Achieving adequate abdominal esophageal length (greater than at least 2 cm) is an essential basis for any antireflux surgery. Preoperative risk-stratification for potential short esophagus is essential for proper patient counseling and operative preparation for a possible esophageal lengthening procedure and should be based on a careful history and review of all available anatomic and physiologic studies. Risk factors for short esophagus include large hiatal hernia, esophageal stricture, Barrett’s esophagus, as well as others, and they are additive to some extent. Even the presence of multiple risk factors, however, is not completely predictive and short esophagus can only be definitively proven intraoperatively after appropriate extensive mediastinal esophageal mobilization. Once a short esophagus is confirmed, several lengthening options exist including a transthoracic Collis procedure, a laparoscopic stapled-wedge modification of the "Collis" gastroplasty, and/or vagotomy.
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