Short Esophagus

Gastro-oesophageal refl ux disease (GERD) is a complex multifactorial disorder whose treatment is based on knowledge of its pathophysiology, natural history, and evolution. The role of anatomic disorders of the oesophagogastric junction in the pathophysiology of GERD has been recently reevaluated. The term “hiatus hernia” includes several different anatomical abnormalities. The morphological characteristics, “size” of the hernia and “nonreducibility” of the oesophagogastric junction into the abdomen, have been only tentatively related to more severe patterns of refl ux disease. A detailed classifi cation of axial hiatus hernias based on the progressive phases of intrathoracic displacement of the oesophagogastric junction was outlined in the 1960s by Zaino et al. and Wolfe. This classifi cation described the presence or absence and the degree of irreducible intrathoracic migration of the oesophagogastric junction as a refl ection of progressive steps of oesophageal shortening. Hiatal insuffi ciency, concentric hiatus hernia, and the short oesophagus defi ned three progressive and permanent steps of intrathoracic migration of the oesophagogastric junction axial to the oesophagus. The irreducible axial intrathoracic migration of the oesophagogastric junction, whether due to fi brosis or to elastic retraction of the oesophageal wall, is a consequence of long-standing disease in which the defective lower oesophageal sphincter is the primary cause of cardial incompetence. The barium swallow may provide the opportunity to accurately identify the presence of early phases of oesophageal shortening as in the condition of hiatal insuffi ciency or concentric hiatus hernia, along with the more obvious short oesophagus condition. However, the radiological defi nition “short oesophagus” is potentially misleading. The oesophagus is truly shortened when it is fi brotic, otherwise it is “elastically shortened.” When the oesophagogastric junction is permanently displaced into the chest, it is clear that cardial incontinence is severe and irreversible if not surgically treated. The presence or not of a truly shortened, fi brotic oesophagus becomes pivotal when surgery is performed, because dedicated procedures are mandatory in order to minimize negative results, particularly when a minimally invasive procedure is being considered. The current defi nition of short oesophagus comprehends four major concepts: a) the short oesophagus is diagnosed only intraoperatively, b) after extensive mobilization of the mediastinal oesophagus, c)when the intraabdominal portion of the oesophagus is shorter than 2–3 cm with no downward tension applied. Although the combination of endoscopy, radiology and manometry has been shown to be associated with a high positive predictive value for short oesophagus, sensitivity and negative predictive value for the combination of these tests are low, and no single criterion has been shown to be associated with a high specifi city or predictive value. The gold standard for determination of short oesophagus is intraoperative oesophageal mobilization followed by an objective assessment of the esophageal length. Recently intraoperative endoscopy has been proposed in order to identify the oesophagogastric junction in relation to the hiatus. Intraoperative endoscopy requires few technical details to precisely measure the length of the intra-abdominal oesophagus: a) to defl ate the stomach to avoid distension of the fundus and the consequent shortening of the submerged oesophageal segment, b) to mark the level of the gastric folds while withdrawing the instrument, c) to measure the distance between the anterior apex of the hiatus. The decision to measure the length of the intra-abdominal oesophagus after isolation, without tension has the advantage to overcome the concept totally subjective of moderate or reasonable or adequate tension applied to pull downward the stomach. It is generally agreed that if a minimum of 2.5 centimetres of tension–free intra-abdominal oesophagus are not obtained after mobilization, the lenghthening gastroplasty should be added to fundoplication. The minimally invasive Collis-Nissen has gained popularity, mainly in tertiary reference centers via a laparoscopic or a combined thoraco-laparoscopic approach. In patients affected by severe GERD and true short oesophagus, we obtained satisfactory long-term results with the thoracoscopic Collis-laparoscopic Nissen in 93.4% of cases (mean follow- up=58.6 months).