True Short Esophagus in Gastroesophageal Reflux Disease
Condition: Gastroesophageal Reflux Disease
MeSH terms: Gastroesophageal Reflux; Esophagitis, Peptic
Study type: Observational

Summary: 
      True short esophagus is controversial in surgery for gastroesophageal reflux disease and
      hiatus hernia. Recently, it was published that extensive esophageal mobilization achieved an
      esophageal length adequate to perform around the esophagus fundoplication in all cases with
      satisfactory long-term results.
    

Detailed description: 
      In the 1960s, surgery for hiatus hernia and gastroesophageal reflux disease were introduced
      based on anatomical principles. The technical foundations of the new surgery were essentially
      dictated by experience. The following findings were reported: the stomach must be wrapped
      around an adequate segment of intra-abdominal esophagus, the antireflux barrier is efficient
      if the fundoplication acts under abdominal pressure and tension over sutures must be minimal
      to avoid disruption. Since the early use of open antireflux surgery, controversy has arisen
      between surgeons who treat patients using dedicated techniques in cases diagnosed with a
      shortened esophagus and surgeons who deny the existence of short esophagus. The clinical
      results achieved by both parties were not different, independently of the adoption of an open
      or minimally invasive technique. In 2008, a multicenter study found that true short esophagus
      was present in almost 20% of patients who were routinely submitted to surgery for
      gastroesophageal reflux disease and/or not axial hiatus hernias; the study was based on
      intraoperative measurements obtained in centimeters of the distance between the gastric folds
      considered the gastroesophageal junction and the apex of the diaphragm after extensive
      mobilization of the intra thoracic esophagus. Recently, in a study performed to assess
      symptomatic recurrence in patients who underwent laparoscopic repair of large hernias, the
      authors did not perform any esophageal lengthening procedures because an adequate segment of
      abdominal esophagus was always achieved after extended esophageal mobilization; they
      concluded that the use of proton pump inhibitors for the medical management of
      gastroesophageal reflux disease may have reduced the formation of peptic stricture, which is
      associated with short esophagus, and that esophageal lengthening procedures should probably
      no longer be applied.

      In this study, the position of the gastroesophageal junction with respect for the
      diaphragmatic hiatus was assessed subjectively. Once more, crucial questions related to the
      debate on short esophagus were raised: is it possible that a) without an objective assessment
      of the position of the gastroesophageal junction , the gastric fundus may be inadvertently
      wrapped around the hypo cardia stomach, which acquires a tubular shape as a consequence of
      progressive esophageal shortening; and b) can the unconventional stomach around stomach
      fundoplication approach achieve good clinical results? To answer these questions, the
      investigators considered cases operated upon to gastroesophageal reflux disease and hiatus
      hernia since 2004, when was routinely adopted the use of intraoperative endoscopic assessment
      of the gastroesophageal junction position with respect for the diaphragmatic hiatus, were
      considered. In this series, participants were grouped according to the radiological
      classification of hiatus hernia, the length of the intra-abdominal esophagus, the surgical
      techniques adopted.
    

Intervention name(s): Surgery
Intervention type(s): Procedure
Intervention description(s): Laparoscopic floppy Nissen, laparoscopic-left thoracoscopic Collis-Nissen, laparoscopic gastric fundus wrapped around the stomach
Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Patients affected by gastroesophageal reflux disease or hiatus hernia submitted to primary
        minimally invasive surgery.
      
Keywords: gastroesophageal reflux disease; hiatus hernia