Belsey Repair Research Articles

Transposition of the esophageal hiatus: a useful addition to Belsey repair of hiatus hernia

A novel method of hiatus hernia repair is presented in the course of which a 4-6 cm incision is made into tendinous portion of the diaphragm beginning at the esophagus hiatus and carried into the anterolateral direction. This allows the mobilized esophagus to be displaced anteriorly. A classic Belsey-procedure is done after which, not only the crura, but also part of the tendinous part of the diaphragm are united posteriorly making recurrence less likely.

The Collis-Belsey Procedure

We reported initial experience with this operation in 1971 [1]. Collis’ technique of gastroplasty was somewhat modified, and a long partial fundoplication was added rather than a Collis’ repair. Our modification uses a transthoracic approach through the left sixth intercostal space. Several technical features warrant emphasis: 1. Exposure and mobilization of the esophagus, cardia and proximal stomach is identical to that used for a Belsey Mark 4 repair. 2. The addition of gastroplasty requires a more extensive removal of the esophagogastric fat pad than the Mark 4 repair. 3. The length and luminal diameter of the gastric tube are considered important features of the anti-reflux mechanism. The tube is fashioned snugly over a No. 48 French bougie, is of uniform diameter from top to bottom, and is usually about 5 cms. in length. 4. A 270 degree partial fundoplication is created over a length of 4 to 5 cms. The length of fundoplication is longer than that used for a standard Belsey repair, — and is created using three rather than two tiers of fundoplicating sutures.

Barrett's esophagus: Does an antireflux procedure reduce the need for endoscopic surveillance?

Barrett's esophagus, a premalignant condition associated with chronic gastroesophageal reflux, carries an approximate 40-fold increase in the incidence of adenocarcinoma. Between 1975 and 1994, 113 patients with Barrett's esophagus underwent antireflux procedures at the Mayo Clinic. The antireflux procedure was performed more than 3 months after the diagnosis of Barrett's disease in 39 patients (34.5%) and during the initial preoperative evaluation in 74 (65.5%). Uncut Collis-Nissen fundoplication was performed in 69 patients (61.1%), Nissen fundoplication was performed in 16 (14.2%), cut Collis-Nissen fundoplication was performed in 12 (10.6%), Belsey repair was performed in nine (8.0%), Collis-Belsey repair was performed in six (5.3%), and Nissen fundoplication with an anterior gastropexy was performed in one (0.9%). There was one operative death (0.9% mortality). Morbidity occurred in 41 patients (36.3%), including cardiac arrhythmia in eight (7.0%), pneumonia in six (5.3%), empyema in five (4.4%), hemorrhage in four (3.6%), myocardial infarction in two (1.8%), and wound dehiscence, wound infection, perforated duodenal ulcer, and postoperative leak in one each (0.9%). Median follow-up for the 112 survivors of operation was 6.5 years (range 4 months to 18.2 years). Excellent or good alleviation of symptoms was obtained in 92 patients (82.2%). Ninety-nine patients (88.4%) are currently alive and 13 (11.6%) have died. Three patients (2.7%) subsequently had adenocarcinoma of the esophagus after the antireflux procedure at 13, 25, and 39 months; two of these died of cancer. The incidence of esophageal carcinoma in this select group of patients was one in 273.8 patient-years of follow-up. We conclude that although antireflux procedures in patients with Barrett's esophagus result in long-term control of reflux symptoms, the possibility of esophageal cancer still exists. Endoscopic surveillance should therefore be recommended. (J T HORAC C ARDIOVASC S URG 1996;111:1135-40)

Circular myotomy and Belsey repair for acquired shortening of the oesophagus.

Fourteen patients with shortening of the oesophagus due to chronic reflux oesophagitis have been treated by a combination of an oesophageal lengthening procedure with a standard anti-reflux repair. Their ages ranged from 18 to 78 years and eight were male. Thirteen patients had a reflux stricture (with additional penetrating ulcer in six) and one had a columnar-lined oesophagus. A complete circular myotomy was performed just below the level of the aortic arch, in combination with a Belsey Mark IV anti-reflux repair. There were no deaths post-operatively but one patient required re-operation for haemorrhage and one underwent oesophageal dilatation before discharge. All patients have now been followed up for over 5 years. Nine patients have required no further treatment for their oesophageal problems, two required two early dilatations each, two required multiple dilatations and one required oesophageal resection for stricture. We suggest that this combination merits further evaluation in the management of patients with short oesophagus due to reflux.

Surgical Treatment of Achalasia: Results with Esophagomyotomy and Belsey Repair

To address the controversy regarding the choice of operation for achalasia, the cases of 57 patients having operation, 38 for the first time (Group 1) and 19 with a previous procedure (Group 2), were reviewed. Surgical emphasis was on hiatal dissection to maximize exposure and use of the Belsey fundoplication to achieve cardiac competence without obstruction. Operative mortality was 1 (1.8%) of 57 patients. In group 1, 21 of the 38 had prior pneumatic dilations. All were treated with esophagomyotomy and a Belsey fundoplication. Clinical results are excellent or good in 30 (88%) of the 34 patients for whom follow-up is available, and are similar in patients with and without prior dilation. Lower esophageal sphincter (LES) pressure decreased from 22.3 to 7.7 mm Hg ( p < 0.001), and pH testing shows no reflux in any of 13 patients. In Group 2, previous operations were esophagomyotomy in 13, esophagomyotomy plus a Nissen fundoplication in 3, and a Nissen fundoplication only in 3. The initial operation failed because of inadequate myotomy in 6 patients, an obstructive Nissen fundoplication in 6, and reflux esophagitis in 7. In these 7 patients, acid reflux testing documented reflux due to cardiac incompetence and delayed clearance. Reoperations included takedown of a Nissen fundoplication in 6, esophagomyotomy and Belsey procedure in 15, Belsey procedure in 1, and resection plus colon interposition in 2. Clinical results are excellent or good in 12 (75%) of the patients with follow-up. These conclusions can be drawn. (1) Esophagomyotomy and Belsey fundoplication lowers LES pressure and provides good results with low risk, even after pneumatic dilation. (2) Failure of myotomy alone is due to either reflux or an inadequate myotomy, both of which are uncommon when exposure for the myotomy is maximal and cardiac competence is reestablished with a Belsey procedure. (3) This approach is also satisfactory for reoperations, although results are poorer.

Postemetic Rupture of Herniated Cardia of the Stomach-Reply

In Reply.— Comments by E. C. James, MD, reiterating some points of his excellent article entitled Postemetic Rupture of Herniated Cardia of the Stomach: A Variant of Boerhaave's Syndrome are noted and appreciated. His conjectures concerning the case described in my Letter to the Editor are not precisely accurate, but his remarks about Belsey and Nissen procedures are cogent. To set the record straight, the modified Belsey repair of my patient's hiatal hernia was done in August 1972. It was done through a right transthoracic approach at the time of pulmonary surgery, leaving the left hemidiaphragm unscathed. Her singular postemetic rupture into the left pleural cavity of a herniated cardia of her stomach occurred almost three years later , in 1975. After she had vomited all ingested materials for three days in 1975, a stat barium swallow examination disclosed an intact hiatal hernia repair with no esophagogastric abnormalities noted. Her continued

Intractable Dysphagia Following Placement of Angelchik Prosthesis for Remix Esophagitis

In 1979, Angelchik and Cohen [1] reported a series of 46 patients in whom a Silastic prosthesis was used to control gastroesophageal reflux. The initial results were good, and to date, no long-term complications have been noted. We discuss a patient in whom severe dysphagia developed following placement of an Angelchik prosthesis. Preoperative evaluation revealed no motor abnormality and no stricture, but there was acute angulation of the gastroesophageal junction. The prosthesis was removed through a left thoracotomy, and a Belsey repair resulted in good relief of symptoms.

Massive Hiatal Hernia with Incarceration: A Report of 53 Cases

Between 1960 and 1980, 53 patients with massive, incarcerated hiatal hernia were treated surgically. In 24 of the 53 patients, there was an associated organoaxial volvulus. The following symptoms and signs, which are almost peculiar to massive, incarcerated hernias, were observed: postprandial precordial distress in 43 patients, upper gastrointestinal bleeding (manifest or occult) in 24 patients, severe dyspnea in 13 patients, and complete obstruction associated with organoaxial volvulus in 4. In only 1 of the 53 patients was the hernia of the true paraesophageal type with the esophagogastric junction remaining in its normal, intraabdominal location. The remainder were all believed to be advanced stages of an ordinary sliding hiatal hernia. Operative treatment consisted of gastroplasty and partial fundoplication in 36 patients, standard Belsey repair in 14, and transabdominal Nissen repair in 3. Gastroplasty and partial fundoplication were used much more frequently during the 1970s, when it was realized that there is a significant incidence of chronic peptic esophagitis and shortening in these patients. Postoperative complications were few in spite of the advanced age of many of the patients. There was one operative death. Only 1 patient was lost to follow-up, and of the 51 patients remaining for analysis, follow-up has extended from 1 to 16 years, with a mean of 6.2 years. No patient has developed recurrent precordial pain, evidence of upper gastrointestinal bleeding, iron deficiency anemia, or severe dyspnea. Seven patients have residual dysphagia; this condition is minimal in 5, and is significant in 2 who require interval esophageal dilation. Nine patients have symptomatic reflux, which is minimal in 5 patients, moderate in 2 patients, and severe in 2 others who were subsequently reoperated on. Contrary to popular concept, our observations indicate that almost all of these patients represent advanced degrees of sliding hiatal hernia with intrathoracic displacement of the esophagogastric junction. This implies a need for an adequate antireflux reconstruction in all patients undergoing operation, as well as an awareness that unanticipated cicatricial changes may be present in the distal esophagus and may prejudice the success of some of the standard hiatal repairs.

Postemetic Rupture of Herniated Cardia of the Stomach

To the Editor.— Indeed, there is nothing new under the sun nor above the diaphragm. The article by Gapp et al (1982;247:811) indicated that isolated rupture through a herniated gastric cardia owing to forceful emesis had not been identified in their review of the literature. I have treated surgically a similar case in 1975. Report of a Case.— A 60-year-old woman had previously undergone a right transthoracic ligation of blebs with pleurodesis and a simultaneous modified Belsey repair of a symptomatic hiatal hernia. Three years later, she was seen for a three-day history of acute left submammary, retrosternal, and subscapular pleuritic chest pains, which were associated with vomiting of all ingested materials. Because of a history of phlebitis, she was treated with intravenous heparin sodium for three days for possible pulmonary emboli. She was subsequently treated with warfarin sodium, tetracycline, and intermittent positive-pressure breathing. A left pleural effusion was treated

Comparison of Nissen fundoplication and Belsey Mark IV in the management of gastroesophageal reflux

Our experience for the past four years with antireflux surgery has been reviewed. The Nissen fundoplication resulted in symptomatic improvement in 87.5 per cent of cases as compared with 64 per cent who were improved after the Belsey Mark IV procedure. Objective evaluation as measured by the standard acid reflux test (SART) revealed recurrent reflux in 9 per cent of those who underwent fundoplication and in 47 per cent of those treated with the Belsey repair. Mortality rates were similar. These results indicate that Nissen fundoplication is superior to the Belsey Mark IV procedure in the management of gastroesophageal reflux.

Intraoperative and postoperative esophageal manometric findings with Collis gastroplasty and Belsey hiatal hernia repair for gastroesophageal reflux

The combination of a Collis gastroplasty with a Belsey Mark IV fundoplication has proved clinically effective in the management of certain patients with complications of gastroesophageal reflux. The present study measured the effect of gastroplasty and Belsey repair on intraluminal pressure changes in the gastroplasty and lower esophagus. Manometric studies were performed preoperatively, intraoperatively, and postoperatively. In each case the gastroplasty segment of the esophagus was found to function as a high pressure zone (HPZ). The pressure in this zone further increased following the fundoplication. It could be diminished with intravenous administration of Buscopan and augmented with intravenously given pentagastrin. The original lower esophageal sphincter in most instances was included in the upper segment of the gastroplasty tube, but the entire length of the gastroplasty tube functioned as an HPZ, and pressures in the tube were considerably higher than those originally present in the lower esophageal sphincter. These studies provide a physiological rationale for the effectiveness of gastroplasty and fundoplication.

Preoperative assessment of esophageal pathology

Panmural esophagitis results in esophageal thickening and shortening and prevents adequate reduction of a hernia. Twenty patients with panmural esophagitis, treated by Belsey repair, have been followed up for more than 5 years; 9 of them remain asymptomatic and 11 have symptomatic reflux, 7 of whom have required further surgery. Belsey also has reported a 45 per cent recurrence rate in patients with this type of disease. Preoperative recognition of panmural esophagitis allows a planned surgical approach and the use of a surgical technique designed for the management of an irreducible hernia. The ability to predict these changes was studied in 124 patients, who were evaluated by history, radiology, endoscopy, and manometry prior to transthoracic hernia repair. The esophagus was inspected at operation to determine the presence of panmural changes. History was of no value in assessment. Radiologically, a large and irreducible hernia was associated with panmural changes, but these changes also occurred in the absence of ulceration. Manometric studies allowed accurate prediction of mural changes. Over 90 per cent of patients with panmural esophagitis have more than 40 per cent disordered motor activity (DMA) in the distal part of the esophagus, and 75 per cent of such patients have more than 60 per cent DMA. Combining these investigative data allowed the accurate prediction of panmural changes in 90 per cent of the 124 patients.

Reflux Control Following Extended Myotomy in Primary Disordered Motor Activity (Diffuse Spasm) of the Esophagus

We have previously reported the results of extended esophageal myotomy and Belsey hiatal hernia repair in 21 patients. Reflux was considered to be a late complication of this operation, and gastroplasty has subsequently been added. Thirty-four patients have now been surgically treated, 17 with myotomy and Belsey repair and 17 with myotomy, gastroplasty, and Belsey repair. Eight of the 17 with Belsey repair developed clinical and roentgenographic signs of reflux 6 to 27 months following operation without evidence of hernia recurrence; 5 of the 8 patients have required further operation, with the addition of gastroplasty for reflux control. Seventeen patients were treated primarily by extended myotomy, gastroplasty, and Belsey repair. None of the patients who underwent gastroplasty have reflux symptoms, and only 1 shows a trace of reflux radiologically.

Gastroesophageal reflux and hiatal hernia: Experiences with the Belsey repair

Reference is made to our two previous publications on the same subject as well as to publications by Belsey and his students, and by Urschel and Paulson. We continue to utilize the Belsey technic with excellent results. Brief reference is made to the concepts relating to this problem which have guided us in selection and management of cases. The surgical technic as presently employed is outlined and illustrated.