The influence of esophageal length on outcomes after laparoscopic fundoplication

Background: It has been suggested that laparoscopic antireflux surgery has been associated with an increased incidence of postoperative paraesophageal hiatus herniation, and that this comes (at least in part) from not perform ing an esophageal lengthening procedure in patients with preoperative esoph ageal shortening. This study was undertaken to determine whether patients w ith esophageal shortening have an increased risk of reoperation after lapar oscopic antireflux surgery. Study Design: All patients who underwent a laparoscopic fundoplication betw een December 1991 and March 1999, and who had undergone preoperative esopha geal manometry in our department were included in this study. Preoperative, operative, and followup data were collected prospectively, and original ma nometry recordings were reviewed to determine the length of the esophagus ( the distance between the midpoints of the upper and lower esophageal sphinc ters). An index of esophageal length versus height was also calculated by d ividing esophageal length by height. Esophageal length and the index were t hen compared with clinical outcomes. In addition, outcomes for the 50 patie nts with the shortest index was compared with outcomes of the 50 patients w ith the longest index. Results: This study included 484 patients from an overall experience of 774 laparoscopic antireflux procedures. Postoperative followup ranged from 3 m onths to 5 years (median 2 years). Mean esophageal length was 23 cm (range 14 to 30 cm). There was a significant correlation between height and esopha geal length (r = 0.44, p < 0.0001). Although patients with large hiatus her nias tended to have a shorter esophagus, preoperative endoscopic esophagiti s grading did not influence length. Esophageal length did not influence the overall requirement for further surgical reintervention, although an analy sis of esophageal length in patients who developed specific complications d emonstrated that postoperative paraesophageal herniation was more likely in patients with a shorter esophagus, and reoperation for a tight esophageal hiatus was less likely in patients with a short esophagus. The incidence of paraeosphageal hernia in the 50 patients with the shortest index was 8% ve rsus 2% in the 50 patients with the longest index (p = 0.36). Conclusions: Although the overall reoperation rate after laparoscopic fundo plication was not influenced by esophageal length, this study did demonstra te an association between esophageal shortening and postoperative paraesoph ageal herniation. But the increased risk of this problem is small, and for this reason a case cannot be made for patients with a manometrically short esophagus to routinely undergo an esophageal lengthening procedure. (J Am C oll Surg 2000;191: 360-365. (C) 2000 by the American College of Surgeons).