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Aiolfi et al. Mini-invasive Surg 2022;6:39 https://dx.doi.org/10.20517/2574-1225.2022.29 Page 3 of 7

value to have SE. However, a definitive diagnosis of SE is possible only at the time of the operation.
Specifically, as stated by Nason et al., intraoperative identification of the true GEJ is mandatory for a precise
SE diagnosis. Specifically, the GEJ is identified below the fat pad at the conjunction of longitudinal
esophageal fibers, which do not have a serosal lining, as they merge with the stomach, which does have a
serosal lining. Therefore, only after fat pad dissection and true GEJ identification can an accurate SE
[21]
diagnosis be accomplished .
Minimally invasive techniques and results
Different techniques have been reported for esophageal lengthening. During the open era, most of them
required a thoracotomy due to the arduous surgical approach to the distal esophagus from the abdomen. By
contrast, minimally invasive approaches gained progressive acceptance with better results in terms of
postoperative functional outcomes and complications. Generally, mediastinal mobilization is necessary to
[22]
obtain at least 3-4 cm of esophagus below the diaphragm without tension . If this mobilization is not
enough, a more extensive transhiatal dissection up to the aortic arch (type 2 mediastinal dissection) may be
required.

Despite the extensive mediastinal dissection, in the case of confirmed SE diagnosis, an esophageal
lengthening procedure is required with different minimally invasive approaches. Swanstrom et al. and Awad
et al. described two hybrids, thoraco-laparoscopic approach via right and left thoracoscopy,
respectively [12,23] . The esophago-gastric junction is approached from the thorax and, with laparoscopic
assistance, a neoesophagus is created using an articulating stapler positioned parallel to the esophagus. Two
other laparoscopic techniques have been proposed. The first procedure, proposed by Johnson et al., consists
[24]
in the creation of an entry point on the anterior gastric wall, 3 cm below the His angle . At this level, a 25
mm circular stapler is inserted and fired over a 48 Fr bougie, thus creating a transgastric antero-posterior
communication. A linear stapler is then inserted through the hole and fired parallel to the esophagus.
Despite the feasibility of this approach, its technical complexity and costs limit its practice utilization. The
fourth procedure was described by Terry and colleagues in 2004 . After distal esophageal dissection, the
[16]
upper portion of the gastric fundus is prepared and a 45-48 Fr bougie is inserted. A mark is made 3 cm
below the His angle and a wedge fundectomy (WF) is performed starting from the greater curvature. Once
the mark is reached, another stapler is oriented parallel to the esophagus. In addition to
Collis/fundoplication, previous studies reported the supplementary effect of gastropexy sutures to further
reduce tension along the esophageal axis. Specifically, Bellevue et al., in their retrospective study, reported
data for Hill gastropexy sutures combined with a traditional Nissen/Collis fundoplication for the treatment
of PEH and SE . Two Hill sutures are placed sequentially through the anterior and posterior collar sling
[25]
musculature of the GEJ and secured to the preaortic fascia.

Up to date, the most commonly adopted procedure for esophageal lengthening is WF. This technique has
documented high technical success rates (up to 90%) with control of reflux symptoms and high patient
satisfaction rate [16,17,26,27] . Postoperative complications after Collis gastroplasty have been reported in up to
36% of cases . Specifically, pulmonary complications such as atelectasis, pneumonia, and pleural effusion
[17]
should be considered in the case of thoracic approach, while staple line leak has been reported in up to 2.7%
of cases [28-30] . Hernia recurrence and recurrent symptoms have been reported ranging from 2% to 30% of
[29]
cases, and approximately up to 6% of patients will need complex redo surgeries . Results are multifaceted,
as the Collis procedure is a compromise. The segment of neo-esophagus is a relatively adynamic segment
without peristalsis, which can lead to dysphagia (3%-13% of patients), particularly in patients with ab initio
altered esophageal motility. Furthermore, conduit size discrepancy can lead to postoperative medium- and
long-term concerns (gradual dilation if too wide/dysphagia if too narrow), and the ectopic gastric mucosa
can continue to produce acid with chronic intra-esophageal acid secretion and esophagitis [31,32] . A 2013 study