An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia ≥ 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n= 11) or open transthoracic Collis gastroplasty (n= 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63–100%) without a corresponding increase in sensitivity (28–42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.