If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Address reprint requests to David T. Cooke, MD, FCCP, FACS, Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of California, Davis Medical Center, 2221 Stockton Blvd, Suite 2112, Sacramento, CA 95817.
The Belsey Mark IV repair or antireflux fundoplication is a classic procedure that has proven to be a successful and durable antireflux operation. Over a 15-year period, Ronald Belsey performed clinical trials to develop and refine the operation, culminating in 4 iterations, with the fourth or Mark IV being the final and most successful. Dr Belsey referred to each version as Mark as a nod to the British Jaguar brand automobile makers for naming their sequential iterations of luxury vehicles Mark I, Mark II, etc. The open Belsey Mark IV fundoplication (BMIV) is performed via a left posterolateral thoracotomy. The goal is to return the “high-pressure zone” of the cardia, otherwise known as the lower gastroesophageal sphincter (LES) to its normal anatomical position below the diaphragm. The BMIV reduces 4-5 cm of distal esophagus to an infradiaphragmatic position in the “high-pressure” upper abdomen, restoring a competent gastroesophageal junction (GEJ). In addition to returning the LES to a high-pressure environment, the BMIV provides an incomplete 240° anterior fundal wrap. The incomplete wrap, as opposed to a complete 360° Nissen fundoplication, is especially useful in the esophagus with underlying motility disorder, avoiding gas bloat syndrome.
reported Belsey’s short- and long-term results in 892 patients, with 84% perceiving excellent or good results, and found a 12% 10-year recurrence rate and 14.7% recurrence rate for patients followed up over 10 years. Operative mortality was only 1%. Similar results in other studies have been reported with low operative mortality and success rates up to 90%.
With the proliferation of minimally invasive surgery, specifically conventional and robotic laparoscopic surgery, the role of the BMIV has diminished. Incomplete fundoplications such as the 180°-200° Dor anterior and the 270° Toupet posterior fundoplications are easily accomplished minimally invasively. Nguyen et al
reported on their group’s initial experience with a thoracoscopic BMIV, and although their study demonstrated that a thoracoscopic BMIV could be performed with optimal perioperative mortality and morbidity, the complexity of the procedure warranted the authors to state an “open thoracotomy for Belsey Mark IV should remain the standard operation for gastroesophageal reflux disease with poor esophageal motility when a thoracic approach is desired.” Regarding BMIV, it is best approached via an open left posterolateral thoracotomy, and appropriate patients should be selected who would benefit from an antireflux procedure using a partial wrap and a thoracotomy.
giant hiatal hernia with potential pleural adhesions and not requiring a gastric lengthening procedure, and esophageal perforation in the setting of esophageal dysmotility such as achalasia or diffuse esophageal spasm.
Preoperative assessment is determined by the underlying pathology. Flexible endoscopy, contrast esophagography with thin barium, and chest computed tomography are all employed for anatomical definition and surgical planning. Esophageal manometry identifies underlying esophageal dysmotility. In the following sections, we describe the open BMIV, which consists of 3 major steps: (1) narrowing a potentially patulous esophageal hiatus, (2) creating a 240° anterior fundoplication, and (3) securing the fundoplication in an infradiaphragmatic position therefore recreating the high-pressure zone of the LES.
The BMIV is approached via the left-sided posterolateral thoracotomy through the sixth intercostal space. This approach provides the best access to both the esophagus and the esophageal diaphragmatic hiatus. Epiphrenic diverticulum listing to the right can be rotated to the left and addressed. Distal esophageal perforations can also be addressed from the left, even if draining to the right hemithorax. Single-lung ventilation with a double-lumen endotracheal tube may improve exposure; however, this is not necessary if the patient is unable to tolerate lung isolation, as the lung usually can be retracted aside. An epidural continuous-infusion pain-control catheter is placed preoperatively to maintain local analgesia (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13).
For indications other than esophageal perforation, the nasogastric tube is left to low wall suction and then removed on postoperative day (POD) 1. Moreover, on POD1, a thin barium esophagram is performed. If this demonstrates no leak, the patient is started on a sips-of-clears diet, and advanced over a period of 24-48 hours to a final soft mechanical diet. The epidural catheter is generally removed on POD3. The chest tubes are removed once total pleural output is <300 cm3/24 hours. For BMIV in the setting of esophageal perforation, patients are started on a sips-of-clears diet on POD3 and advanced daily to clears, and then full liquids. A thin barium swallow study is obtained on POD7, and if the result is negative, the patient’s diet is advanced to mechanical soft solid food. The angled chest tube or Blake drain placed along the primary repair is removed after a favorable esophagram.
Postoperative complications include those germane to a thoracotomy, including atelectasis and hospital-acquired pneumonia. Aggressive postoperative pulmonary physiotherapy and early ambulation is important to avoiding pulmonary complications. Other complications include bleeding from improper hemostatic control of short gastric vessels or unidentified full-thickness injury to the cardia during gastric mobilization. Long-term complications include gas bloat syndrome secondary to a more than 240° wrap, or injury to the bilateral vagus nerves. This may require takedown and redo fundoplication.
In certain clinical situations such as epiphrenic diverticulum, esophageal perforation in the setting of underlying esophageal dysmotility and giant esophageal hernia with suspected chronic pleural-based adhesions,
a thoracotomy with BMIV may be a valuable and effective technique. When an esophageal lengthening procedure is required, a Collis gastroplasty should be favored. The incomplete 240° wrap makes the BMIV an effective antireflux procedure in patients with underlying esophageal dysmotility, such as achalasia or diffuse esophageal spasm, and avoids gas bloat syndrome.
Though declining in the era of minimally invasive surgery, the BMIV remains a valuable surgical technique in tailored settings and should remain in the highly skilled esophageal surgeon’s armamentarium.
Long term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment.