38: Belsey–Mark IV Fundoplication/Collis Gastroplasty

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.

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 with impaired esophageal motility identified preoperatively may benefit from the improved esophageal clearance provided by the partial fundoplication of the Belsey procedure as compared with the “tighter” circumferential wrap described by Nissen. In the setting of incarcerated paraesophageal hernia with gastric volvulus, when an urgent operation is indicated to prevent gastric necrosis or bleeding, it may not be known whether the patient has normal motility or a foreshortened esophagus. A Collis–Belsey approach will address both concerns in this setting.

A thorough assessment of the patient is of paramount importance in determining the appropriate surgical approach. A detailed history of symptoms and prior interventions can give an accurate impression of the severity of the disease process. All patients should undergo esophagogastroduodenoscopy (EGD) both to assess the anatomic relationship of the esophagogastric junction (EGJ) to the diaphragm as well as the degree of esophagitis and the presence of stricture. EGD also can define the size and degree of organoaxial volvulus of a paraesophageal hernia. A barium esophagram may be helpful to further assess esophageal length and the anatomy of the paraesophageal hernia. A foreshortened esophagus will produce tension on the hiatal repair or fundoplication and these patients benefit greatly from an esophageal lengthening procedure. Peptic stricture of the distal esophagus is indicative of a transmural inflammatory process which, as it heals, causes a cicatricial scar which binds the esophageal mucosa and submucosa to the muscularis. Fibrosis involving the inner circular muscle layer produces luminal stricture, whereas involvement extending to the outer longitudinal muscle layer leads to esophageal shortening.

An assessment of esophageal motility with a manometric pressure catheter is essential. This instrument affords appropriate characterization of the intrinsic esophageal function, which, if abnormal, may mandate partial fundoplication to avoid significant dysphagia postoperatively. A complete evaluation will include quantification of the extent of reflux with 24-hour pH monitoring and correlation of symptoms with periods of decreased distal esophageal pH.

The recent introduction of accurate high-resolution manometric (HRM) studies has paved the way for even more accurate characterization of both motility within the esophageal body and function of the lower esophageal sphincter. The technique uses a manometry catheter with multiple, closely spaced sensors to gather accurate manometric data throughout the entire length of the esophagus rather than from a limited number of isolated positions. These data may be independently evaluated as a pressure tracing. More recently, a technique known as esophageal pressure topography (EPT) plotting⁴ has provided even more detailed analysis of HRM studies. This process uses an interpolated average of data between sensors to create a seamless isobaric color plot, which permits the function of the entire esophagus to be presented in a single visual display. The improved data have rendered this approach the new gold standard for the diagnosis of esophageal motility disorders.⁵ Distinct HRM patterns are identifiable for each pathologic condition,⁶ allowing the surgeon to make accurate preoperative assessments of the extent of dysmotility and to develop the appropriate operative plan. This is especially important with respect to the choice of fundoplication.

Occasionally, a hiatal hernia may be detected incidentally on plain chest radiographs (Fig. 38-1). It may manifest as a retrocardiac air-fluid level. If a paraesophageal hernia is causing symptoms of postprandial pain, retching, or early satiety, an abdominal CT scan may reveal the abnormally positioned intrathoracic stomach (Fig. 38-2).

Once the patient is deemed an appropriate surgical candidate, a careful evaluation of their pulmonary function and cardiac health should be undertaken both by the surgeon and the anesthesiologist. We routinely recommend preoperative anesthesia consultation both to achieve this goal and to discuss thoracic epidural placement and other strategies for postoperative pain control.

We are indebted to Pearson's excellent description of the Collis–Belsey procedure in the chapter on open gastroplasty in his textbook of Esophageal Surgery.⁷

Anesthesia

A thoracic epidural catheter and arterial line are placed in the preoperative holding area. After induction of general anesthesia, a double lumen endotracheal tube is placed to provide optimal lung isolation and maximal exposure. The anesthesiologist will also assist with placement of the esophageal Bougie to aid proper sizing of the gastroplasty.

Positioning and Incision

An upper endoscopy may be performed at the outset of the procedure to assess for the presence of stricture or other pathology before commencing the fundoplication and gastroplasty. This would not be obligatory in the setting of an elective repair, when all the obligatory data have been obtained. However, when gastric volvulus and the threat of gastric necrosis necessitate an urgent trip to the operating room, it is prudent to inspect endoscopically before making an incision. Upper endoscopy is performed most easily when the patient is still in the supine position.

When the operative procedure begins, the patient should be in the left thoracotomy position, with pressure points padded appropriately. After properly securing the patient, the operating table should be flexed to open the left interspaces for maximal exposure. A generous sixth or seventh interspace posterolateral thoracotomy is created, dividing the muscle of the latissimus dorsi but sparing the serratus anterior. Occasionally, a rib will need to be “shingled” posteriorly to achieve better exposure, but this is not common if the interspace is opened slowly and widely to allow gentle rib spreading.

Dissection of the Esophagus and Stomach

The inferior pulmonary ligament is divided with electrocautery to permit the lung to retract into the upper hemithorax and expose the esophagus, which lies anterior to the descending aorta and posterior to the pericardium. There may be a large hernia sac above the hiatus. Whether this is present or not, the initial circumferential dissection of the esophagus should be at the level of the inferior pulmonary vein to permit identification of both vagus nerves. Beginning the dissection at this level allows one to mobilize a sufficient length of esophagus to facilitate the gastroplasty and a tension-free return to the abdomen. A Penrose drain is passed around the esophagus and used for gentle retraction.

Attention is then turned to the hiatus. The hiatal hernia sac (which consists of parietal pleura), phrenoesophageal membrane, and peritoneum should be dissected from the hiatus circumferentially. By dividing the hernia sac, the serosa of the stomach is exposed, and the abdomen may be entered safely (Fig. 38-3). The crura should be dissected free during this stage. To freely deliver the stomach into the chest, the gastrohepatic omentum, which tethers the cardia below the diaphragm, is divided at this point. To more fully mobilize the fundus, the highest 2 to 3 short gastric vessels may be ligated and divided (Fig. 38-4). These maneuvers are especially helpful in situations of intrathoracic gastric volvulus to ensure that proper orientation of the stomach is maintained once it is reduced to the abdomen. Three to five crural closure sutures (0 braided polyester) are placed but left untied.

The gastroesophageal junction (GEJ) is identified with its overlying fat pad. Dissection of the fat pad, elevating it off the GEJ, commences at its posterolateral aspect, just to the left of the posterior (right) vagus nerve. As the fat pad is dissected anteriorly, the anterior (left) vagus nerve is mobilized along with the fat pad and retracted to the right and away from the EGJ. Small vessels coursing between the fat pad and the gastric wall may need to be controlled individually with electrocautery, vascular clips, or direct ligation.

Creation of the Gastric Tube (Esophageal Lengthening)

A gastric tube is created from the cardia of the stomach (Fig. 38-5A). A 48 to 50F Bougie is passed into the stomach along the lesser curvature by the anesthesiologist and guided by the surgeon to avoid malpositioning or perforation during placement. The fundus is retracted and a thick tissue stapler is placed alongside the Bougie and fired to add 4 to 5 cm of extra length to the esophagus (Fig. 38-5B). This permits the neo-GEJ to lie without tension below the diaphragm. However, since this neoesophagus (gastric tube) will not retain normal esophageal motility, segments longer than 4 to 5 cm are not advised. We oversew the gastroplasty staple line with 3-0 polypropylene suture, taking care not to narrow the gastric tube.

Fundoplication and Return to the Abdomen

The fundoplication is a partial wrap of 270 degrees created with three rows of horizontal mattressed, double-armed 2-0 or 3-0 braided polyester or silk sutures. The sutures should be placed partial thickness (seromuscular), but must be deep enough to permit apposition of the fundus to the esophagus without tearing out. The middle suture of each row should straddle the staple line used to create the gastric tube (Fig. 38-6A). The other sutures of each row are therefore 135 degrees left and right of the middle suture. The next row is spaced 1.5 cm from the fold created by tying down the sutures in the previous row (Fig. 38-6B). The last row of sutures is not tied down after placement; rather, the needles are passed into the abdomen via the hiatus and then back up through the diaphragm to anchor the reconstruction (Fig. 38-6C). A malleable retractor or sterile spoon can be used to protect the abdominal viscera during this maneuver. The transdiaphragmatic sutures should continue the 270-degree spacing of the fundoplication. The GEJ, with its fundoplication in place, is then returned to the abdomen and the transdiaphragmatic sutures are tied down to anchor the wrap to the underside of the diaphragm anteriorly (Figs. 38-7 and 38-8). The crural sutures are then tied down, establishing an adequate length of the posterior aspect of the hiatus. When tied, the reconstructed hiatus should remain lax enough to admit a finger alongside the esophagus. A completion flexible endoscopy may be of assistance in ensuring both the fundoplication and crural repair are appropriate.

A nasogastric tube is placed with guidance by the surgeon at the field. The chest is irrigated, and a flexible or standard chest drain is placed. The chest is closed in standard fashion after ensuring good lung reexpansion. Every effort is made to extubate the patient in the operating room at the completion of the case.

In the recovery room, the patient is assessed for adequacy of analgesia. A chest radiograph is obtained to assess lung reexpansion and confirm the placement of the chest and nasogastric drains. The patient should be positioned in the bed with 20 to 30 degrees of head elevation. Maintenance IV fluid is provided at a minimal hourly rate and care is taken to avoid fluid overload to both prevent pulmonary dysfunction and minimize bowel edema which might contribute to both ileus and early difficulty with passage of esophageal contents beyond the fundoplication. By postoperative day 1, ambulation and significant time out of bed should be a mandatory goal for all patients.

Perioperative antibiotics are continued for 24 hours. Prophylactic subcutaneous heparin or enoxaparin and lower extremity pneumatic compression boots are used.

The chest tube is typically able to be removed by postoperative day 2, provided the daily output is less than 200 to 300 cc. The nasogastric tube is discontinued either postoperative day 1 or 2 with adequate recovery of bowel function. After the nasogastric tube is removed, a barium swallow may be performed both to ensure that edema at the level of the fundoplication does not cause temporary dysphagia and to check for occult leak at the gastroplasty staple line or at the sites of the esophageal or gastric sutures. If the swallow is unremarkable, the patient is allowed sips of clear liquids and, once tolerated, advanced to clear liquids ad lib. The next day, soft solid food may be introduced. The patient is typically discharged on this diet as well. Pills may be taken orally when required; but if possible, liquid formulations (i.e., oral liquid narcotic analgesics) or crushed pills should be used to avoid the possibility of medication impaction at the level of the fundoplication. The hospital length of stay is typically 4 to 5 days. At the postoperative follow-up visit, more substantial food may be reintroduced provided the patient has no significant complaints of dysphagia.

Dysphagia

Dysphagia represents the most common both immediate and delayed complication of the procedure. In almost all cases, this is related to stricture of the distal esophagus, usually present at the time of the operation. Treatment should be approached endoscopically with Bougie dilation. In many cases, postoperative esophageal edema may be the etiology of dysphagia, though repeated dilation may be necessary over an interval of time in some patients.

Gastric Leak

Suture-line breakdown at the construction of the gastroplasty has also been described⁸ in the perioperative period. Should a leak be suspected, the diagnosis can be made definitively with a contrast fluoroscopy study. The vast majority of these leaks will respond to expectant management strategies, with the patient being kept nothing by mouth and nourished with the use of total parenteral nutrition or distal enteral feedings (if access is available). The swallow study should be repeated in 2 to 3 weeks to assess the persistence of a leak. In some rare cases, operative exploration and repair may be required and this would best be approached through an abdominal incision so as not to disrupt the diaphragm repair. By reinforcing the staple line at the time of the initial operation, the rate of leak at this site may be further reduced.

Bleeding

Some series⁸ have reported erosive esophagitis associated with shallow-based bleeding ulcers following operative repair. Interestingly, these were found proximal to prior sites of stricture. Initial characterization and, if possible, management with upper endoscopy is preferred in this situation. Transfusion of blood products may be needed if the degree of bleeding is significant. In Orringer and Sloan's series, all patients with bleeding responded to addition of H₂ blocker or PPI with resolution of bleeding.

Recurrent Reflux

A persistence or recurrence of GERD symptoms is seen in a subset of patients treated with Collis gastroplasty and Belsey fundoplication. This can be a result of altered gastric function (i.e., from vagus nerve injury during the hiatal dissection) or may demonstrate a failure of the reconstructed esophagogastric junction to act as a physiologic barrier. A gastric emptying study using technetium-labeled food products can be beneficial in determining the contribution of relative gastroparesis to the reflux symptom complex. In fact, this is a part of the routine preoperative evaluation in some centers. In patients with delayed gastric emptying, addition of a promotility agent (metoclopromide, erythromycin, etc.) often result in amelioration of symptoms. Long-term use may not be required. In the patient group with normal gastric motility, reflux symptoms can usually be well controlled with the addition of PPIs to the postoperative medication regimen.

The efficacy and safety of the Belsey fundoplication have been well documented since Skinner and Belsey published their series of 1030 patients in 1967 showing 85% of patients to be free of reflux symptoms at a minimum follow-up of 5 years.¹ When combined with a gastroplasty procedure to yield further esophageal length, good-to-excellent symptomatic relief has been shown in up to 80% of patients reproduced in several studies. Pearson et al. reported on 24 patients in their initial description of the combined procedure and found only 2 patients to have residual acid reflux symptoms, though these were improved in comparison to the preoperative condition. They also found residual, though improved, dysphagia in 7 of the 24 patients.³ In a longitudinal study of this patient cohort, Pearson and his colleagues followed 25 patients treated with Collis gastroplasty and Belsey fundoplication over a period of at least 5 years from their operation. Excellent clinical results were achieved in 24 of these patients and confirmed objectively with EGD and barium esophagram.⁹

The success of the combined operation stems from the decrease in tension on the fundoplication; particularly at the buttress sutures of the hiatal repair, which constituted a common site of recurrence in patients undergoing a Belsey fundoplication alone. Manometric study of the procedure in vivo both intraoperatively and postoperatively demonstrates reconstitution of the distal esophageal high-pressure zone at the level of the gastroplasty tube.¹⁰ Postprocedure reflux as documented by pH monitoring has also been shown to return to normal levels.¹¹ In a longitudinal study, Pearson showed the operation to be effective in treatment of stricture with patients remaining free of dysphagia at 5 years.⁹

The Collis–Belsey approach to the treatment of reflux disease and paraesophageal hernia no longer represents first-line treatment in most patients with the development of minimally invasive techniques. However, the operation remains an important modality of treatment in patients with foreshortened esophagus and distal esophageal stricture. In this difficult patient subset, an excellent long-term result may be achieved. A thorough preoperative evaluation is essential in the selection of appropriate operative candidates with careful attention being paid to the anatomy of the distal esophagus and the motility of the esophageal body. Patients undergoing the operation should be made aware that endoscopic evaluation may be necessary in the course of their postoperative care and the surgeon should be aggressive in pursuing EGD in patients with persistent symptoms of reflux or dysphagia postoperatively.

The open transthoracic surgical approach to reflux can be extremely useful in reoperative cases, particularly in patients who have had multiple upper abdominal procedures including gastric bypass surgery. Less stomach is required than for a complete wrap, making definitive therapy possible. This approach may also be applicable to patients who require urgent surgery for a perforation of a peptic stricture.