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Ann Thorac Surg 1997;64:790-794
© 1997 The Society of Thoracic Surgeons
Joseph B. Whitehead Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. A retrospective study was conducted of 276 patients who underwent the Belsey Mark IV antireflux procedure at our institution between 1979 and 1995. The indication for operation was gastroesophageal reflux disease refractory to medical therapy in 137 patients, gastroesophageal reflux disease with symptomatic stricture or Schatzki's ring in 36, achalasia or epiphrenic diverticulum in 74, paraesophageal hernia in 27, and esophageal mass in 2. Fifteen patients (5.4%) had undergone prior antireflux operations.
Results. There was one perioperative death (0.4%) resulting from an apparent myocardial infarction in an 87-year-old woman who underwent operation for paraesophageal hernia with volvulus. Two patients had contained leaks diagnosed by routine postoperative contrast studies; both were managed successfully without operation. Two patients required early reoperation for recurrent symptoms: 1 underwent a repeated Belsey Mark IV procedure and the other underwent an esophagogastrectomy. An additional 7 patients experienced late recurrence of symptoms requiring surgical management. The overall complication rate was 10.1%, with minor pulmonary complications (2.1%) and atrial arrhythmias (1.8%) occurring most commonly.
Conclusions. The Belsey Mark IV procedure is a safe and effective operation for the management of gastroesophageal reflux disease with complications, and it compares favorably with other antireflux procedures.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The surgical management of gastroesophageal reflux disease (GERD) has progressed over the past 50 years from an emphasis on resection with reanastomosis [1], to a focus on reduction of the hiatus hernia [2], and ultimately to various "antireflux" operations designed to improve the physiologic function of the lower esophageal sphincter and the gastroesophageal junction. These have included complete (360-degree) wraps (the Nissen fundoplication), partial wraps (the Thal and Hill fundoplications), and the creation of an "exaggerated intraabdominal segment of esophagus" (the Belsey Mark IV procedure) [3]. Approaches to the gastroesophageal junction have been through the abdomen [4, 5] and through the chest [4, 6], with the recent addition of "minimally invasive" techniques [7]. Classic indications for surgical management of GERD have been complications such as esophagitis with stricture formation and esophagitis refractory to medical management [2]. The choice of procedure and approach traditionally has depended on the surgeon's personal experience and preference; few data have been published that permit comparison of the various procedures (Table 1
). In view of current trends in the surgical treatment of GERD, we set out to review our institutional experience with the Belsey Mark IV procedure for the management of complicated GERD.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patient Selection and Clinical Technique
Indications for operation in patients undergoing operation for primary GERD included esophagitis with formation of a stricture or Schatzki's ring and reflux symptoms that were refractory to medical therapy. Other indications for the Belsey Mark IV procedure in our patient population included paraesophageal hiatus hernia and prophylaxis against GERD in patients undergoing operations for motility disorders. All patients underwent flexible or rigid esophagoscopy in the operating room before operation to assess the presence and degree of esophagitis, and most patients had endoscopic biopsy samples taken at the time of operation. The surgical approach was through a left posterolateral (sixth interspace) thoracotomy (with the single exception of a patient with situs inversus). A two-layer suture line was created as in the original description of the procedure [3], except that we have modified the technique slightly so that the second layer of sutures is tied before being passed beneath the diaphragm. This allows the sutures to be tied under direct visualization, so that the surgeon can be assured that the knot does not slip or pull through. Postoperative esophagograms were obtained routinely before hospital discharge and at the 1-month clinic visit. Patients were followed up at the Emory Clinic by the operating surgeon at 1 month, 6 months, and then annually unless they preferred to be followed up by their gastroenterologist or primary care physician.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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): modified Heller myotomy in 75 (27%), open dilation of a stricture or division of a Schatzki's ring in 29 (10.4%), additional esophageal procedures in 9, pulmonary resection in 6, and operations for peptic ulcer disease in 3. The total number of cases per year at our referral center has decreased as antireflux operations have become more commonplace in the community and as pharmacologic treatment of GERD has become more effective. Surprisingly, there was no significant change over time in the proportion of patients undergoing other procedures in combination with the Belsey Mark IV operation (Fig 1).
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The overall perioperative complication rate was 10.1% (Table 3). Two patients required early reoperations for recurrent symptoms. The first was a 58-year-old woman with GERD refractory to medical therapy who underwent an uneventful Belsey Mark IV procedure, had a satisfactory early symptomatic and radiographic result, and was discharged home. She returned 1 month later with recurrence. At reoperation, her repair was found to be disrupted and she underwent a Nissen fundoplication. Once again, her symptoms returned after 1 month. She ultimately underwent esophagectomy with colon interposition 2 years later. She continues to have moderate dysphagia and "heartburn." The second patient was a 55-year-old woman with steroid-dependent asthma and GERD that was believed to exacerbate her respiratory symptoms. She underwent a Belsey Mark IV operation and recurrent reflux developed despite an intact wrap. One month later, she underwent a Collis-Nissen procedure, which was successful. Two patients had iatrogenic esophageal perforations in the operating room while undergoing esophagoscopy. These were repaired without sequelae. Five additional patients had "technical" complications: 2 patients had contained radiographic leaks that were managed successfully without operation, 1 patient had a chylothorax, and 1 patient required reexploration for bleeding after a Belsey Mark IV procedure and resection of an esophageal leiomyoma. The fifth patient was a 49-year-old woman with recurrent symptoms 9 months after a transabdominal Nissen fundoplication. She was found to have a primary motility disorder, and underwent takedown of her Nissen wrap, Heller myotomy, and Belsey Mark IV fundoplication. After operation, she had a stricture that was dilated under fluoroscopy. Medical complications most commonly included pulmonary complications (pneumonia or lobar atelectasis) in 2.1% of patients and atrial arrhythmias in 1.8% (see Table 3).
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Seventy-nine patients or immediate family members (29%) were contacted by telephone at least 1 year after operation. Dysphagia was absent or present only occasionally in 79%, and required intervention in 6%. Patients who had no postoperative dysphagia did not experience this symptom later, with the exception of a single patient who had the onset of dysphagia 12 years after a successful operation. Symptoms of GERD were absent or occasional in 84%, required medications in 16%, and required further intervention in 1.5%. Gastroesophageal reflux disease recurred over time in a proportion of patients (Fig 2). The presence of postoperative dysphagia or GERD was not associated with sex or age, and was unrelated to the original indication for operation. Wound complaints (minor discomfort with certain movements) and inability to belch or vomit were present in 2 (2.5%) and 3 (3.8%) patients, respectively.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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) [3–6] demonstrate a fairly high (usually 80% to 90%) degree of long-term success in relieving the symptoms and sequelae of GERD with the Belsey Mark IV procedure as well as with the Nissen and Thal fundoplications. The literature in general is difficult to interpret because the choice of procedure has depended largely on the surgeon's and institution's preference and experience, and because it is difficult to define a "successful" antireflux procedure. Many patients have symptoms that are nonspecific and difficult to quantify both before and after operation. The presence of detectable reflux by esophagograms or pH studies does not necessarily correlate with symptoms [6]. Therefore, we have chosen to focus on definitive perioperative complications as well as the requirement for postoperative dilation or return to the operating room, and to attempt to relate this to clinical symptomatology.
It is our goal to report our experience with the Belsey Mark IV procedure to add to the existing database for antireflux operations and, by doing so, to help surgeons decide how best to approach GERD in any given patient. In half our patients, the Belsey Mark IV operation was performed for "simple" GERD that was refractory to medical management. In the other half, it usually was performed for GERD with complications that required surgical management, or in conjunction with operations for motility disorders in which the primary surgical procedure had a significant probability of causing reflux. In this second group of patients, the Belsey procedure was combined with other esophageal or thoracic operations. There was no significant difference in the complication rate between these groups of patients. There was surprisingly little or no tendency over time for the percentage of patients with complications to increase (see Fig 1). We did observe a trend toward a decreasing total number of cases per year, which probably is attributable in part to the advent of more successful medical treatment, to an increased degree of comfort with antireflux operations in the community, and to recent advances in the laparoscopic management of GERD.
Even though many of our patients were elderly and had significant medical histories, the perioperative complication rate was low and the mortality negligible. Although our long-term follow-up is far from complete in this retrospective study, it provides valuable information about a large group of patients who are likely to have a higher failure rate than that of our overall population. If we define "failure" as the need for either reoperation or endoscopic esophageal dilation, our "success" rate of 95% compares favorably with the literature (see Table 1). This remains true even when we include patients who later experience mild, medically managed GERD symptoms (see Fig 2). It generally is thought that the use of a 360-degree wrap results in a greater chance that the patient will be unable to vomit but a potentially more complete avoidance of reflux. If reflux symptoms can be prevented in more than 80% of patients (see Fig 2), it may be unnecessary to accept the increased complications of a 360-degree wrap.
The Belsey Mark IV procedure is a safe and effective operation for the management of symptomatic GERD and for GERD complicated by esophagitis with stricture formation. It also can be combined reliably with other transthoracic operations. This operation can be performed with minimal morbidity and essentially no mortality. As operations for GERD continue to evolve, it will become increasingly important to assess critically short- and long-term results.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Address reprint requests to Dr Mansour, Cardiothoracic Surgery, The Emory Clinic, 1365 Clifton Road NE, Atlanta, GA 30322.
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References |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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