1. SECONDARY SHORT ESOPHAGUS DUE TO PROLONGED REFLUX: STILL A PROBLEM?
9/15/2018
SECONDARY SHORT ESOPHAGUS DUE TO PROLONGED REFLUX: STILL A PROBLEM?
Ognyan Brankov
University Department of Pediatric Surgery
Hospital “Pirogov” – Sofia, Bulgaria
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2. 9/15/2018
Background
The problem of the short esophagus in antireflux surgery is widely discussed for many years. The association between severe esophagitis, stricture formation, and esophageal shortening is supported by many previously published studies.
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3. 9/15/2018
Background
Acquired esophageal shortening most commonly occurs in patients with chronic gastroesophageal reflux disease. Other entities associated with esophageal shortening include giant hiatal hernias in the newborn, Barrett’s esophagus, caustic ingestion, which can result in a profound inflammatory reaction and subsequent fibrosis with significant cephalad displacement of the gastroesophageal junction.
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4. The purpose of our presentation is to discuss the pathogenesis of the short esophagus, to review the history of treatment, and to present the challenges which might arise while performing a laparoscopic surgical procedures.
In our initial experience with laparoscopic surgery we faced the problem and have been forced twice to convert to open surgery because of refractory shortening and fibrotic periesophageal adhesions into the mediastinum.

5. There are three main types of esophageal hiatus hernia:
J.Alvin Merendino Displacement of the esophagus into a new diaphragmatic orifice in the repair of para-esophageal and esophageal hiatus hernia. Ann of Surgery, 129,2,1949,
There are three main types of esophageal hiatus hernia:
1. Short esophagus with "thoracic" stomach (rare)
2. Normal esophagus; the stomach herniates about the esophagus into the hernial sac. However, the esophagus remains in its normal situation and does not occupy a position in the sac (para-esophageal).
3. Normal esophagus; the stomach herniates through the esophageal hiatus pushing the esophagus ahead of it into the sac.

6. Transthoracic displacement of the esophagus
K.Alvin Merendino I
Transthoracic displacement of the esophagus
Displacement of the esophagus into a new diaphragmatic
orifice in the repair of para-esophageal and esophageal hiatus hernia. Ann Surgery, 129,2,1949,

7. K.Alvin Merendino II Abdominal Approach
The ventral esophageal displacement provides an extension of the intraabdominal portion.

8. K. Alvin Merendino, D.H. Dillard The Concept of Sphincter Substitution by an Interposed Jejunal Segment for Anatomic and Physiologic Abnormalities at the Esophagogastric Junction Ann Surg, 1955,Vol 142, 3,
1955 Merendino developed experimentally and clinically the concept of cardiac sphincter substitution with interposition of pedicled jejunal patch for certain clinical conditions.
A tentative working classification has evolved where this procedure might have merit:
Physiological Disorders
I. Cardiac sphincter relaxation.
A. Reflux esophagitis with complications
B. Congenitally short esophagus

9. The patient with a hiatus hernia and a markedly short
J. Leigh Collis from Queen Elizabeth Hospital, Birminghan An Operation for Hiatus Hernia with short Oesophagus Thorax (1957), 12, 181
The patient with a hiatus hernia and a markedly short
oesophagus presents a problem, for which there is
not at present a generally accepted line of treatment.
The shortening of the oesophagus makes the problem
unsuitable for treatment by the standard operations for hiatus
hernia, while some of the suggested treatments,
such as oesophago-jejunostomy, are so formidable
that they are unsuitable for the frail and often
aged subjects.

10. “Collis 1” procedure
Thorax (1957), 12, 181
Downward positioning of the GE junction in order to restore the acute angle of His.

11. J. Leigh Collis Gastroplasty Thorax (1961), 16, 197
“Collis II” procedure
The classic Collis procedure – achieving a sufficient abdominal esophageal length.
The goal is a surgical reflux control. The main part of the stomach will be seen to enter well below the diaphragm and at an acute angle.

12. But Collis did not perform a fundoplication because it
was believed at that time that intraabdominal reduction
of the GEJ and recreation of the acute angle of His was
effective as an antireflux barrier.
The Collis gastroplasty alone, without a
wrap, did not control reflux (Adler RH, 1990).

13. In order to ensure a antireflux barier after performing the esophageal lengthening procedure a Nissen fundoplication wrap is made – the so called combined Collis-Nissen reconstruction of the esophagogastric junction.
Orringer MB, Sloan H, Ann Thorac Surg. 1978;25(1):16-21.

14. Next stepp – the “Stapler” Collis – cut and uncut
Cameron BH, Cochran WJ, McGill CW. The uncut Collis-Nissen fundoplication
J Pediatr Surg 1997; 32:887– 891.

15. Steichen FM. Abdominal approach to the Collis gastroplasty and Nissen fundoplication. Surg Gynecol Obstet 1986; 162:372–374

16. Laparoscopic Collis technique

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Our clinical data (1990 – 2009)
For a period of 20 years a total 171 children were operated on for different pathological condition: 138 for GERD, 12 for congenital hiatus hernia and 21 children for secondary reflux following the prolonged dilatation treatment for lye stricture.
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18. 9/15/2018
Clinical data
In 27 of all the children we diagnosed a secondary short esophagus which was treated by means of different surgical procedures.
Age – between 4 and 9 years
Male Female - 11
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19. Clinical data GERD with fibrous esophageal stricture n = 17
9/15/2018
Clinical data
GERD with fibrous esophageal stricture n = 17
Secondary brachiesophagus due to lye corrosion n = 7
Neonatal thoracic stomach (Thoraxmagen) n = 3
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20. Clinical investigation
9/15/2018
Clinical investigation
The diagnosis was carried out by barium
esophagogram, endoscopy, 24-h pH
monitoring and radionuclide studies.
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21. Results
All endoscopic examinations showed mucosal erosion at the level of the fibrous stricture impassable for the scope.
During barium study a wide open cardia is demonstrated, with an obtuse angle of Hiss. A marked hiatal hernia is present and regurgitation of the contrast material is demonstrated.
The 24-hour pH-monitoring showed prolonged acid reflux with a reflux-index of 18 to 67 %
The reflux scintigraphy confirmed the diagnosis

22. According to the classification of K
According to the classification of K.Horvath we divide our cases as follow:
True, nonreducible short esophagus (GERD - 3)
Transthoracic fundoplication (2), uncut Collis gastroplasty (1)
True but reducible short esophagus (mistreated GERD – 11, lye stricture – 7)
Deep mediastinal dissection “Merendino” (18)
Apparent short esophagus (GERD – 3, HH - 3).
Thoraco-laparotomy and stricture resection (3), “Merendino” (3)
K. D. Horvath, Lee L. Swanstrom, B. A. Jobe,
The Short Esophagus Ann Surg (2000) Vol. 232, No. 5, 630–640

23. Surgical procedures in 27 children
9/15/2018
Surgical procedures in 27 children
Abdominal Nissen fundoplication n = 21
Laparo-thoracotomy with intrathoracic esophago–gastro anastomosis n = 3
Transthoracic esophago–gastro anastomosis n = 2
Uncut Collis gastroplasty n = 1
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24. Transabdominal Merendino procedure
Standart Nissen fundoplication was performed in 21 cases. In order to ensure a longer intraabdominal esophageal portion we adapt the transthoracic procedure of Merendino. After deep mediastinal dissection of the esophagus we incise the hiatus arch about 3 cm and positioned the esophagus anteriorly.

25. Laparo-thoracotomy a. intrathoracic anastomosis
Three children with refractory strictures
Underestimate periesophageal changes
Extremely shortening of the esophagus

26. Right thoracotomy a. intrathoracic anastomosis
Right thoracotomy, stricture resection, fundoplication. After resection of the stricture we perform a partial fundoplasty, similar to the “Inkwell esophagogastrostomy” procedure in the meaning of P. Ottosen.
Ottosen, P.a.al: Acta Chir. Scand., 117: l, 1959.

27. Neonatal thoracic stomach (Thoraxmagen)
Total herniation – 2 children
Partial herniation – 1 child
Surgery – Laparotomy, Nissen n = 2
Right thoracotomy, reposition, relaparotomy

28. Secondary brachiesophagus due to lye corrosion
Persistent gastro-esophageal reflux was found in 9 children. They showed symptoms of progressive dysphagia related to increasing stenosis of the esophageal lumen. During prolonged dilatation treatment of severe corrosive esophagitis in children, an inflammatory shortening of the esophagus may lead to secondary GER. This shortening of the muscle wall may cause incompetence of the cardia and a hiatal hernia.

29. We have defined three grades of secondary brachiesophagus: I dgr – obtuse angle of Hiss, insignificant reflux II dgr – small fixed hiatal hernia, moderate reflux III dgr – marked HH, deteriorated esophagus, expressive reflux
Grade II and III are indication for antireflux plasty

30. Postoperative complications – 9 (33 %)
Recurrence - 6 (1 HH, 1 GERD, 4 lye stricture)
Paraesophageal hernia – 2
Slipped Nissen – 1
Mediastinal abscess after extensive mediastinal mobilisation 1
Redo Surgery – 4 children Esophagocoloplasty – 4 children

31. Additionally four children with lye stricture required a second stage esophageal replacement due to irreversible changes and persistent stricture despite antireflux procedure.
Coloplasty n = 3
Gastroplasty n = 1

32. Conclusions
Esophageal shortening as a complication of advanced gastroesophageal reflux disease is seen in % of patients with GERD. For such patients undergoing laparoscopic antireflux surgery, the procedure hold the risk of recurrence due to excessive tension.
Kleinmann E, Halbfass HJ Zur Problematik des „short esophagus“ in der laparoskopischen Antirefluxchirurgie Der Chirurg Apr; 72 (4):408-13

33. Most of cases with short esophagus can be appropriately managed with extensive mediastinal mobilization of the esophagus to achieve the required intraabdominal esophageal length to perform a wrap.
The remaining require different aggressive surgical approaches to create an adequate antireflux valve mechanism at the gastro-esophageal junction.

34. Because a short esophagus is uncommon, a laparoscopic surgeons should be familiar with its diagnosis and management. A complete understanding of this entity and methods for surgical correction are needed to avoid typical postoperative complications.