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.