Laparoscopic antireflux surgery and the thoracic surgeon: what now?

The Belsey Mark IV procedure in the era of minimally invasive antireflux surgery

BACKGROUND

Different surgical techniques exist in the treatment of giant and complex hiatal hernia. The aim of this study was to identify the role of the Belsey Mark IV (BMIV) antireflux procedure in the era of minimally invasive techniques.

METHODS

A single-center, retrospective cohort study was conducted. All patients who underwent an elective BMIV procedure aged 18 years or older, during a 15-year period (January 1, 2002 until December 31, 2016), were included. Demographics, pre-, per- and postoperative data were analyzed. Three groups were compared. Group A: BMIV as first procedure-group B: BMIV as a second procedure (first redo intervention)-group C: patients who had two or more previous antireflux interventions.

RESULTS

A total of 216 patients were included for analysis (group A n = 127; group B n = 51; group C n = 38). Median follow-up in groups A, B and C was 28, 48 and 56 months, respectively. Patients in group A were older and had a higher American Society of Anesthesiologists score compared to groups B and C. There was zero mortality in all groups. The severe complication rate of 7.9% in group A was higher compared with the 2.9% in group B and 3.9% in group C. Long-term outcome showed true recurrence, defined as both radiographic recurrence as well as associated symptoms, in 9.5% of cases in group A, 24.5% in group B and 44.7% in group C.

CONCLUSIONS

The BMIV procedure is a safe procedure with good results, moreover in the aging and comorbid patient with primary repair of a giant hiatal hernia.

Transthoracic fundoplication using the Belsey Mark IV technique versus Nissen fundoplication: A systematic review and meta-analysis

BACKGROUND

Nissen fundoplication is considered the cornerstone surgical treatment for hiatal hernia repair. Belsey Mark IV (BMIV) transthoracic fundoplication is an alternative approach that is rarely utilized in today's minimally invasive era. This study aims to summarize the safety and efficacy of BMIV and to compare it with Nissen fundoplication.

METHODS

We searched MEDLINE, Scopus, and Cochrane Library databases for single arm and comparative studies published by March 31st, 2022, according to PRISMA statement. Inverse-variance weights were used to estimate the proportion of patients experiencing the studied outcome and random-effects meta-analyses were performed.

RESULTS

17 studies were identified, incorporating 2136 and 638 patients that underwent Belsey Mark IV or Nissen fundoplication, respectively. A total of 13.8% (95% CI: 9.6-18.6) of the patients that underwent fundoplication with the BMIV technique had non-resolution of their symptoms and 3.5% (95% CI: 2.0-5.4) required a reoperation. Overall, 14.8% (95% CI: 9.5-20.1) of the BMIV arm patients experienced post-operative complications, 5.0% (95% CI: 2.0-9.0) experienced chronic postoperative pain and 6.9% (95% CI: 3.1-11.9) had a hernia recurrence. No statistically significant difference was observed between Belsey Mark IV and Nissen fundoplication in terms of post-interventional non-resolution of symptoms (odds ratio [OR]: 1.49 [95% Confidence Interval (95%CI):0.6-4.0]; p = 0.42), post-operative complications (OR:0.83, 95%CI: 0.5-1.5, p = 0.54) and in-hospital mortality (OR:0.69, 95%CI: 0.13-3.80, p = 0.67). Belsey Mark IV arm had significantly lower reoperation rates compared to Nissen arm (OR:0.28, 95%CI: 0.1-0.7, p = 0.01).

CONCLUSIONS

BMIV fundoplication is a safe and effective but technically challenging. The BMIV technique may offer benefits to patients compared to the laparoscopic Nissen fundoplication. These benefits, however, are challenged by the increased morbidity of a thoracotomy.

Surgeon specialty does not influence outcomes of hiatal hernia repair

BACKGROUND

Hiatal hernia repair is commonly performed by both general and thoracic surgeons. The present study examined differences in approach, setting, and outcomes by specialty for hiatal hernia repair.

METHODS

Adults undergoing hiatal hernia repair were identified in the 2012-2019 American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped by specialty of the operating surgeon (thoracic surgery vs general surgery). Generalized linear models were used to evaluate the effect of specialty on mortality, major morbidity, and 30-day readmission.

RESULTS

Among 46,739 patients, 5.0% were operated on by thoracic surgery. General surgery operated on younger patients (44.7 years vs 47.0, P < .001) with lesser systemic illness (American Society of Anesthesiologists class ≥3 50.4% vs 54.8%, P < .001) compared to thoracic surgery. General surgery more commonly used laparoscopy (95.0% vs 82.6%) and less commonly used thoracic approaches than thoracic surgery (0.6% vs 8.5%, P < .001). From 2012 to 2019, the proportion of cases performed as an outpatient by general surgery increased (28.1% to 46.4%, P < .001), but it remained stable for thoracic surgery (0.1% to 0.7%, P = .10). After risk adjustment, thoracic surgery specialty was not associated with mortality (odds ratio 0.9, 95% confidence interval 0.5-1.5), major morbidity (0.9, 95% confidence interval 0.7-1.1), or readmission (0.9, 95% confidence interval 0.8-1.1). Rather, factors including surgical approach (laparotomy 1.6, 95% confidence interval 1.4-1.9; thoracoscopy/thoracotomy 2.0, 95% confidence interval 1.5-2.7), inpatient case status (2.4, 95% confidence interval 2.2-2.7), increasing ASA class, and functional status more strongly influenced major morbidity.

CONCLUSION

Operative factors, surgical approach, and patient comorbidities more strongly influence outcomes of hiatal hernia repair than does surgeon specialty, suggesting continued safety of hiatal hernia repair by both thoracic and general surgeons.

A comparison between Belsey Mark IV and laparoscopic Nissen fundoplication in patients with large paraesophageal hernia

OBJECTIVES

Laparoscopic Nissen fundoplication is the most commonly performed operation for the repair of large hiatal hernias. We compared outcomes between the Belsey Mark IV fundoplication and the laparoscopic Nissen fundoplication.

METHODS

A retrospective review was performed over a 10-year period on patients who had repair of large paraesophageal hernia. Patients who received the Belsey Mark IV (n = 118) were matched 1 to 1, by year of surgery, gender, and age, with patients who received laparoscopic Nissen fundoplication. We compared these 2 groups, examining recurrence, need for reoperation, perioperative outcomes, and symptomatic follow-up as defined by the Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire.

RESULTS

Recurrence rates were similar between patients who had a Belsey Mark IV and laparoscopic Nissen fundoplication (8.4% vs 16.1%, P = .11). However, the esophageal leak rate was higher in patients who received a laparoscopic Nissen fundoplication compared with the Belsey Mark IV (6.8% vs 0%, respectively, P = .006), and patients who received a laparoscopic Nissen fundoplication had higher rates of reoperation (9.3% vs 2.5%, respectively, P = .05). Gastroesophageal Reflux Disease-Health Related Quality of Life symptom scores were similar between groups with symptoms in laparoscopic Nissen fundoplication and Belsey Mark IV, being excellent (74.4% vs 81.4%), good (9.3% vs 7.0%), fair (9.3% vs 0), and poor (7.0% vs 11.6%), respectively (P = .52).

CONCLUSIONS

Laparoscopic Nissen fundoplication for large paraesophageal hernias was associated with an increased incidence of leak and reoperation when compared with Belsey fundoplication. Belsey Mark IV fundoplication should be considered when deciding on what operation to perform in patients with large paraesophageal hernias.

Roux-en-Y gastric bypass for obesity after Belsey-Mark IV for large hiatus hernia and intrathoracic stomach, in combination with gastroesophageal reflux disease

BACKGROUND

Obesity is an increasing problem worldwide; patients who remain obese after non-surgical interventions are potential candidates for surgical intervention. Laparoscopic Roux-en-Y gastric bypass (RYGB) has proven its effects on excess weight loss and its positive effect on comorbidities and also, on reflux correction.

CASE REPORT

Our patient, a 53-year-old male, with a BMI of 45 kg/m² and type 2 diabetes, underwent a Belsey-Mark IV procedure in another center because of a large hiatus hernia and intrathoracic stomach, in combination with gastroesophageal reflux disease (GERD). He consulted at our center concerning his morbid obesity. After a positive preoperative evaluation a RYGB was performed with an uneventful postoperative course.

CONCLUSION

RYGB is a safe and feasible procedure to perform after a Belsey-Mark IV procedure. To our knowledge, this is the first and only report of a RYGB after a Belsey-Mark IV procedure. There were no intra-operative complications and 18 months follow-up was unremarkable, with a 78.10% excess weight loss (EWL), at 86 kg, and no remaining symptoms of GERD. We also mention resolution of the patient's diabetes mellitus type 2 measured by the cessation of the glucophage, which is an added health benefit.

The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia

BACKGROUND

The Belsey Mark IV operation has been used for the management of hiatal hernia for over 40 years, but with the introduction of laparoscopic techniques its role has become questionable. To determine the current role of this procedure we present a contemporary series of patients.

METHODS

We reviewed fifteen consecutive patients, mean age of 63 years, who underwent a Belsey Mark IV fundoplication for gastroesophageal reflux in the presence of a hiatal hernia in our Department from January 2005 to March 2011. Indications for the thoracic approach included paraesophageal hernias, recurrent hiatal hernias and previous upper abdominal surgery.

RESULTS

There was no operative mortality. Immediate postoperative morbidity included 1 case of bleeding, 1 case of pneumonia and 1 case of atrial fibrillation. The mean length of stay was 5.9 days. After a mean follow-up time of 49 months, all patients reported total or partial alleviation of their symptoms. No hernia recurrence was detected during barium swallow examination.

CONCLUSIONS

The Belsey approach is a procedure that can be useful as an alternative in selected cases when there are co-morbidities complicating the transabdominal (laparoscopic) approach.

Levels of evidence available for techniques in antireflux surgery

The objective of this study was to determine the levels of evidence and grades of recommendations available for techniques in antireflux surgery. Areas of technical controversy in antireflux surgery were identified and developed into eight answerable questions. The external evidence was surveyed using the databases Medline and EMBASE. Abstracts and appropriate articles were identified from January 1966 to December 2005. A set of search strategies was systematically employed to determine the levels of evidence available for each clinical question. Primary outcome measures included the determination of levels of evidence and grade of recommendation based on The Oxford Center for Evidence-Based Medicine. Secondary outcome measures included for randomized controlled trials were Jadad scores, noting the presence of a sample size calculation, and the determination of an effect estimate and the reporting of a confidence interval. Higher quality randomized controlled trials (mostly level 2b, occasional level 1b) existed to answer three questions: whether to complete a 360 degrees or partial wrap; whether or not to divide the short gastric vessels; and whether to perform laparoscopic or open surgery. Lower quality randomized controlled trials were available to determine whether the use of mesh was helpful, whether or not to use a bougie catheter for calibration of the wrap, and whether an anterior or posterior wrap results in a superior outcome. This was deemed to be of inferior grade of recommendation due to the lack (< 2) of trials available and the sole presence of level 2b evidence. The final two questions: whether to complete fundoplication using a thoracic or abdominal approach and whether to use intraoperative manometry relied exclusively upon level 4 evidence and thus received a lower grade of recommendation. A higher Jadad score seemed to be associated with studies having a higher level of evidence available to answer the question. Sample size calculations were given to answer three questions. Effect estimate was difficult to interpret given inconsistent findings, composite outcomes and lack of reported confidence intervals. In conclusion, antireflux surgery has many randomized controlled trials available upon which to base clinical practice. Unfortunately, these are generally of poor quality. We recommend that esophageal surgeons determine consistent outcome measures and endeavor to improve the quality of randomized controlled trials they perform.

A tailored surgical approach for gastro-oesophageal reflux disease: the Nottingham experience

OBJECTIVE

The objective was to assess the results which can be achieved by tailoring the anti-reflux procedure to the anatomical and functional situation of the patient with gastro-oesophageal reflux disease (GORD).

PATIENTS AND METHODS

Two hundred and seventy six patients undergoing a primary tailored anti-reflux procedure between 1986 and 1996 were evaluated. An anti-reflux procedure was selected on the basis of the anatomical and functional findings assessed by means of barium video, endoscopy, manometry and prolonged pH monitoring. The operations performed were Nissen fundoplication (77), total fundoplication gastroplasty (TFG; 140) and Belsey Mark IV (BMIV; 59). The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to previously published criteria (Orringer MB, Skinner DB, Besley HR. Long-term results of the mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25-31). Patients with recurrent symptoms were fully re-investigated.

RESULTS

Mean hospital stay was 8.2 days (5-32 days). There was one hospital death (0.36%). Mean follow-up was 6.7 years (range, 2.2-13.1 years). Overall excellent or good results were achieved in 247 (89.5%) patients (92.2% in Nissen, 90.7% in TFG and 83.1% in BMIV group, P=0.1). In patients without oesophagitis (n=72), the success rate was 93.1%, while for patients with grade IV oesophagitis (n=89) this was 87.6% (P=0.2). Kaplan-Meier freedom from recurrent or new, operation-induced, symptoms at 10 years was 88.1% (89.5% in Nissen, 87.4% in TFG and 73.8% in BMIV groups, P=0.08).

CONCLUSIONS

These data suggest that where the appropriate anti-reflux procedure is selected, surgery can achieve satisfactory mid- and long-term success rates across the spectrum of GORD. When oesophageal shortening is evident, or merely suspected, we favour a TFG. In the presence of impaired motility and no evidence of oesophageal shortening, a BMIV is the preferred approach. The Nissen procedure is used for uncomplicated cases.