42: Management of Shortened Esophagus

For many years, there has been a controversy in the surgical literature regarding the existence or relevance of the short esophagus to gastroesophageal reflux disease (GERD) and antireflux surgery.^1-5 A center that performs a high volume of antireflux procedures reported the prevalence to be approximately 14% in patients presenting for surgical treatment of GERD or paraesophageal hernia.² The normal esophagus is 39 to 41 cm from the incisors and has an abdominal component of approximately 2 to 3 cm in length. In patients with short esophagus, the abdominal component is less than 2.5 cm. A battery of preoperative tests and intraoperative findings enable the surgeon to recognize the short esophagus.

The etiology of esophageal shortening is multifactorial. Chronic inflammation, which causes scarring and fibrosis, may be the culprit of intrinsic esophageal shortening.³ Extrinsic short esophagus may be due to proximal displacement of the esophagus secondary to an enlarging hiatal hernia.⁵ Surgical esophageal lengthening can be accomplished by extensive mediastinal mobilization with or without a Collis gastroplasty.⁶ The goal of Collis surgery is to obtain adequate esophageal length below the hiatus. There is general consensus that an unrecognized short esophagus can cause tension on the surgical wrap, resulting in wrap failure secondary to herniation, slippage, or wrap disruption. Experts differ on the incidence, impact, and correct therapy for short esophagus, and opinions vary widely in the literature. There are those who espouse the liberal use of esophageal lengthening,^1,2 some recommend extensive mediastinal mobilization with selective lengthening,³ and others “never lengthen” based on the belief that short esophagus is a surgical myth.⁴ It is noteworthy that some have changed their views over time.^2,3 Swanstrom et al.,² initially estimated that laparoscopic mediastinal mobilization alone was the adequate treatment for only 30% of patients with short esophagus. Recently, however, they have taken the opposite view—that aggressive mediastinal dissection and esophageal mobilization are adequate for most patients and liberal use of Collis gastroplasty is never indicated. Among other benefits, the Collis gastroplasty is known to minimize the incidence of postoperative dysphagia, postoperative acid reflux, and hiatal hernia recurrence.³ The exact percentage of patients who truly need a Collis gastroplasty is unknown.

In our practice, a significant number of patients referred for failed antireflux procedures are found to have a short esophagus at reoperation. This finding, together with the knowledge that there is little controversy about the need for a tension-free hernia repair, forms the basis of our liberal use of esophageal lengthening procedures when extensive mobilization is not sufficient.

At our institution, all patients with GERD symptoms undergo routine endoscopy, upper gastrointestinal study, pH probe analysis (see Chapter 37), and manometry (see Chapters 33 and 37) as part of the preoperative evaluation. Patients with paraesophageal hernia are evaluated according to the severity of their symptoms (Chapter 46). In the emergent setting (e.g., incarceration), manometry and pH probe analysis are not performed. In the elective and semielective settings (e.g., subacute intermittent volvulus), we order manometry without pH probe analysis. Manometry is the essential tool for deciding whether to perform a full or partial wrap because it provides definitive information about the status of the lower esophageal sphincter (LES) and presence of an esophageal motility disorder.⁷ During endoscopy, the length of the esophagus should be measured and recorded (distance from the incisors to the Z-line). Endoscopy also provides information about the existence and type of hiatal hernia (see Chapters 37 and 45).

The gastroesophageal junction (GEJ) is a high-pressure zone in the distal esophagus that enables swallowing and prevents reflux. Its proper function is multifactorial, depending on anatomic location as well as physiologic function. It is well established that approximately 2.5 cm of abdominal esophageal length is needed for the GEJ to function properly. Findings on endoscopy of a large hiatal hernia (>5 cm), Barrett esophagus (BE), stricture, or total esophageal length of less than 38 cm should raise suspicion of possible esophageal shortening and the need for Collis gastroplasty.^8-10 The upper gastrointestinal study complements esophagogastroduodenoscopy (EGD) with radiographic images that further our understanding of the patient's anatomy. Ultimately, the decision to lengthen the esophagus can only be made intraoperatively, after full esophageal mediastinal mobilization, abdominal dissection, and fat pad medialization have been performed. Consequently, informed consent to perform an esophageal lengthening procedure should be obtained preoperatively from all patients with possible short esophagus.

Chronic inflammation secondary to the recurrent noxious stimulation of acid reflux and possibly bile can lead to chronic injury, scarring of the distal esophagus, and axial shortening (Fig. 42-1). Short esophagus with GEJ displacement can precipitate the development of a paraesophageal hernia. The severity of reflux or presence of extensive esophageal fibrosis may lead to reversible or irreversible changes in esophageal function. The esophagus will respond to the removal of noxious stimuli in most patients. Rarely is the damage irreversible such that it causes permanent dysmotility necessitating esophagectomy. However, since most patients regain esophageal function after removal of the noxious stimuli, it is our practice always to offer an antireflux procedure at the outset.

Esophageal fibrosis and a lack of elasticity predispose to mechanical wrap failure because increased tension and recoil eventually lead to wrap herniation. Short esophagus has been implicated in the failure of laparoscopic Nissen fundoplication, which should be performed tension-free around the distal intra-abdominal esophagus. If this is not possible, esophageal lengthening maneuvers are indicated. These include mediastinal dissection and laparoscopic Collis gastroplasty. Some argue that high mediastinal esophageal dissection in patients with short esophagus can achieve a tension-free fundoplication with optimal results. Others argue that these circumstances call for a combined approach and advocate a more liberal use of Collis gastroplasty in this subgroup. Unfortunately, there are no prospective, randomized studies that can answer this question definitively.

Preoperative evaluation enables operative planning that will alert the surgeon to the possibility of short esophagus and other motility disorders. Our preferred operative approach for treating the short esophagus is laparoscopy. In the rare case of a hostile abdomen, we advocate surgical repair via left thoracotomy. The surgical success depends on tailoring the correct procedure to meet the patient's individual circumstances. Mediastinal esophageal mobilization dissection is classified as type 1, when the circumferential dissection measures less than 5 cm, and type 2, when it is 5 to 10 cm.

There is general consensus about the need to perform type 1 mediastinal mobilization of the short esophagus to obtain maximal esophageal length and perform a tension-free operation. The controversy concerns whether there is an additional need to perform esophageal lengthening or Collis gastroplasty.³ In 1957, Collis described the procedure known as open gastroplasty, the formation of a short neoesophagus by tabularization of the proximal stomach. In addition, he stated that extended transthoracic mediastinal mobilization attained adequate esophageal length in most patients with short esophagus.⁶ In 1993, Swanstrom et al.,² described the first minimally invasive Collis gastroplasty, which they performed by a combined right thoracoscopy and laparoscopic approach. Johnson et al.,¹¹ then introduced a laparoscopic Collis procedure in which they used a circular stapler to create a window below the angle of His to facilitate stapling of a gastric wedge. This procedure was associated with ischemia of the gastric apex. Thus, when reticulating staplers were introduced, the laparoscopic procedure was again modified and the standard procedure is currently used.¹² We believe that the controversy about esophageal lengthening is, in part, due to the transient increased morbidity that has been associated with the evolution of this new laparoscopic technique.

Collis gastroplasty combined with Nissen fundoplication is an effective procedure for patients with a short esophagus. Patient satisfaction, postoperative quality of life, and improvement in quality of life in reflux and dyspepsia score after laparoscopic Nissen–Collis fundoplication are comparable to values observed in patients treated with Nissen fundoplication alone.¹³ In addition, the Nissen–Collis procedure was shown to be safe with 7-year follow-up in a small subset of patients with short esophagus and complicated severe reflux disease.¹⁴

Historically, the variability in the use of the Collis gastroplasty to treat giant paraesophageal hernia repair was associated with short-term recurrence rates of 12% to 42%. Laparoscopic Nissen–Collis fundoplication repair of giant or recurrent paraesophageal hernia with mesh reinforcement was shown to minimize short-term recurrence to 4.7%. Most patients reported excellent symptomatic results when evaluated with the GERD Health-Related Quality of Life questionnaire.¹⁵ Recently, Luketich et al., reported that they performed laparoscopic Nissen–Collis fundoplication in 52.5% of patients who underwent reoperation for recurrent GERD. The quality of life and patient satisfaction after Collis gastroplasty with fundoplication were good in 82% of this cohort.¹⁶ Thus, in our large-volume practice, we liberally perform laparoscopic Nissen–Collis fundoplication.

On complete evaluation of the patient, a tailored approach is offered to treat short esophagus. Surgeons who perform redo antireflux procedures should be familiar with the full scope of fundoplication procedures (see Chapters 38-40 and 42), because the patient's unique circumstances will warrant a tailored approach.¹⁷

We prefer the abdominal approach, when possible. Laparoscopic Nissen fundoplication is the “gold standard” for GERD or paraesophageal hernia. However, up to 14% of patients will require a Collis lengthening procedure, with or without hiatal repair. Rarely, we use other operations, such as Toupet or Dor (see Chapter 40), with a partial wrap for coexisting dysmotility. Regardless of the number of prior surgeries or techniques used (open vs. laparoscopic), we approach all antireflux operations using minimally invasive technique. Rarely, a frozen abdomen is encountered, rendering the abdominal approach technically prohibitive, and we offer a Belsey–Collis procedure instead (see Chapter 38). In our experience, over 95% of these surgeries can be completed minimally invasively without resort to open technique.

The patient is induced using combined anesthesia (i.e., general anesthesia with endotracheal intubation and epidural analgesia). Endoscopy is performed. The patient is placed supine in the lithotomy position. Both arms are tucked in at the sides, and the bed is placed in a shallow anti-Trendelenburg position. A nasogastric tube is inserted for drainage and decompression of the stomach. The stages of the operation are identical to those described in Chapter 39 (Nissen fundoplication). Briefly, these include placement of the camera port using Hassan technique, followed by placement of four additional ports, division of the short gastric vessels with the anterior and posterior gastrosplenic ligaments, opening of the left gastrophrenic ligament with exposure of the left crus, opening of the gastrohepatic ligament, division of the peritoneum over the right crus, and opening of the overlying peritoneum to expose its edge. We do not attempt to directly identify the esophagus before opening the crura because of the risk of perforation. The esophagus is revealed by its orientation, longitudinal muscle fibers, and the vagus nerves, which lie medial to the crura. We avoid dividing any structure that could be confused with the vagus nerves until both nerves have been identified. The right crus is dissected from its confluence to the median arcuate ligament, where it joins the left crus. Great care to prevent perforation of the esophagus or stomach should be taken during mobilization of the GEJ. The esophagus is retracted upward, and a window is opened and widened bluntly to reveal the left side of the abdomen. Finally, we open the superior esophagophrenic ligament.

Esophageal Mobilization

The esophagus in our opinion should be mobilized high in the mediastinum to obtain adequate esophageal length. An understanding of thoracic esophageal anatomy is essential when performing mediastinal mobilization (Fig. 42-2). Care should be taken not to injure the left and right vagus nerves (12–3 o'clock and 6–9 o'clock), the aorta and aortic esophageal branches (6 o'clock), the posterior membranous wall or the left mainstem bronchus (deep 2 o'clock), the azygos vein (deep 10 o'clock), the pleura (bilateral), and the pericardium (12–3 o'clock). In general, caution should be taken when performing this dissection because serious injury may result if the surgeon loses anatomic orientation.

Practically speaking, once the esophagus has been dissected free of the crural elements, we grasp the fat pad and pull it caudally to the patient's left. Through another port, we retract the right crus away from the esophagus using a Kittner to allow blunt and sharp dissection of the esophagus high into the mediastinum. The dissection proceeds in a clockwise fashion by appropriate retraction. In this way, the esophagus can be freed at least 5 to 7 cm proximal to the hiatus, which usually provides sufficient length for a “no-tension” wrap. This maneuver requires experience, and care must be taken to avoid injury to the vagii or aorta and to avoid entering the pleurae. On occasion, one should expect the patient to have subcutaneous emphysema or neck discomfort postoperatively due to dissection of CO₂ in the mediastinum.

Assessing Esophageal Length

After esophageal mobilization is complete, the fat pad is medialized (taking care not to injure the anterior vagus nerve). This facilitates an accurate tension-free assessment of the level of the GEJ. In making this assessment, one considers the esophageal length measured during intraoperative endoscopy, findings on barium swallow, and the visualized location of the GEJ when no traction is placed on the stomach. A Collis lengthening procedure is performed at this juncture, if the esophagus appears to be short despite lengthening. The nasogastric tube is removed, and a bougie (size 52–58 based on the patient's height and weight) is inserted to 50 cm (Fig. 42-3A). The 5-mm left midclavicular port is replaced by a 12-mm port. The stomach is then aligned and stabilized using a grasper on the left side of the GEJ and an additional grasper on the short gastric line near the region of the first short gastric artery. A reticulating Endo-GIA stapler (with a 30-mm blue staple cartridge) is applied for three sequential firings, forming a gastric wedge of cardia that is fashioned and removed (Fig. 42-3B and Table 42-1).

Hiatal Closure and Wrap Formation

After the gastroplasty is complete, the bougie is withdrawn to 25 cm. We routinely close the crura using an Endostitch device (Auto Suture, Norwalk, CT) and a Ti-rite knot (Ti-rite Knot Device, Wilson-Cook Medical, Winston-Salem, NC). With access from the left midclavicular port, the esophagus is elevated, exposing the crura, which are visually assessed for strength. If they appear weak or the patient has a large paraesophageal hernia, we request rehydration of a biodegradable collagen mesh (SurgAssist System, Power Medical Interventions, New Hope, PA) by the scrub nurse on the back table. Typically, at least three stitches are needed for crural closure. The first is placed beyond the crural confluence (V, similar to a vascular anastomosis). Before tying the last stitch, the bougie is reintroduced to 50 cm and the hiatal closure is assessed. Optimally, there should be a few millimeters between the esophagus and the diaphragm. If a mesh reinforcement of the crura is indicated, the mesh is cut to size and sutured anteriorly to itself and to the diaphragm and then posteriorly to itself and the hiatus. Securing the mesh in this manner prevents migration and provides a biologic scaffold, thereby reducing the incidence of recurrence owing to hiatal hernia.

The choice of fundoplication depends on the results of preoperative manometry testing. We perform a laparoscopic Nissen–Collis fundoplication for most patients with short esophagus. This procedure is similar to the laparoscopic Nissen fundoplication described in Chapter 39. The apical point of the staple line is brought under the esophagus and “shoeshined” with the greater curvature (Fig. 42-4A). This operation is similar to the laparoscopic Nissen fundoplication with one important exception: the target point of the stitch (wrap-“esophagus”-wrap) used to secure the wrap in the Nissen– Collis procedure is the Collis gastroplasty or neoesophagus (Fig. 42-4B). The bougie then is removed. A nasogastric tube is placed, and the ports are closed laparoscopically. After gaining consciousness, the patient is extubated and taken to recovery.

On postoperative day 1, we routinely obtain a barium swallow to rule out perforation or leak after Collis gastroplasty. If the swallow is normal, we remove the nasogastric tube and slowly advance the diet to clear oral fluids. Early prevention of postoperative nausea and vomiting is important to decrease the rate of wrap failure. In our experience, postoperative nausea and delayed motility are more common in patients with short esophagus. Symptoms usually can be abated by administering Reglan and/or erythromycin. Patients are discharged after they are able to tolerate enough daily liquids to prevent dehydration. Postoperatively, we educate our patients to eat slowly and in small amounts. Patients are sent home on a full liquid diet for 2 weeks. If problems are not encountered, they are advanced to a regular diet devoid of bread and carbonated beverages. Postoperative dysphagia is common and can persist for a variable length of time.

The major pitfalls of short esophagus include all the pitfalls and dangers described for the laparoscopic Nissen fundoplication (see Chapter 39). In addition, patients undergoing surgery for short esophagus experience poorer overall outcome compared with patients undergoing primary simple antireflux procedures, because they typically suffer from long-standing disease and have more pronounced pathology that may be less reversible in nature. Patient selection is key because at the completion of surgery, the patient's esophagus must reach normal length as the result of mobilization or Collis gastroplasty. Preoperative esophageal motility tests will dictate the preferred wrap (e.g., no history of achalasia, diffuse esophageal spasm, or scleroderma).

Important operative danger points include:

• Unidentified perforation or damage to the hollow viscus, stomach, or esophagus during retraction or dissection and mobilization of the esophagus.

• Improper hiatal closure due to (1) incomplete or loose hiatal closure that may lead to postoperative hiatal hernia or (2) tight hiatal closure that may lead to esophageal obstruction and consequently achalasia.

• Mediastinal esophageal mobilization increases the risk of uncontrolled bleeding in the thorax, pneumothorax, and injury to the vagus nerves.

• Inadequate mobilization of gastric fundus and distal esophagus may lead to suboptimal position of the fundoplication and, as a result, inadequate function.

The diagnosis and treatment of the short esophagus are controversial. Esophageal shortening is associated with chronic esophageal disease and complicated GERD (e.g., presence of large hiatal hernia, BE, esophageal stricture, or long-standing disease). Preoperative evaluation may suggest the possibility of short esophagus; however, its predictive value for gastroplasty is low. Operative assessment after complete mediastinal esophageal mobilization is used by some to identify short esophagus of a degree that requires the formation of a Collis gastroplasty. The extent of mediastinal esophageal mobilization and the need for Collis gastroplasty are controversial. It is probable that with greater experience and confidence in esophageal mobilization, the requirement for surgical extension decreases. With improvements in laparoscopic skills and equipment over the last 15 years, the laparoscopic Nissen–Collis fundoplication has evolved. Lacking prospective randomized trials, the indication for esophageal lengthening is surgeon-dependent. Most patients undergoing antireflux surgery for GERD or paraesophageal hernias will not require an esophageal lengthening procedure to reduce the GEJ below the esophageal hiatus.

The incidence of short esophagus is probably related to the degree and duration of reflux or paraesophageal hernia. Collis gastroplasty is particularly useful in patients with BE, long-standing giant paraesophageal hernias, obesity, and those undergoing reoperation for a failed fundoplication. Surgeons who are reluctant to perform a Collis extension should remember that the success of a Nissen–Collis will always be greater than that of a redo Nissen, which is often required when a short esophagus is not sufficiently addressed at the time of initial operation.