Short esophagus: How much length can we get?

Introduction: Laparoscopic antireflux surgery requires an adequate length of intra-abdominal esophagus. Short esophagus can cause wrap herniation and poor clinical outcomes. The aim of the study is to measure maximum length of esophageal elongation with transhiatal mediastinal dissection. Methods: This is a review of a prospective database created in the tertiary referral center between 2003 and 2006. One hundred and six patients with gastroesophageal reflux disease and suspected short esophagus on barium swallow were studied. Patients underwent antireflux surgery with extended transhiatal mediastinal dissection to elongate short esophagus. Routine measurement of intra-abdominal esophageal segment length with intraoperative esophagogastroscopy and laparoscopy was utilized to define the gastroesophageal junction (GEJ) in order to quantify total intra-abdominal esophageal length. Postoperative 24-h pH manometry, UGI series, and symptom scores were recorded to document the clinical outcomes. The aim of the dissection was to mobilize ≥3 cm of intra-abdominal esophagus. Results: Total esophageal elongation was achieved with a mean of 2.65 (range 2-18) cm. Resultant intra-abdominal esophageal length was measured with a mean of 3.15 (range of 3 to 5) cm. None of the preoperative "short esophagus" required Collis' gastroplasty post extended mediastinal dissection. All preoperative symptom scores showed significant improvements with mean follow-up of 18 (9-36) months. Mean distal esophageal acid exposure normalized in all patients studied postoperatively. Conclusion: Short esophagus can be safely elongated with extended mediastinal esophageal dissection. This technique can obviate the need for Collis' gastroplasty and improve overall outcome after antireflux surgery. We recommend that extended transhiatal mediastinal dissection be performed to establish 3 cm of intra-abdominal esophagus at the time of antireflux procedures.