Collis Belsey Fundoplication - Indications, Procedure, and Complications

Introduction:

Hiatal hernia, gastroesophageal reflux disorder (GERD), esophageal sphincters, and shortened esophagus are certain conditions that require a surgical procedure called Collis Belsey fundoplication. In a few conditions, there is a shift in the junction of the stomach and esophagus, causing the gastric contents to move into the thoracic cavity (above the diaphragm). Collis Belsey fundoplication surgery involves resecting the affected area and rejoining them in a certain way, thereby maintaining the continuity and place of the gastroesophageal junction (GEJ).

What Is Collis Belsey Fundoplication?

Collis Belsey fundoplication is a surgical procedure used to manage hiatal hernia and recurring gastroesophageal reflux disorders. This surgery combines Collis gastrotomy and Belsey Mark IV fundoplication procedures.

What Is Hiatal Hernia?

Hiatal hernia is a condition in which the upper part of the stomach is pushed back into the chest cavity through an opening in the diaphragm (a muscle that separates the thoracic cavity containing the lungs, heart, and abdominal cavity containing stomach, intestines, liver). Usually, the stomach and esophagus join at the opening of the diaphragm. But in the case of a hiatal hernia, the top part of the stomach is pushed up through the hiatus into the chest cavity. The hiatus is where the esophagus (food pipe) joins the stomach through the diaphragm. Therefore is called a hiatal hernia.

Causes of Hiatal Hernia:

An increase in the pressure of the abdominal cavity caused due to coughing, straining during bowel movement, vomiting, pregnancy, obesity, or any injury in the area.

Types of Hiatal Hernia:

Hiatal hernias are broadly classified as:

• Uncomplicated (Sliding) Hiatal Hernias - Hiatal hernias without any complication.

• Complicated (Para Esophageal) Hiatal Hernias - Hiatal hernias with bleeding and obstruction.

What Are the Symptoms of Hiatal Hernia?

Usually, patients with Hiatal hernias are asymptomatic, but few show symptoms of gastroesophageal reflux disease (GERD), in which the stomach contents are pushed back to the esophagus. The symptoms include:

1. Heartburn.

2. Bloating.

3. Burping.

4. Bad taste in the mouth.

5. Chest pain.

What Are the Diagnostic Methods for Hiatal Hernia?

Hiatal hernia can be diagnosed properly through endoscopy. Endoscopy is a procedure where a small tube with a camera and light source is placed to visualize the affected area.

What Are the Treatment Options for Hiatal Hernia?

It is usually a symptomatic treatment:

1. Antacids (to weaken stomach acids).

2. Proton pump inhibitors (to produce lesser acid in the stomach).

But, patients with complicated hiatal hernia require Collis Belsey fundoplication surgery.

What Are the Risk Factors Indicating the Need for Collis Belsey Fundoplication?

The risk factors indicating the need for Collis Belsey fundoplication are as follows:

• Reflux esophagitis (peptic stricture) causin narrowing of the esophagus over time due to damage in the lining of the esophagus.

• Periesophagitis from prior operation causing nflammation of tissues surrounding the esophagus.

• Transthoracic hiatal hernia repair, transabdominal hiatal hernia repair (surgeries carried out to treat hiatal hernia).

• Repair of perforation or surgery to manage perforations (loss of continuity in the gastrointestinal tract can result in perforation due to untreated abscess or infection).

• Obesity.

• Esophageal spasm causing painful contractions within the esophagus (tube connecting your mouth and stomach).

• Achalasia (a rare condition that makes it difficult for food to pass through the food pipe).

• Chronic obstructive pulmonary disease (a disorder that causes obstructive airflow from the lungs).

• Complicated hiatal hernia with esophageal shortening.

What Are the Pre-operative Assessments for Collis Belsey Fundoplication?

• Reasonable medical and surgical history.

• Esophagogastroduodenoscopy (EGD) - Endoscopy of the stomach, esophagus, and duodenum is performed.

• To assess the anatomic position of the junction of the stomach and esophagus to the diaphragm.

• To assess the size and location of the hernia.

• Assessment of esophageal motility is done with the help of a manometric pressure catheter.

• CT (computed tomography) scan is performesd to detect abnormally positioned stomach.

• Plain chest X-rays is done to see retro cardiac air-fluid level on the X-rays indicating the presence of a hiatal hernia.

• Pulmonary (lung) function and cardiac health are also assessed.

How Is Collis Belsey Fundoplication Procedure Performed?

The surgery is performed under general anesthesia. After the induction of anesthesia, a double-lumen endotracheal tube is placed for proper airway management. An esophageal bougie is placed to widen the esophagus properly.

Positioning and Incision:

• An endoscopy is performed to eliminate any other complications before the surgery begins.

• The patient is positioned in the left thoracotomy position. In this position, an incision is placed, creating postero-lateral thoracotomy.

Dissection of Stomach and Esophagus:

• With the help of electrocautery, ligaments are divided to expose the lung for retraction.

• Upon retraction of the lung, the esophagus is exposed and incised to facilitate a tension-free area.

• After this, the hiatus hernia is properly dissected, exposing a portion of the stomach.

• Retraction of essential organs and ligating of the blood vessels are carried out simultaneously.

• The junction of the stomach and esophagus is then identified.

Lengthening of Gastric Tube:

• A gastric tube is created from the upper part of the stomach, and a bougie (tube for expanding the esophagus) is passed into the stomach.

• This aids in forming a new GEJ or gastroesophageal junction (a junction between the stomach and esophagus) below the diaphragm.

Fundoplication:

• It is a procedure in which the upper part of the stomach is partially wrapped around the esophagus and is sutured.

• The new GEJ and fundoplication are returned to the abdomen, and sutures are placed.

• At the end of the procedure, an endoscopy is carried out to ensure that the fundoplication is proper.

• The surgery ends with proper extubation (removing the tubes inserted to maintain the airway) and suturing of the incisions.

What Is the Post Operative Management of Collis Belsey Fundoplication?

The post operative management of Collis Belsey fundoplication involves:

• The patient is positioned with a 20-degree to 30-degree elevation of the head in the bed. The patient is assessed for proper analgesia (pain relieving protocol).

• A chest X-ray is suggested to assess lung re-expansion.

• IV (intravenous) fluids are given continuously.

• The patient should be able to get out of bed and walk by himself by the end of the first day.

• Antibiotics are continued for one day.

• The nasogastric tube is removed, and barium swallow (an imaging test that identifies abnormalities in the upper gastrointestinal tract) is performed to check for leaks after the surgery.

• If the swallow does not show any defect, the patient is allowed to take clear fluids, and if tolerated, soft food may be introduced.

• The patient is admitted to the hospital for four to five days, after which they are discharged.

What Are the Complications Associated With Collis Belsey Fundoplication?

Complications associated with Collis Belsey fundoplication include:

• Dysphagia (difficulty in swallowing).

• Gastric leak (a leak of stomach contents from a surgical joint).

• Bleeding.

• Recurrent reflux (a condition where stomach acid is recurrently pushed back into the esophagus).

Conclusion

With the development of advanced minimally invasive procedures, Collis Belsey fundoplication is not preferred as the first line of treatment. Even then, it is a preferred treatment line for hiatal hernia, shortened esophagus, and stricture. In such patients, an excellent long-term result is obtained. It is always necessary to carry out a proper pre-operative assessment to select the patients for surgery