the recurrence of symptoms associated with GERD.
When performed via a minimally invasive laparoscopic procedure, patients can expect a shorter recovery period and lower risk of developing complications.
How is the Procedure Performed?
Patients who have been suffering from GERD for an extended period are prone to various complications. One of which is a shortened oesophagus. If surgery is performed without incorporating a Collis gastroplasty procedure, the chances of the procedure failing resulting in the recurrence of the symptoms greatly increase.
Patients selected to undergo surgical treatment for GERD are those who have previously undergone nonsurgical treatment methods that have failed to improve their condition. Prior to the procedure, these patients are made to undergo several diagnostic tests, such as esophagogastroduodenoscopy (EGD) with biopsy, oesophageal manometry, barium oesophagram, or a gastric emptying test.
On the day of surgery, the patient is transferred to the operating room and placed in a modified lithotomy position. The patient lies flat on a table with legs open and raised. The table is then raised at a 25-degree angle. The patient is administered with general anaesthesia so he or she will be asleep throughout the procedure.
The surgeon will then create about five incisions in the patient’s upper abdominal area where special surgical instruments will be inserted.
The first part of the procedure involves locating the lower part of the oesophagus where the LES is found. This part is also the lesser curvature of the stomach. The surgeon will then carefully create an incision in the stomach to extend the oesophagus and complete a Collis gastroplasty procedure. The incision is then sutured and the remaining portion is wrapped around the newly extended oesophagus and kept in place using at least three additional sutures. This completes the Nissen fundoplication procedure.
Once completed, the instruments are removed and the remaining incisions are closed using sutures. The patient will remain in the hospital for at least a day to recover. If no complications occur during this period, the patient will be discharged to continue recovery at home.
The patient will be placed on a strict diet for a few days. After a follow-up checkup with the attending doctor, the patient may continue with regular work activities.
Possible Risks & Complications
It is important to understand that cases of a short oesophagus are very uncommon, which is why oesophageal lengthening procedures are usually not performed. If during a laparoscopic Nissen fundoplication procedure, the surgeon suspects that the length of the oesophagus is insufficient, he or she may perform a Collis gastroplasty to reduce the chances of failure.
Unfortunately, even though Collis gastroplasty improves the success rate of a Nissen fundoplication procedure, it also increases the risks associated with laparoscopic surgery.
It is also important to understand that oesophageal lengthening is performed as a solution to a perceived complex problem. The recovery process may be shortened by performing a minimally invasive procedure but the chances of complications developing remain. Thus, the patient will likely to undergo an extended period of monitoring and follow-up consultations.
References: * Karen D. Horvath MD, Lee L. Swanstrom MD, Blair A Jobe MD;”The short esophagus: Pathophysiology, Incidence, Presentation, and Treatment in the Era of Laparoscopic Antireflux Surgery”; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421216/
- Swanstrom LL, Marcus DR, Galloway GQ;”Laparoscopic Collis Gastroplasty is the treatment of choice for the shortened esophagus”; http://www.ncbi.nlm.nih.gov/pubmed/8651389