Esophageal shortening during the era of laparoscopic surgery

An effective method for determining the presence of a short esophagus preop eratively would be helpful to surgeons. In this study 260 patients underwen t primary laparoscopic antireflux surgery: 44 of them were suspected to hav e esophageal shortening on the basis of (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hern ia greater than or equal to 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessme nt. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underw ent a lengthening procedure: left thoracoscopically assisted laparoscopic C ollis gastroplasty (n = 11) or open transthoracic Collis gastroplasty (n = 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rat e (61%); a combination of tests resulted in an increase in the specificity (63-100%) without a corresponding increase in sensitivity (28-42%), Preoper ative testing is thus useful for predicting the need for an esophageal leng thening procedure. Endoscopy is the best screening test for the short esoph agus. A well planned prospective trial to test the reliability of each test is needed.