Intra-abdominal Esophageal Length Research Articles

565. LAPAROSCOPIC TREATMENT OF HIATAL HERNIAS COMBINED WITH MODIFIED TOUPET FUNDOPLICATION. SURGICAL TECHNIQUE

Abstract Introduction Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias. Aim This study aims to describe our surgical technique of laparoscopic repair in hiatal hernias, including sliding, paraesophageal and mixed types. Material and Methods A total of 65 consecutive patients underwent laparoscopic hiatal hernia repair by the same surgical team within 4 years. Results Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac en bloc, 3 cm of intra-abdominal esophageal length, crural closure and an effective anti-reflux procedure as our modified Toupet fundoplication. Conclusions Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have significant reflux disease, an operative repair is required. A minimally invasive approach is safe and can provide excellent outcomes in the hand of experts. https://we.tl/t-KgcOuSyEMt

Technical Considerations and Approach to Redo Foregut Surgery.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redohiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissectionto free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Minimally invasive fundoplication for gastroesophageal reflux disease

: Gastroesophageal reflux disease (GERD), is one of the most common gastrointestinal diseases treated by physicians, with most patients being successfully managed medically. Patients with refractory or persistent disease may be treated using minimally invasive surgical techniques. Patients may also elect for surgical treatment of GERD to avoid the potentially deleterious effects of long term antisecretory [proton pump inhibitor (PPI)] use. Preoperative workup is critical to establish the presence of GERD, to rule out concomitant or alternative pathology, and to document the presence or absence of coexisting esophageal motility disorders. When the technical tenants are respected, laparoscopic fundoplication is a safe and effective treatment of GERD. The general principles involve adequate mobilization of the gastroesophageal junction and gastric fundus, high mediastinal dissection, and demonstration of adequate intraabdominal esophageal length. This is followed by secure closure of the diaphragmatic crura, as well as creation of a fundoplication to reinforce the typically hypotonic lower esophageal sphincter. The type of fundoplication used is typically influenced by preoperative manometry, presence of dysphagia, and patient age. Long term symptomatic relief, without the need for antisecretory medications, is achievable for the majority of properly selected patients. Postoperative morbidity and mortality are uncommon following laparoscopic treatment of GERD. The following manuscript describes our method for performance of both laparoscopic complete and partial fundoplication.

Evolution in the treatment of gastroesophageal reflux disease over the last century: from a crural-centered to a lower esophageal sphincter-centered approach and back.

The surgical management of gastroesophageal reflux disease (GERD) has evolved significantly over the past century, driven by increased understanding of the physiology of the reflux barrier, its anatomic components, and surgical innovation. Initially, emphasis was on reduction of hiatal hernias and crural closure as the etiology behind GERD was felt to be solely related to the anatomic alterations caused by hiatal hernias. With persistence of reflux-related changes in some patients despite crural closure, along with the development of what is now modern manometry and the discovery of a high-pressure zone at the distal esophagus, focus evolved to surgical augmentation of the lower esophageal sphincter (LES). With this transition to an LES-centric approach, attention shifted to reconstruction of the angle of His, ensuring sufficient intra-abdominal esophageal length, development of the now commonly employed Nissen fundoplication, and creation of devices that directly augment the LES such as magnetic sphincter augmentation. More recently, the role of crural closure in antireflux and hiatal hernia surgery has again received renewed attention due to the persistence of postoperative complications including wrap herniation and high rates of recurrences. Rather than simply preventing transthoracic herniation of the fundoplication as was originally thought, diaphragmatic crural closure has been documented to have a key role in re-establishing intra-abdominal esophageal length and contributing to the restoration of normal LES pressures. This progression from a crural-centric to a LES-centric approach and back has evolved along with our understanding of the reflux barrier and will continue to do so as more advances are made in the field. In this review, we will discuss the evolution of surgical techniques over the past century, highlighting key historical contributions that have shaped our management of GERD today.

Hill Modified, a Novel Approach: Technique Description and Experience in Patients with Laparoscopic Sleeve Gastrectomy.

Gastroesophageal reflux disease (GERD) is a common disease among patients with obesity, with an associated prevalence of 39 to 61% between the population who attends a bariatric surgery evaluation. Laparoscopic sleeve gastrectomy (LSG) has become a popular and valid option for obesity treatment, even though the literature is ambivalent regarding the increase or decrease in GERD after this surgery. Thus, it is necessary to propose new surgical techniques as a solution to GERD in patients with a concomitant LSG or with a history of it. Therefore, we present a modified technique based on Hill's gastropexy described originally in 1967. Describe and propose a surgical procedure for GERD management based on the Hill technique that can be applied in all patients who undergo an LSG or with a history of it. Retrospective observational study with a prospective database in which we described, Hill modified technique in a group of 16 patients with GERD who underwent this procedure concomitantly with an LSG or who presented with GERD after LSG with a 3-year follow-up. The surgical technique is based on an intra-abdominal esophageal length of a minimum of 3 cm and posterior fixation of the gastroesophageal junction to the crus. Postoperative controls have shown satisfactory results in the control and management of GERD symptoms in this group of patients, with very few to no complications associated with the procedure and without reintervention or medication out of the standard protocol. Hill modified technique can be used and presented as an option for GERD control in patients with LSG.

A626 Hiatal hernia repair 14 years after gastric bypass with implantation of bioabsorbable mesh

Gastric bypasses (GB) can have late complications. One of these complications is hiatal hernia with pouch migration into the mediastinum. This can cause dysphagia, reflux and even aspiration. Bariatric surgeons need to be aware of this problem, how to diagnose it, and how to treat it. This video highlights the case of a patient who underwent a laparoscopic GB in 2004. She maintained about a 45 kg weight loss but over the last 2 years had developed progressively worse symptoms of dysphagia and reflux. She was referred to our center and upper gastrointestinal series and computed tomography revealed intra-thoracic pouch migration. The video shows the images and the operative approach. Standard trocar placement for bariatric/foregut surgery is used. The pouch is dissected out of the mediastinum and adequate intra-abdominal esophageal length is obtained. The diaphragm is closed with a posterior cruroplasty and a piece of bioabsorable mesh is used as reinforcement. Post operative images are shown.

PS01.064: LAPAROSCOPIC FUNDOPLICATION: NEW ASPECTS IN NEURAL ANATOMY OF THE ESOPHAGOGASTRIC JUNCTION

Abstract Background In laparoscopic fundoplication the mobilisation of the distal esophagus and the proximal stomach are mandatory in order to obtain enough intraabdominal esophageal length and to enable a posterior fundoplication. In surgical literature and in most anatomic illustrations there are no nerves described between diaphragm and stomach. Moreover the mechanism of the so-called postfundoplication complaints is not fully understood yet. We intraoperatively observed small nerve branches penetrating the left crus of the diaphragm lateral of the hiatus, presumably going into the stomach. Their course (from lateral to medial) suggested that they could be branches of the splanchnic nerves or phrenic nerves rather than branches of the vagus. It was the aim of the study to find these nerves in cadavers and to describe their origin and their target organ. Methods 53 cadavers (23 male 30 female, age range: 35–103 years) were dissected with special attention to the course of the nerves penetrating the left crus of the diaphragm. The whole course of the nerves was documented with drawings and photos. Results In 17 out of 53 cadavers, one or two splanchnic nerves were found. Seen from below, they penetrated the left crus of the diaphragm in mean at the 4 o`clock (range: 2–5) position, in mean at a distance of 2cm (range: 0–5) from the hiatus, all of them going into the stomach (cardia or fundus). Ten out of them had an additional branch going into the coeliac ganglion. In 14 cadavers, a branch of the phrenic nerve was found, penetrating the left crus at a 4 o`clock position, in mean at a distance of 7,3cm (range: 3–10). These phrenic nerves mostly went into the stomach (fundus), but in two cases, additional branches going to the coeliac ganglion were found. Conclusion Branches of the splanchnic nerves and of the phrenic nerve, penetrating the left crus of the diaphragm at the 3–5 o`clock position are regularily found. Most of them go to the stomach, and some also have branches to the coeliac ganglion. The role of these nerves is not clear yet, but they all are cut regularily during a laparoscopic (posterior) fundoplication. Disclosure All authors have declared no conflicts of interest.

PS01.002: INTERSPHINCTERIC ESOPHAGEAL LENGTH IN ADULTS

Abstract Background High Resolution Manometry (HRM) has replaced standard water perfused manometery as the gold standard for esophageal testing. While normal and abnormal parameters continue to be refined for HRM there is no literature related to manometric esophageal length in adult population using HRM. Aim of this study is to define normal range for esophageal length and variation with patient height. Methods An IRB approved, prospectively maintained esophageal testing registry was queried to identify patients who underwent HRM between 11/01/2016 and 11/01/2017. Patients with history of previous esophageal surgery, hiatal hernia or major disorders of peristalsis were excluded. Inter-sphincteric esophageal length (cm) was measured from the lower border of UES to the upper border of LES during inhalation. Esophageal Length Index (ELI) was calculated by dividing the esophageal length by patient height. Results A total of1139 patients underwent HRM in the study period of which 235 patients met inclusion criteria and form the cohort for this study. Mean age was 57.3; BMI was 27.3. Median height was 166.6 cm, inter-sphincteric length was 22.4 cm. Mean ELI was 0.135 (+ 0.012), with 5th and 95th percentile range of 0.113 and 0.154 respectively (Figure 1). Conclusion Esophageal length and ELI varies in the normal population. An ELI of < 0.113 draws attention to possible short esophagus. It would be interesting to correlate these parameters with intra-abdominal esophageal length in patients undergoing hiatus hernia repair. Disclosure All authors have declared no conflicts of interest.

Modern diagnosis and treatment of hiatal hernias.

Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias. A literature review of contemporary and latest studies with highest quality of evidence was completed. This information was examined and compiled in review format. Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac, 3cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure. Repairs not amenable to key steps may undergo gastropexy and gastrostomy placement as an alternative procedure. Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have reflux disease, an operative repair is required. A minimally invasive approach is safe and has improved outcomes.

Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening With Low Morbidity and Rare Symptomatic Recurrence

The aim of this study was to assess symptomatic recurrence in patients who underwent a laparoscopic repair of large hiatal hernia without an esophageal lengthening procedure. Patients who underwent a laparoscopic repair of a large hiatal hernia from September 2009 to September 2015 by a single surgeon were identified in the retrospective review. The patients were followed up prospectively by the operating surgeon using a structured questionnaire, administered by telephone, to assess the symptoms. Symptomatic recurrence was defined as the requirement for a reoperative procedure for symptomatic recurrent hiatal hernia. There were 215 laparoscopic repairs. Reoperations (n = 35) and type I hernias of <4 cm (n = 49) were excluded. The study population included 131 patients: 36 had type I hernia, 4 had type II hernia, 37 had type III hernia, and 54 had type IV hernia. There were 102 women and 29 men, aged 63 (56-74) years. For repair, 102 Toupet, 28 Nissen, and 1 Dor fundoplications were performed. The duration of the operation was 138 (119-172) minutes. Adequate esophageal length was obtained by mediastinal esophageal mobilization in all patients, without Collis gastroplasty. A mesh was used in 106 patients. There was 1 conversion and 2 delayed esophageal leaks. The length of stay was 2 (1-3) days. Perioperative complications included atrial fibrillation in 5 patients, gastric distension or ileus in 5 patients, reintubation in 3 patients, heparin-induced thrombocytopenia in 1 patient, and temporary dialysis in 1 patient. There was no 30-day or in-hospital mortality. The questionnaire was completed by 99 out of 131 patients (76%) at 24 (9-38) months; of the 99 patients, 85 (86%) were free of preoperative symptoms; 91 (92%) were satisfied with the operation; and 73 (74%) were off proton pump inhibitors. Reoperation for symptomatic recurrent hiatal hernia occurred in 8 of the 99 patients (8%), 2 in the perioperative period and 6 at 25 (8-31) months. Laparoscopic repair of large hiatal hernia can be performed with low morbidity and results in excellent patient satisfaction. Tension-free, intra-abdominal esophageal length can be achieved laparoscopically without Collis gastroplasty. Reoperation for symptomatic recurrence is rare.

Laparoscopic Paraesophageal Hernia Repair with Acellular Dermal Matrix Cruroplasty

Laparoscopic paraesophageal hernia repair (LPEHR) has been shown to be both safe and efficacious. Compulsory operative steps include reduction of the stomach from the mediastinum, resection of the mediastinal hernia sac, ensuring an appropriate intraabdominal esophageal length, and crural closure. The use of mesh materials in the repair of hiatal hernias remains controversial. Synthetic mesh may reduce hernia recurrences, but may increase postoperative dysphagia and result in esophageal erosion. Human acellular dermal matrix (HADM) may reduce the incidence of hernia recurrence with reduced complications compared with synthetic mesh. A retrospective review of all cases of laparoscopic hiatal hernia repair using HADM from December 2008 through March 2010 at a single institution was performed evaluating demographic information, BMI, operative times, length of stay, and complications. Forty-six LPEHRs with HADM were identified. The mean age of patients was 60.3 years (± 13.9); BMI 30.3 (± 5.3); operative time 182 minutes (± 56); and length of stay 2.6 days (± 1.9). Nine of 46 (19.6%) patients experienced perioperative complications, including subcutaneous emphysema without pneumothorax (n=2), urinary retention (n=1), COPD exacerbation (n=2), early dysphagia resolving before discharge (n=1), esophageal perforation (n=1), delayed gastric perforation occurring 30 days postoperatively associated with gas bloat syndrome (n=1), and PEG site abscess (n=1). There were 2 clinically recurrent hernias (4.3%). Radiographic recurrences occurred in 2 of 26 patients (7.7%). Six of 46 (13%) patients reported persistent dysphagia. LPEHR with HADM crural reinforcement is an effective method of repairing symptomatic paraesophageal hernias with low perioperative morbidity. Recurrences occur infrequently with this technique. No meshrelated complications were seen in this series.

Short esophagus: how much length can we get?

Laparoscopic antireflux surgery requires an adequate length of intra-abdominal esophagus. Short esophagus can cause wrap herniation and poor clinical outcomes. The aim of the study is to measure maximum length of esophageal elongation with transhiatal mediastinal dissection. This is a review of a prospective database created in the tertiary referral center between 2003 and 2006. One hundred and six patients with gastroesophageal reflux disease and suspected short esophagus on barium swallow were studied. Patients underwent antireflux surgery with extended transhiatal mediastinal dissection to elongate short esophagus. Routine measurement of intra-abdominal esophageal segment length with intraoperative esophagogastroscopy and laparoscopy was utilized to define the gastroesophageal junction (GEJ) in order to quantify total intra-abdominal esophageal length. Postoperative 24-h pH manometry, UGI series, and symptom scores were recorded to document the clinical outcomes. The aim of the dissection was to mobilize>or=3 cm of intra-abdominal esophagus. Total esophageal elongation was achieved with a mean of 2.65 (range 2-18) cm. Resultant intra-abdominal esophageal length was measured with a mean of 3.15 (range of 3 to 5) cm. None of the preoperative "short esophagus" required Collis' gastroplasty post extended mediastinal dissection. All preoperative symptom scores showed significant improvements with mean follow-up of 18 (9-36) months. Mean distal esophageal acid exposure normalized in all patients studied postoperatively. Short esophagus can be safely elongated with extended mediastinal esophageal dissection. This technique can obviate the need for Collis' gastroplasty and improve overall outcome after antireflux surgery. We recommend that extended transhiatal mediastinal dissection be performed to establish 3 cm of intra-abdominal esophagus at the time of antireflux procedures.

Wedge gastroplasty and reinforced crural repair: Important components of laparoscopic giant or recurrent hiatal hernia repair

Laparoscopic repair of a giant hiatal hernia (>50% of the stomach above the diaphragm) is associated with short-term recurrence rates of 12% to 42%. Recurrent hiatal hernias often have significantly altered anatomy, making laparoscopic repair challenging. We hypothesized that increasing intra-abdominal esophageal length by means of Collis wedge gastroplasty, complete fat-pad dissection, hernia-sac excision, and primary reinforced crural repair would minimize short-term recurrence and provide adequate symptomatic relief. From January 1, 2001, though May 1, 2005, 61 patients underwent laparoscopic repair of a giant or recurrent hiatal hernia with a Collis wedge gastroplasty and Nissen fundoplication. Symptomatic outcomes were assessed with a validated questionnaire (Gastroesophageal Reflux Disease Health-Related Quality of Life). We obtained postoperative radiographic imaging to objectively assess anatomic results at a median of 1.13 years. Of the 61 patients, 12 (20%) were referred to our institution after previous repairs. Operating time averaged 308 +/- 103 minutes. The median hospital stay was 4 days. Postoperative complications occurred in 5 (8.2%) patients. One (1.6%) patient died of cardiac complications. Postoperatively, 52 (85%) patients completed the questionnaire with mean a Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire score of 1.15 +/- 2.78 (scale, 0-45; 0 = asymptomatic). Overall, 51 (98%) of the 52 respondents were satisfied with their surgical outcome. Postoperative radiographic data were available for 54 (89%) patients. We identified no recurrences at 1-month follow-up, and only 4.7% (2/42) had evidence of radiographic recurrence at 1 year or more. Consistent use of a Collis wedge gastroplasty with reinforced crural repair minimizes short-term recurrence after minimally invasive giant hiatal hernia repair. Symptomatic results are excellent in most patients.

EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure

In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication. EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined. EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern. EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Stapled-wedge Collis gastroplasty for the shortened esophagus

Background Minimally invasive Collis gastroplasty is an established technique for managing the shortened esophagus. The purpose of this report is to describe our new technique, the wedge gastroplasty, and report the short-term outcomes. Methods All patients (n = 143) undergoing laparoscopic fundoplication from May 2000 to March 2001 were assessed intraoperatively for shortened esophagus. After mediastinal dissection, 15 patients with inadequate intraabdominal esophageal length underwent wedge gastroplasty. Preoperative symptoms, operative times, and short-term outcomes were evaluated. Results Mean operative time was 184 ± 36 minutes (range 138 to 258). There was 1 cervical esophageal tear from bougie passage and no other minor or major complications. At 6 weeks, there was more improvement in esophageal symptoms compared with extraesophageal symptoms. Conclusions Wedge gastroplasty is effective in decreasing symptoms in patients with shortened esophagus and takes less time to perform than other gastroplasty techniques. Further study is needed to assess long-term outcomes.

Extended hiatoplasty: Early experience with a simple technique to increase the intraabdominal esophageal length in complicated gastroesophageal reflux

Purpose: The aim of this paper is to describe the experience of the Division of Pediatric Surgery of State University of Campinas Medical School with a simple technique of extended hiatoplasty to achieve intraabdominal placement of the distal esophagus in difficult situations. Methods: From April 1997 to November 1999, 7 patients who had either complicated or recurrent gastroesophageal reflux (GER) underwent open (2 patients) or laparoscopic (5 patients) correction of GER that included an extended hiatoplasty. All had undergone previous unsuccessful clinical or surgical treatment. To investigate the severity of the disease, diagnostic endoscopy or barium swallow were performed before surgery. Postoperatively, these children underwent clinical evaluation or any additional diagnostic procedure deemed necessary. Results: Using the extended hiatoplasty, a good length of intraabdominal esophagus could be achieved in every patient. No complications resulted from the procedure itself. There was a late instance of paraesophageal hernia with recurrence of GER attributable to disruption of the hiatoplasty, which was rerepaired through a laparoscopic approach. Symptomatic improvement was observed in all but the patient with caustic stricture. Conclusions: Extended hiatoplasty is a simple maneuver that may represent a good option to increase the length of intraabdominal esophagus in patients with a short esophagus secondary to severe GER disease, being associated with a high success rate and low morbidity. J Pediatr Surg 36:555-558. Copyright © 2001 by W.B. Saunders Company.

The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery.

To discuss the pathophysiology and incidence of the short esophagus, to review the history of treatment, and to describe diagnosis and possible treatments in the era of laparoscopic surgery. The entity of the short esophagus in antireflux surgery is seldom discussed in the laparoscopic literature, despite its emphasis in the open literature for more than 40 years. This may imply that many laparoscopic patients with short esophagi are unrecognized and perhaps treated inappropriately. Intrinsic shortening of the esophagus most commonly occurs in patients with chronic gastroesophageal reflux disease that involves recurring cycles of inflammation and healing, with subsequent fibrosis. The actual incidence of the short esophagus is estimated to be approximately 10% of patients undergoing antireflux surgery. Of this group, 7% can be appropriately managed with extensive mediastinal mobilization of the esophagus to achieve the required esophageal length. The remaining 3% require an aggressive surgical approach, including the use of gastroplasty procedures, to create an adequate length of intraabdominal esophagus to perform a wrap. Several effective minimally invasive techniques have been developed to deal with the short esophagus. Because a short esophagus is uncommon, there is a natural concern that many surgeons will not perform enough antireflux procedures to become familiar with its diagnosis and management. A complete understanding of the short esophagus and methods for surgical correction are critical to avoid "slipped" wraps and mediastinal herniation and to achieve the best patient outcome.

An Improved Surgical Technique for the Complicated Hiatal Hernia with Gastroesophageal Reflux

Although so-called valve reconstruction procedures at the gastroesophageal junction provide marked relief for most patients with gastroesophageal reflux and hiatal hernia, there is a recurrence rate of 10 to 15%. Many of the recurrences are in patients with obesity, severe pulmonary disease, or stricture, or in patients who have developed a recurrence from other previous types of surgical therapy. Since the primary cause of failure in hiatal hernia repair is tension on the distal esophagus, which is created as a result of securing an adequate length of intraabdominal esophagus, the Collis gastroplasty, which lengthens the esophagus by construction of a tube of the lesser curvature of the stomach, combined with a Belsey reconstruction of the gastroesophageal angle and dilation in cases of stricture, has been successfully employed over the past three years in patients with factors that predispose to recurrence. This technique provides adequate length without tension, and in more than 39 such patients there has been no evidence of reflux or recurrence of hernia by clinical symptoms or cine esophagogram. No mortality or significant morbidity has been observed.