The short esophagus—recognition and management

Conclusion

Esophageal shortening is a real and clinically important issue for surgeons performing antireflux surgery. The ability to identify these patients preoperatively is based predominantly on experience; however, particular awareness and appropriate preparations should be made for patients demonstrating esophageal strictures and large fixed hiatal hernias. Management should include extensive mobilization of the esophagus to facilitate a tension-free reduction of the esophagogastric junction into the abdominal cavity with subsequent meticulous closure of the esophageal hiatus and anchoring of the repair within the abdomen. If tension-free reduction cannot be achieved, surgeons should be prepared to proceed with a procedure involving Collis gastroplasty or an operation such as the Hill procedure, which involves reliable anchoring within the abdominal cavity. It is currently estimated that approximately 1.5% of patients presenting for antireflux surgery will have some degree of esophageal shortening, and various estimates indicate that 20% to 70% of this population will require specialized surgery because of the inability to establish a tension-free reduction of esophagogastric junction. Based on projections that 20,000 to 40,000 antireflux procedures will be performed in the United States in the year 2000, calculations would show that between 1200 and 2500 patients will require specialized operations for esophageal shortening. Surgeons should be making every attempt to identify these patients preoperatively and have the flexibility to manage them appropriately at the time of antireflux repair.