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 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.

Evaluation and Diagnosis of Patients

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 ...