BACKGROUND: While esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, physiologic outcomes data are sparse in these patients. This study describes the long-term follow-up algorithm and outcomes for patients who underwent antireflux surgery with Collis gastroplasty at our institution. METHODS: Patients who underwent esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of GERD or paraesophageal hernia (PEH). Symptom questionnaires were used at different intervals during follow-up. Barium esophagram, upper endoscopy with biopsies and catheterless esophageal acid monitoring (BRAVO) were recommended. Patients with abnormal studies underwent further treatment. RESULTS: Between 1996 and 2002, 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large PEH, and 20 (30%) had a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic follow-up was available in 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%), and 84% of patients were off medications. Physiologic follow-up was achieved in 37% of the patients. Of those undergoing follow-up studies, 17% had recurrent hiatal hernia, and 80% with esophagitis and pathologic esophageal acid exposure--despite 65% reporting symptomatic improvements compared to preoperative symptoms. Two patients developed Barretts changes that were not present preoperatively. CONCLUSIONS: Distal esophageal injury can persist after EGD with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. While Collis gastroplasties are mechanically appealing, these results call into question the liberal application of this technique during EGF.