True Short Esophagus in Gastroesophageal Reflux Disease
True Short Esophagus in Gastroesophageal Reflux Disease
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.
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.
Inclusion Criteria:

 -  Patients submitted to primary minimally invasive surgery for gastroesophageal reflux
 diseases or hiatus hernia.

 -  Age > 18 years.

 Exclusion Criteria:

 -  Patients already submitted to minimally invasive surgery for gastroesophageal reflux
 diseases or hiatus hernia for recurrence of the disease.

 -  Patients submitted to open surgery for gastroesophageal reflux diseases or hiatus
 hernia.

 -  Patients affected by other esophageal diseases.

 -  Age < 18 years.