Chapter 42: Management of Shortened Esophagus

INTRODUCTION

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 approximately 2 to 3 cm in length. In patients with short esophagus, the abdominal component is less than 2.5 cm, and often there is no intraabdominal esophagus visible. A battery of preoperative tests and intraoperative findings enable the surgeon to recognize the short esophagus.

The etiology of esophageal shortening is multifactorial. Like most structures, the living esophagus is elastic and held in place proximally by its connections to the pharynx and its attachments and distally at the level of the hiatus. As soon as it is mobilized or removed, it rapidly contracts and becomes shorter. There is general consensus that an unrecognized short esophagus can cause tension on the surgical wrap created for antireflux procedures, resulting in wrap failure secondary to herniation, slippage, or wrap disruption. Chronic inflammation, which causes scarring and fibrosis, may also be the cause of intrinsic esophageal shortening.³ Extrinsic short esophagus is most commonly due to proximal displacement of the esophagus secondary to an enlarging hiatal hernia.⁵ While it is certainly possible to stretch the esophagus and anchor it distally in the hiatus and/or abdomen, this approach is usually unsustainable in the long run due to the tension generated. Surgical esophageal lengthening with minimal if any tension is therefore required and can be accomplished by extensive mediastinal mobilization with or without a Collis gastroplasty.⁶ The goal of either approach is to generate adequate esophageal length below the hiatus. Experts differ on the incidence, impact, and best therapy for the short esophagus, and opinions vary widely in the literature. There are those who espouse the liberal use of esophageal lengthening (by the Collis or equivalent approaches),^1,2 while 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 ...