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Ovaere S, Depypere L, Van Veer H, Moons J, Nafteux P, Coosemans W. The Belsey Mark IV procedure in the era of minimally invasive antireflux surgery. Dis Esophagus 2023; 36:doad042. [PMID: 37408470 DOI: 10.1093/dote/doad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
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.
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Affiliation(s)
- Sander Ovaere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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Sato Y, Tanaka Y, Ohno S, Endo M, Okumura N, Takahashi T, Matsuhashi N. Optimal surgical approaches for esophageal epiphrenic diverticulum: literature review and our experience. Clin J Gastroenterol 2023; 16:317-324. [PMID: 36723767 DOI: 10.1007/s12328-023-01765-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
Esophageal epiphrenic diverticulum is a rare condition usually secondary to a primary esophageal motility disorder. Although epiphrenic diverticulum may be treated by thoracoscopic and laparoscopic management, the optimal surgical approach have not been established. We successfully treated a left epiphrenic diverticulum along with achalasia and paraesophageal hernia by a planned combination of thoracoscopic and laparoscopic procedures aided by preoperative simulation using three-dimensional imaging. We reviewed a series of 17 reports on esophageal epiphrenic diverticulum that required either planned or unplanned unexpected transthoracic surgery. The main reasons for requiring a transthoracic approach were adhesions, site and size of the diverticulum, and length of the diverticulum neck. Unplanned procedure changes were required in 12 of the 114 cases for a conversion rate of 10.5%. Diverticulectomy, myotomy, and fundoplication were the most common surgical treatments administered at 42.6%. Based on literature review and our experience, we have developed a flowchart to identify the characteristics of epiphrenic diverticulum cases that require a transthoracic approach. This flowchart can help to determine therapeutic strategies and the optimal surgical approach to esophageal epiphrenic diverticulum treatment and may reduce unplanned changes in the surgery.
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Affiliation(s)
- Yuta Sato
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Yoshihiro Tanaka
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan.
| | - Shinya Ohno
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Masahide Endo
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Naoki Okumura
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Takao Takahashi
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Nobuhisa Matsuhashi
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
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Reza JA, Bakhos C, Su S, Petrov R, Abbas AE. Robotic Belsey Mark IV Repair of the Paraesophageal Hernia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:84-89. [PMID: 36744735 DOI: 10.1177/15569845221150014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Surgical repair of paraesophageal hernias in patients with hostile abdomen is challenging. Despite its utility as an open procedure, the adoption of the minimally invasive Belsey Mark IV procedure has been limited because of the complexity of using traditional video-assisted thoracoscopic instrumentation. The robotic platform offers additional degrees of freedom, which enables minimally invasive transthoracic approach despite challenging anatomy. The purpose of this article is to describe a technique of robotic approach for the Belsey Mark IV operation. METHODS We retrospectively reviewed 5 cases of the robotic Belsey Mark IV procedure completed at a single institution between June 2018 and November 2021. Data were collected from a review of the medical records, including operative reports, anesthesia records, imaging, and clinical notes. The operative technique is described in the present article. There were 4 men and 1 woman. The average age of the patients was 64.4 ± 13.6 years, with an average body mass index of 24.5 kg/m2. Three patients had undergone previous transabdominal hiatal hernia repair, and 2 of them had 2 prior repairs. One patient underwent simultaneous pulmonary left lower lobectomy for cancer with the Belsey Mark IV procedure. RESULTS The average operative time was 209 ± 95 min (110 to 360 min). The average postoperative length of stay was 4.2 days, and 2 patients experienced complications including bleeding and persistent air leak (after lobectomy). The average blood loss was 67 ± 25 mL. CONCLUSIONS The robotic platform enables a transthoracic minimally invasive approach to the Belsey Mark IV operation.
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Affiliation(s)
- Joseph A Reza
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Charles Bakhos
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Stacey Su
- Department of Surgical Oncology, Division of Thoracic Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Roman Petrov
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Surgery, Division of Thoracic Surgery, Brown University, Providence, RI, USA
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Abstract
Diverticula of the middle and lower third of the esophagus are commonly associated with esophageal motility disorders. The increase of intraluminal pressure leads to an outpouching of the mucosal and submucosal layers through the esophageal muscle coat. These pouches are also called false diverticula, because they only consist of the mucosal and submucosal esophageal layers. In contrast, the more rarely encountered true diverticula that retain the complete esophageal wall are generally associated with periesophageal granulomatous lymph node disease. Treatment of both true and false diverticula is generally indicated in symptomatic patients; however, even state of the art minimally invasive surgery is accompanied by considerable perioperative morbidity and should only be performed in carefully selected patients. This aim of this article is to summarize the available scientific evidence and to provide the reader with an updated guide to best clinical practice in the treatment of esophageal diverticula.
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Andolfi C, Wiesel O, Fisichella PM. Surgical Treatment of Epiphrenic Diverticulum: Technique and Controversies. J Laparoendosc Adv Surg Tech A 2016; 26:905-910. [DOI: 10.1089/lap.2016.0365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ciro Andolfi
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Ory Wiesel
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - P. Marco Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA, Boston, Massachusetts
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Markakis C, Tomos P, Spartalis ED, Lampropoulos P, Grigorakos L, Dimitroulis D, Lachanas E, Agathos EA. The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia. BMC Surg 2013; 13:24. [PMID: 23829509 PMCID: PMC3717073 DOI: 10.1186/1471-2482-13-24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 06/26/2013] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Charalampos Markakis
- 2nd Propaedeutic Department of Surgery, Laiko General Hospital, University of Athens, Tritonos 20 Str, Paleo Faliro, 17561 Athens, Greece.
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Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience. Surg Today 2012; 43:1-7. [DOI: 10.1007/s00595-012-0386-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 09/05/2010] [Indexed: 11/26/2022]
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-69. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Ruiz De Angulo Martín D, Ortiz Escandell MÁ, Martínez De Haro LF, Munítiz Ruiz V, Parrilla Paricio P. Divertículos epifrénicos: ¿cuándo y cómo operar? Cir Esp 2009; 85:196-204. [DOI: 10.1016/j.ciresp.2008.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
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Abstract
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.
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Affiliation(s)
- M Neufeld
- Division of Thoracic Surgery, Department of Surgery, Calgary Health Region, University of Calgary, Calgary, Alberta, Canada
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