Assessment of esophageal length

Esophageal shortening is a consequence of scarring and fibrosis associated with repetitive esophageal injury. Anatomic shortening of the esophagus can compromise the ability to perform an adequate tension-free fundoplication and may result in an increased incidence of breakdown or thoracic displacement of the repair. Esophageal length is best assessed preoperatively using video roentgenographic contrast studies and endoscopic findings. Endoscopically, hernia size is measured as the difference between the diaphragmatic crura, identified by having the patient sniff, and the GE junction, identified as the loss of gastric rugal folds. We consider the possibility of a short esophagus in patients with strictures or those with large hiatal hernias (greater than 5 cm), particularly when the latter fail to reduce in the upright position on a video barium esophagram.
The definitive determination of esophageal shortening is made intraoperatively when, after thorough mobilization of the esophagus, the GE junction cannot be reduced below the diaphragmatic hiatus without undue tension on the esophageal body. Surgeons performing fundoplication have reported varying incidences of esophageal shortening, attesting to the judgment inherent in defining and recognizing undue tension. An advantage of transthoracic fundoplication is the ability to mobilize the esophagus extensively from the diaphragmatic hiatus to the aortic arch. With the GE junction marked with a suture, esophageal shortening is defined by an inability to position the repair beneath the diaphragm without tension. In this situation, a Collis gastroplasty coupled with either a partial or complete fundoplication may be performed.
Potential pitfalls of laparoscopic fundoplication include the elevation of the diaphragm due to pneumoperitoneum, potentially contributing to a false impression that esophageal length is adequate, and the limited ability to mobilize the esophagus relative to the transthoracic approach. In our experience, the failure to appreciate esophageal shortening is a major cause of fundoplication failure and is often the explanation for the slipped Nissen fundoplication. In many such instances, the initial repair is incorrectly constructed around the proximal tubularized stomach rather than the terminal esophagus. Surgeons opting to perform fundoplication laparoscopically in the setting of potential esophageal shortening must be vigilant of esophageal tension, technically facile at extensive mediastinal mobilization of the esophagus while preserving vagal integrity, and able to perform a laparoscopic or open transabdominal Collis gastroplasty should esophageal lengthening be necessary.