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