38: Belsey–Mark IV Fundoplication/Collis Gastroplasty

Introduction

The management of gastroesophageal reflux disease and hiatus hernia has continually evolved in both general and thoracic surgery over the last century. Although the introduction of improved medical management in the form of H₂ blockers and proton pump inhibitors (PPIs) has reduced the number of patients presenting to the surgeon for management of this disease, a well-defined role for surgical treatment remains in the circumstances of medical failure or medication intolerance as well as for a fixed anatomical abnormality. Beginning in the late 1950s with the work of Belsey, Nissen, Hill, and Collis and extending through the present day, there has been great debate as to the optimal surgical approach to reflux disease and repair of paraesophageal hernia. Most recently, minimally invasive approaches have gained favor. However, the traditional techniques of open hiatal hernia repair and fundoplication are required in select patient groups. This chapter will discuss the current application of the transthoracic Collis–Belsey approach to hiatal hernia repair with a focus on appropriate patient selection and evaluation.

General Principles

The operation now attributed to Belsey is the culmination of several rounds of clinical experimentation spanning over a decade's worth of experience. Dr. Belsey's original intent was to create a general approach to the management of reflux disease, and several iterations were needed to arrive at the Mark IV version, which is most commonly used today.¹ In parallel to Belsey's work, Collis also sought to develop a surgical solution for gastroesophageal reflux, focusing on the importance of obtaining an adequate length of intra-abdominal esophagus to allow for a tension-free acute angle of esophageal entry into the stomach. Looking for ways to achieve this, he published the first description of the tubularization of a section of the lesser curvature of the stomach for use as a distal esophageal equivalent in 1957.² In 1971, Pearson et al.³ published a series of 24 patients with peptic stricture of the distal esophagus treated with a combination gastroplasty and Belsey hiatal hernia repair. They reported excellent results with either resolution or improvement in the symptoms of dysphagia in all patients.

The “Collis–Belsey” operation, as described by Pearson, gained a great amount of support as an approach to hiatal hernia repair and a viable antireflux procedure. In recent years, however, the advent of efficacious minimally invasive approaches to the surgical treatment of GERD has limited application of the Collis–Belsey procedure to a relatively specific subset of patients with esophageal stricture and foreshortened esophagus. The operation also has a defined role as an option in the repair of hiatal hernia in the obese patient in whom the bulk and pressure from the abdominal viscera and omentum limit visualization with an abdominal or laparoscopic approach.

A transthoracic approach to paraesophageal hernia may also be preferred in the reoperative setting in patients who have had a prior abdominal repair. In addition, patients ...