Collis Gastroplasty and Hiatoplasty for Short Esophagus after Bariatric Surgery

Gastroesophageal reflux disease is diagnosed at an alarming rate after laparoscopic sleeve gastrectomy. Revisional surgery with conversion to Roux-en-Y gastric bypass does not guarantee reflux control and is associated with morbidity. There is a need to optimize the objective foregut patient pathway prior to bariatric surgery and to perform concurrent hiatal repair in individuals with a defective esophago-gastric junction and abnormal esophageal acid exposure. The role of adjunctive surgical procedures (hiatal reinforcement, fundoplication, magnetic sphincter augmentation) is still controversial due to  lack of follow-up and standardized reporting. Hiatal hernias are often detected during the course of a bariatric operation, or other operations at or near the diaphragmatic hiatus. The hernias can be detected by noting “dimpling” anterior to the esophagus, or noting a large hernia sac with contents. There are many references in the literature of increased complications, particularly heartburn, after placement of an adjustable gastric band in patients with a hiatal hernia. Because of this association with gastroesophageal reflux symptoms, many now recommend looking for, and repairing hiatal hernias at the time of gastric band insertion. The etiology of giant hiatal hernia is not entirely clear, and two potential mechanisms exist: (1) gastroesophageal reflux disease (GERD) leads to esophageal scarring and shortening with resulting traction on the gastroesophageal junction and gastric herniation; and (2) chronic positive pressure on the diaphragmatic hiatus combined with a propensity to herniation leads to gastric displacement into the chest, resulting in GERD. The short esophagus and GERD are key concepts to understanding the pathophysiology of giant hiatal hernia, and these concepts are critical to address this problem appropriately.  A successful repair of giant HH requires adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair), recognition and correction of a short esophagus, and a well-performed antireflux procedure. Collis gastroplasty is an important component of laparoscopic giant paraesophageal hernia (GPEH) repair in patients with persistent shortened esophagus after aggressive laparoscopic mobilization.