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Page 2 of 7 Aiolfi et al. Mini-invasive Surg 2022;6:39 https://dx.doi.org/10.20517/2574-1225.2022.29

The pathogenesis of recurrence is multifaceted and caused by a combination of repetitive
diaphragmatic/esophageal movements, positive intra-abdominal vs. negative intrathoracic pressure, and
tension at the crura. Two directions of tension should be pondered: along the length of the esophagus
[4]
(axial) and between the crural pillars (radial) . To improve repair and ideally reduce recurrence, tension
along these vectors should be decreased . Axial tension is assessed intraoperatively by measurement of
[5,6]
intra-abdominal esophageal length. If shorter than 2 cm, short esophagus (SE) should be suspected . Radial
[7]
tension is the lateral tensile force exerted from splayed pillars in a centrifugal direction away from the
hiatus. There are no simple maneuvers to ease its assessment, and this is generally judged by tactile and
visual clues [8-10] . These are prone to heterogeneity, variability, and limited reproducibility.

The aim of this narrative review is to summarize the contemporary knowledge on techniques for axial and
radial tension assessment and minimization during laparoscopic PEH repair.

METHODS
The review of current literature was completed until 25 February 2022 using PubMed, Scopus, Web of
Science, Google Scholar, Cochrane Review, and the Society of American Gastrointestinal and Endoscopic
Surgeons (SAGES) guidelines. Search terms included the following: “paraesophageal hernia” AND
“esophageal lengthening” AND “ Collis gastroplasty” AND “laparoscopy” AND “minimally invasive” AND
“crural repair”. Results were thoroughly reviewed for significance.

DISCUSSION
Axial tension-definition and diagnosis of short esophagus
In 1961, John Leigh Collis described his procedure to enable functional esophageal lengthening. The
original description consisted in the creation of a neo-esophagus by performing a vertical gastroplasty
without fundoplication . Later, the technique was modified with the adding of a transthoracic
[11]
fundoplication to correct the underlying pathologic gastroesophageal reflux disease (GERD), probably the
cause of esophageal fibrosis and consequent visceral shortening.

The definition and identification of short esophagus (SE) remain controversial. Generally, it is defined as a
gastroesophageal junction (GEJ) that after surgical mobilization does not lie more than 2 cm below the
diaphragmatic hiatus . The pathophysiology is multifaceted. Chronic GERD is considered the foremost
[12]
cause of shrinking and visceral shortening. Specifically, depending on the site exposed, fibrosis can lead to
circumferential strictures (in the case the circular layer is most involved) or shortening (in the case the
[13]
longitudinal layer is injured) . Caustic ingestion, scleroderma, or inflammatory bowel disease (i.e., Crohn’s
disease) may be associated with SE. The precise incidence of SE is not defined [14,15] , but studies coming from
high volume centers show that up to 20% of subjects with GERD will require a lengthening procedure
because of SE [16,17] .

Accurate diagnosis of SE is mandatory for an efficacious anti-reflux surgery. Preoperative barium swallow
study, upper endoscopy, and high-resolution manometry have been proposed to possibly provide some
warnings. Specifically, Horvath et al. and Urbach et al. identified long GERD, failed anti-reflux procedures,
lower esophageal sphincter alterations such as hypo- or aperistalsis, a GEJ > 5 cm above the hiatus, grade C-
D esophagitis, Barrett esophagus, history of peptic ulcers, and non-reducible hiatus hernia (HH) as potential
indicators of SE [18,19] . Unfortunately, none of these criteria show high sensitivity and specificity. Similarly,
Yano et al. proposed the esophageal length index in an attempt to predict SE . This results from the ratio
[20]
between the esophageal length, measured from the incisors to the GEJ (in centimeters), and the patient
height (in meters). They found that patients with a score higher than 19.5 had an 83% negative predictive