Esophageal Lengthening Research Articles

Is there a Proper Way to Treat Shortened Oesophagus ? About a Series of 67 Patients

Introduction and objective: During the work-up of gastro-oesophageal reflux disease (GORD) patients, barium swallow may show a shortened oesophagus with a non-reducible gastro-oesophageal junction. In our department, in such cases, a Collis-Nissen operation is usually planned. But, the proper reducibility of the gastro-oesophageal junction (GOJ) in the abdomen is difficult to assess peroperatively.The aim of this study is to compare retrospectively the follow-up of an oesophageal lengthening procedure (CollisNissen gastroplasty) versus a standard Nissen in the management of patients with primary short oesophagus or secondary to previous Nissen fundoplication.Patients and methods : Between 01/2000 and 12/2009, 67 patients with a short oesophagus on X-Ray were operated on for proven GORD : 27 (Group A) underwent a Collis-Nissen fundoplication. In 40 patients (Group B), the GOJ was reduced easily and a standard Nissen fundoplication was judged sufficient by the experimented surgeon.Follow up included Quality of Life evaluation using the Gastrointestinal Quality of Life Index (GIQLI) and a barium swallow.Results : 64 patients agreed to participate. Mean follow up was 46 months (4-122). Mean postoperative GIQLI score was 108 in group A, 97 in group B.Barium swallow was performed in 61 patients. In group A, seven patients out of 25 (28%) presented a intrathoracic migration on X-Ray while in group B, it was noted in 20 patients (55%).Conclusion : According literature, Collis gastroplasty allows a tension-free fundoplication to be performed to correct a shortened oesophagus. Though our series of brachy-oesophagus is small, it confirms a better outcome after a CollisNissen gastroplasty, compared to the classical Nissen fundoplication.

A novel technique for gaining extra length of the abdominal esophagus

During gastrectomies for carcinomas of the esophagogastric junction, it is often desirable to gain additional length of the abdominal esophagus to construct an intra-abdominal esophagojejunal anastomosis. In this report, we describe a technique of esophageal mobilization that combines transhiatal dissection with transection of both vagus nerves at 3 points: first, at a level 2 cm to 3 cm below tracheal bifurcation; second, 3 cm to 5 cm above the hiatus; and, finally, at the level of the hiatus. Using this technique in 11 patients with carcinoma of the esophagogastric junction, we achieved lengthening of the abdominal esophagus by 3.7 cm ± 1.2 cm (mean ± standard deviation). In all cases, the additional esophageal length permitted the completion of an oncologically adequate resection and the execution of a safe intra-abdominal esophagojejunal anastomosis.

Combination of Spit Fistula Advancement and External Traction for Primary Repair of Long-Gap Esophageal Atresia

Primary repair of long-gap esophageal atresia with almost complete absence of thoracic esophagus was usually believed to be impossible. Thus, esophageal replacement with colon or gastric interposition seemed inevitable. Esophageal lengthening techniques could be an alternative approach. Herewith we describe for the first time the successful combination of the stepwise subcutaneous advancement of the upper esophageal segment (Kimura's technique) with transthoracic traction on the lower esophageal segment (Foker's technique). This combined lengthening technique leads to the primary repair of a long-gap esophageal atresia.

The short esophagus: Intraoperative assessment of esophageal length

To define the frequency and predictors of short esophagus in a case series of patients undergoing antireflux surgery. An observational prospective study from September 10, 2004, to October 31, 2006, was performed at 8 centers. The distance between the esophagogastric junction as identified by intraoperative esophagoscopy and the apex of the diaphragmatic hiatus was measured intraoperatively before and after esophageal mediastinal dissection; a distance of 1.5 cm was arbitrarily determined to categorize cases as long (>1.5 cm) or short (<or=1.5 cm). One hundred eighty patients were enrolled; the mean age of patients was 49.3 +/- 15.3 years. At the first measurement (after isolation of the esophagogastric junction), the median distance between the esophagogastric junction and the apex of the hiatus was equal to or shorter than 1.5 cm in 68 (37.7%) patients; at the second measurement (after full mediastinal isolation), the measurement of the distance was still shorter than 1.5 cm in 34 (18.8%) patients and between 1.5 and 2.5 cm in 24 (13.4%) patients. The median length of the mediastinal esophageal dissection was 6 cm (range 1-12 cm). An esophageal lengthening procedure was performed in 26 (14.4%) patients. The duration of symptoms (P = .047), the General Health domain of the SF-36 questionnaire (P = .001), and an x-ray barium swallow (P = .000) are predictive factors for a "true" short esophagus. True short esophagus is present in about 20% of patients undergoing routine antireflux surgery. Radiology, severity, and duration of symptoms are predictors of true foreshortening.

Staged esophageal lengthening with internal and subsequent external traction sutures leads to primary repair of an ultralong gap esophageal atresia with upper pouch tracheoesophagel fistula

Primary repair of very long gap esophageal atresia (EA) with almost complete absence of thoracic esophagus has usually been thought impossible. Thus, esophageal replacement with colon or gastric interposition seemed inevitable. In contrast, J. Foker described a technique of lengthening the pouches with traction sutures and making primary repair possible. To contribute clinical experience to this discussion, we report about esophageal elongation in a child with long gap EA and an upper pouch tracheoesophageal fistula (TEF). The patient presented as a preterm baby with a long gap EA of almost 9 vertebral bodies (7 cm) and additionally TEF on the upper pouch. Initially, he was treated with a gastrostomy and replogle suction of the upper pouch. Tracheoesophageal fistula was repaired, and the upper pouch brought from the neck into the thoracic inlet. At the same time thoracotomy was performed, and the lower esophageal segment mobilized and fixed to the prevertebral fascia under moderate tension. The tension reduced the gap between both pouches to about 3.5 cm. After 4 weeks, both pouches were mobilized further. However, the remaining gap did not allow primary anastomosis at that time, so the traction sutures were reconfigured and brought out externally through the skin above and below the incision. Daily increases in tension resulted in the ends virtually touching within 10 days. Now a contrast study showed the two lumens within 5 mm of each other, and primary anastomosis was completed without difficulty. Postoperative diagnosed gastroesophageal reflux and anastomotic stricture were controlled by a Thal hemifundoplication and dilatations. In conclusion, staged esophageal lengthening may be considered for a primary repair of EA even in cases with ultralong gap and TEF.

Vagotomy During Hiatal Hernia Repair: A Benign Esophageal Lengthening Procedure

IntroductionThis study describes the use of vagotomy in patients during complex laparoscopic esophageal surgery (e.g., reoperative antireflux surgery (rLARS) or paraesophageal hernia (PEH) repair) when, after extensive esophageal mobilization, the gastroesophageal junction cannot be made to reach the abdomen without tension. In doing so, we hope to understand the risk incurred by vagus nerve division in this setting in order to evaluate its role in managing the short esophagus. MethodsOne hundred and sixty-six patients underwent rLARS or PEH repair between 1/1998 and 6/2003 at our institution. Clinical data was obtained from a prospectively maintained database and systematic patient questionnaires administered for this study. Follow-up was available for 102 (61%) of these patients, at a median of 19 months (range 6–69 months). ResultsFifty-two patients underwent rLARS while 50 patients underwent PEH repair. Thirty patients had a vagotomy during the course of their operation (Vag Group; 20 anterior, six posterior, four bilateral), 13 in the rLARS group (25%), and 17 in the PEH group (34%). The primary presenting symptoms for rLARS and PEH repair patients were improved in 89% in the Vag Group and 91% in the No Vag Group. Similarly, there was no difference in the severity of abdominal pain, bloating, diarrhea, or early satiety between the Vag and No Vag groups at follow-up. No patient required a subsequent operation for gastric outlet obstruction. ConclusionsVagotomy during rLARS and PEH repair does not lead to a higher rate delayed gastric emptying, dumping syndrome, or other side effects. Thus, we propose vagotomy to be a legitimate alternative to Collis gastroplasty when extensive mobilization of the esophagus fails to provide adequate esophageal length.

Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias–preliminary clinical and functional results of a prospective case series

Background Because fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus. Methods Twenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery. Results Total reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery ( P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery ( P = .001). The respective values of the indigestion score were 3.4 and 2.0 ( P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent. Conclusions LMAH seems to be feasible, safe, and has no significant side effects.

Long gap esophageal atresia: lengthening technique and primary anastomosis

Objective The treatment of long gap esophageal atresia remains a major surgical challenge. The authors describe a modification of a lengthening technique based on tissue expansion to avoid sutures cutting through the esophagus. Methods Between January 2004 and August 2006, 4 patients did not respond to stretching, and underwent this modified esophageal lengthening technique using silastic tubes. Results and Follow-up All infants recovered and have an intact esophagus. All infants developed gastroesophageal reflux. Thal antireflux procedure was performed in the first infant. The other 3 patients were managed conservatively. Follow-up ranged between 6 and 34 months. Conclusions The tissue expansion principle can be successfully applied in the esophagus through external traction. Silastic tube fixation at esophageal ends may help to apply even traction and avoid sutures cutting through the esophageal tissue.

HP28P METANALYSIS OF RECURRENCE AFTER LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIA

Introduction Recurrence &amp; reflux are two most important remote complications of lap‐PEH repair (concluded by us at a previous USG meeting UK). However the extent of recurrence remains unknown.Aim To determine the true incidence of recurrence of recurrence after lap‐PEH repair.Material &amp; methods A metanalysis was performed. PubMed, Embase, hand search and personal communication were used to access and appraise studies. Inclusion criteria were full‐text papers from 1991 to date describing lap‐PEH repair on &gt;25 pts, at least 6 m follow up and addressing recurrence. ‘Wrap migration’ papers were excluded. Papers were appraised and data was isolated on summary sheets. MS Office Excel 2005 was used to plot results and represented in graphs. Statistics involved calculating odds, 95 ci and alternative scenario.Results 15 studies were eligible (all retrospective). A total of 1132 pts with 100 recurrences were noted. Overall rec rate (in all pts) was 8.8% and was 10.4% if only followed‐up patients (n = 748/1132) were considered. When patients with objective evidence (follow‐up Ba esophagogram) were used (301/1132), ‘true’ rec rate was 25.5% (i.e. 1 in 4 repairs recurred). Learning curve did not appear to be an issue. The studies revealed broad 95 ci and touching the line‐of‐no‐effect thereby increasing the ‘chance factor’. When alternative model was applied, esophageal lengthening (by Collis‐Nissen gastroplasty) revealed a significant protective influence.Conclusion The true incidence of lap‐PEH recurrence is 25.5%. Mandatory (protocol) follow‐up esophagograms at 1 y are essential. Subconsciously, two emphasis points in the repair have emerged – hiatoplasty and (superadded) esophageal lengthening.

Evaluation of acellular human dermis reinforcement of the crural closure in patients with difficult hiatal hernias

Biologic prosthetics may circumvent mesh-related complications at the esophageal hiatus by becoming remodeled by native cells. We present our experience with acellular human dermal matrix in the repair of difficult hiatal hernias (HH). Records of 17 patients who underwent laparoscopic HH repair using acellular human dermis to buttress the crural closure were analyzed. Hernias were paraesophageal (PEH) in 12 patients, large type 1 in 1 patient, and recurrent after prior HH repair in 4 patients. Barium swallow (BAS) was obtained 6-12 months after surgery. (Data are presented as mean +/- standard deviation.) Mean patient age was 65 +/- 12 years and BMI was 31 +/- 4. Mean gastroesophageal (GE) junction distance above the diaphragm in the PEHs was 4.9 +/- 1.5 cm; 9 of 12 patients with PEH had more than 50% of the stomach in the chest. Mean operating time was 273 +/- 48 min. Average hiatal defect size was 4.7 x 2.7 cm, with 4.2 +/- 1.2 sutures used to close the crura. Nissen fundoplication was performed in all patients, esophageal lengthening in four patients, and anterior gastropexy in three patients. Mean hospital length of stay (LOS) was 2.3 +/- 0.8 days. Mean followup was 14.4 +/- 4.4 months. Postoperatively, only one (6%) patient had heartburn/regurgitation, one (6%) had mild dysphagia, and two (12%) take proton pump inhibitors. Followup BAS at 10.3 +/- 4.9 months after surgery showed small recurrent hernias in two patients (12%), but only one was symptomatic. In addition, there was one symptomatic failure of a redo Nissen in an obese patient. Reoperative gastric bypass 15 months later showed an intact crural closure with a remodeled buttress site. Acellular human dermal matrix may be an effective method to buttress the crural closure in patients with large hiatal hernias. Longer followup in larger numbers of patients is needed to assess the validity of this approach.

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients

This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair. Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test. Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures. Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.

Definitive management of isolated esophageal atresia: Experience at NICH Karachi

<b>Background:</b> Definitive treatment of isolated esophageal atresia (IEA) is still controversial. A study was conducted to review cases of IEA in our department with a view to evaluate the long term results of definitive surgery in these patients.<b> <br>Materials and Methods: </b> Nine consecutive patients with IEA were included in the study. All babies initially underwent cervical esophagostomy and feeding gastrostomy. One baby also had anorectal atresia and needed a colostomy. In 6 babies, end esophagostomy was performed while in 3 babies, lateral esophagostomy was performed. Of the 6 babies with end esophagostomy, two underwent jejunal Interpositioning, two had serial extra-thoracic lengthening and two reverse gastric tube interpositiong. Three babies with lateral esophagostomy were planned for delayed primary repair.<br><b> Results: </b> Both babies with jejunal interpositiong initially did well; serious gastro-esophageal reflux occurred in one baby who needed antireflux surgery. At 6 years follow-up both children had redundant Jejunum. Recurrent Respiratory tract infection remained a problem in one child while other is doing well. Of the two babies with extrathoracic lengthening it was possible to perform end to end anastomosis in one baby but in the other extrathoracic lengthening did not work and gastric transpositioning was performed. Of the two babies with reverse gastric tube interpositioning one developed esophageal stenosis at the site of anastomosis and is on serial dilatations. Other died due to anastomotic leak and mediastinitis. In all the three babies with lateral esophagostomy spontaneous lengthening of esophagus was noted. End to end anastomosis was possible in two of these babies who are doing well. One is waiting definitive surgery. Number of complications, hospital stay and cost of surgery was least in patients with lateral esophagostomy. <br><b> Conclusion:</b> Various methods of definitive treatment have been proposed for isolated esophageal atresia but each having its own complications. Treatment therefore has to be individualized. Lateral esophagostomy with spontaneous esophageal growth may be a good option in developing countries with limited facilities.

Surgical Approach to Gastroesophageal Reflux Disease: What the Radiologist Needs to Know

Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.

Controversies in paraesophageal hernia repair; a review of literature

The surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure. An electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome. A total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected. Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.

Multistaged esophageal elongation technique for long gap esophageal atresia: experience with 7 cases at a single institution

Background/Purpose Esophageal reconstruction for long gap esophageal atresia (LGEA) is still controversial. We successfully managed 7 cases of patients with LGEA by doing staged elongation of the native esophagus and subsequent end-to-end anastomosis. The technique and efficacy of this procedure are evaluated. Methods During the last 10 years, 7 patients with LGEA (Gross type A, 5; B, 1; C, 1) underwent multiple extrathoracic esophageal elongations (ETEEs) of the upper esophagus and subsequent esophagoesophagostomy. Medical records were reviewed in regard to the number of ETEE before definitive esophageal reconstruction, interval between each ETEE, operation time, time before initiation of sham feeding, duration of hospital stay, and complications. Results The definitive esophageal reconstruction was successfully achieved without major complications in all patients after 2 to 4 stages of ETEE. The interval between each ETEE was 72 days on average. The average operation time was 98 minutes. The elongation was 1 to 3.5 cm during each session. Oral sham feeding was recommenced 4.1 days after each ETEE, and the hospital stay was 9.6 days on average. Gastroesophageal reflux occurred in all patients, requiring antireflux surgery. Conclusions We conclude from our experience ( a) that effective esophageal lengthening with preservation of the native esophagus was achieved with multiple ETEE in LGEA and ( b) that this procedure allows oral sham feeding at home until esophageal reconstruction.

Long Gap Esophageal Atresia Successfully Treated by Esophageal Lengthening Using External Traction Sutures

Long Gap Esophageal Atresia Successfully Treated by Esophageal Lengthening Using External Traction Sutures

Dynamic esophageal lengthening for long gap esophageal atresia: Experience with two cases

This report describes two infants with long gap esophageal atresia managed by dynamic esophageal lengthening. Preliminary traction on the atretic ends of the esophagus permitted subsequent primary anastomosis under significant tension. One patient has done well, while the other developed an anastomotic stricture requiring resection. The esophagus was preserved in both infants.

Objective outcomes after laparoscopic giant hiatal hernia repair: Minimization of hernia recurrence

Abstract Introduction: Laparoscopic giant hiatal hernia (GHH) (> 50% of stomach above the diaphragm) repair is associated with a 12–40% early recurrence rate. We applied specialized laparoscopic maneuvers to address this potential technical compromise. Methods: 43 patients underwent GHH laparoscopic repair (34 virgin, 9 reoperative) with esophageal lengthening. Specific emphasis was placed on meticulous preservation of crural integrity, complete sac excision, routine gastroesophageal fat-pad dissection, and Collis gastroplasty. A totally intraabdominal wedge Collis gastroplasty (using simplified EndoGIA stapler techniques) combined with Nissen fundoplication was performed. A validated questionnaire assessed functional outcomes at a 7.8 month median (range, 2–42). Postoperative esophagram objectively evaluated for possible hiatal hernia recurrence at a 7.5 month median (range, 1–26). Results: Operating time averaged 299 ± 108 minutes; wedge gastroplasty added only 10 minutes (mean). Median hospital stay was 4 days (range, 1–43). Perioperative complications occurred in 9% (4/43) of patients: 1 esophageal leak, 1 respiratory failure, 1 gastric-bloat readmission, and 1 pneumothorax. Complete postoperative data were available for 74% (32/43). There was 1 (3%) miniscule, asymptomatic radiographic recurrence. Most patients reported on questionnaire, excellent results in each of 9 symptoms (e.g., heartburn resolved in 94% [30/32]). GERD-related medications were discontinued in 78% (25/32). The mean postoperative GERD Quality-of-Life score was 1.2 ± 3.2 (scale 0–45; 0=asymptomatic). Overall, 97% (31/32) were satisfied with their surgical outcome. Conclusions: Consistent application of specialized techniques in minimally-invasive GHH repair yields a very low rate of early recurrence. Functional results are excellent in most patients, translating to high levels of satisfaction with the procedure.

Very long gap esophageal atresia successfully treated by esophageal lengthening using external traction sutures

Esophageal atresia with a 6-cm gap or longer and a very short distal segment represents the extreme of this disorder’s spectrum, the treatment of which can be challenging. Very often, several surgical procedures have to be carried out to maintain the patient’s own esophagus. The authors report on a child born with isolated esophageal atresia without fistula and a very long gap (8.5 vertebral spaces in length). Delayed anastomosis was accomplished using a combination of various procedures that included a waiting period allowing for spontaneous esophageal growth, mobilization of the distal segment, and esophageal lengthening by external traction sutures. The aim of this report is to define the role of the traction method in the repair of this kind of atresia.

The surgical treatment of the intrathoracic migration of the gastro-oesophageal junction and of short oesophagus in gastro-oesophageal reflux disease.

In the rush to implement laparoscopic surgery for gastro-oesophageal reflux disease (GORD), the necessity to treat a short oesophagus with dedicated techniques was not always adequately considered. The aim of this study was to define the frequency, patterns and surgical treatment of the intrathoracic migration of the g-o junction and short oesophagus in GORD. Between 1980 and 2003 our group indicated surgery only for severe and complicated GORD and for drawbacks of medical therapy. Preoperatively patients underwent clinical-instrumental work up. The various degrees of the intrathoracic migration of the g-o junction were classified according to the barium swallow. A total of 319 patients operated upon were grouped according to the periods 1980-1991 and 1992-2003 with 149 and 170 patients, respectively. In the first period only 'open' procedures were performed; the Collis gastroplasty in addition to the antireflux procedure was performed when reduction of the g-o junction in the abdomen required excessive tension. In the second period mini-invasive techniques were progressively introduced. During laparoscopy, the relationship between the g-o junction and the hiatus, and the need to elongate the oesophagus, was assessed by intraoperative oesophagoscopy. The Collis gastroplasty was performed in 29% in the first period and in 23% in the second period. Radiology was a strong predictor of the necessity to elongate the oesophagus. In the second period, global long-term results improved with respect to the first period; P = 0.047 (first period satisfactory 82%, poor 18%, median FU 84, 12-252 months; second period satisfactory 93%, poor 7%, median FU 34, 6-126 months). In the second period, Collis-Nissen and Collis-Belsey procedures had satisfactory results in 80% and poor in 20%. In surgery for severe GORD, the Collis procedure is required in 23% of operations; radiology helps to plan surgery; intraoperative endoscopy avoids unnecessary oesophageal lengthening.