Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus.

BACKGROUND

The shortened esophagus has long been recognized as a potential complicating factor for reflux surgery or the repair of paraesophageal hernias. We discuss the incidence of shortened esophagus encountered in a prospective series of laparoscopic hiatal hernia repairs and present our current operative strategies for dealing with this problem, including a new technique for preforming a cut Collis gastroplasty for severe cases.

METHODS

A prospectively gathered database on laparoscopic fundoplications (n = 213) and giant paraesophageal hernia repairs (n = 25) revealed 34 (14%) patients who had shortened esophagus as defined by the gastroesophageal (GE) junction being > 5 cm above the hiatus. Presentation preoperative diagnosis, operative times, techniques, and outcomes were evaluated.

RESULTS

Three categories of dissection were determined from review of the operative data of these 34 patients. Category I (a normal esophagus easily brought into the abdominal cavity with minimal dissection) occurred in 30% of patients. Category II occurred in 50% of patients and was defined as shortened esophagus requiring extensive mediastinal dissection to allow the GE junction to be brought 2 cm below the diaphragm. Category III patients (20%) were unable, in spite of extensive dissection, to have their GE junction sufficiently reduced to permit fundoplication. Four of these patients had a simple cural closure and gastropexy. Three patients underwent an endoscopic Collis gastroplasty to lengthen the esophagus and allow a tension-free fundoplication. Patients who had a type I or type III dissection with Collis gastroplasty did uniformly well. Patients having type II dissections or no fundoplication had a higher rate of postoperative hernia recurrences and reflux disease.

CONCLUSION

Approximately 14% of patients presenting for surgical treatment of gastroesophageal reflux disease or paraesophageal hernias demonstrate a shortened esophagus. While 30% of these patients are easily treated laparoscopically, 20% to 70% may benefit from an esophageal lengthening procedure. Proper utilization of the Collis gastroplasty should minimize the incidence of postoperative dysphagia, postoperative acid reflux, and hiatal hernia recurrence.