1. Collis Nissen for the Short Esophagus Collis Nissen for the Short Esophagus Bill Richards, MD, FACS Professor and Chair Surgery Bill Richards, MD, FACS Professor and Chair Surgery University of South Alabama University of South Alabama MISS 2011

2. Anatomic Fundoplication Failure After Laparoscopic Antireflux Surgery Soper Ann Surg 290 fundoplications over 6 year period 290 fundoplications over 6 year period 7% anatomic failure of the fundoplication demonstrated 7% anatomic failure of the fundoplication demonstrated

3. Anatomic Failures: Does Size Matter? Soper Ann Surg 1999 > 3 cm Hernia 12/90 (13%) < 3 cm Hernia 8/200 (4%)

4. Soper Conclusions 3-4 cm intraabdominal length 3-4 cm intraabdominal length No tension No tension

5. Risk of Needing a Collis Urbach et al Surg Endosc 01

6. Prepare for Collis Gastroplasty Preop determination of >6 cm Hiatal Hernia Preop determination of >6 cm Hiatal Hernia Recurrent Hiatal Hernia Recurrent Hiatal Hernia Initial Type III repairs Initial Type III repairs

7. Technique Collis Intraoperative endoscopy Intraoperative endoscopy Identify Z line Identify Z line Add 12 mm trocar in mid axillary line left side Add 12 mm trocar in mid axillary line left side 42 French dilator 42 French dilator Increases esophageal length 4-5 cm Increases esophageal length 4-5 cm Endoscopy Endoscopy R/o leaks at end of procedure R/o leaks at end of procedure

10. Long-term Evaluation of patients satisfaction and reflux symptoms after Laparoscopic Fundoplication with Collis Gastroplasty

12. Postoperative Function Following Laparoscopic Collis Gastroplasty for Shortened Esophagus Blair, Horvath, Swanstrom Arch Surg. 1998;133:867-874.

13. Copyright restrictions may apply. Jobe, B. A. et al. Arch Surg 1998;133:867-874. Coronal section through a Collis- Nissen fundoplication The neoesophagus may contain functional gastric mucosa 50% of the time, resulting in esophagitis but with poor symptom correlation. This mandates the use of medical acid suppression when neoesophageal acid production is documented.

14. Collis Nissen Good technique for the truly short esophagus which does exist Good technique for the truly short esophagus which does exist 42 French bougie 42 French bougie wedge fundectomy technique wedge fundectomy technique Prepare for the case! Prepare for the case! Long term PPI use Long term PPI use Endoscopic surveillance Endoscopic surveillance