PRELIMINARY-RESULTS OF THORACOSCOPIC BELSEY MARK-IV ANTIREFLUX PROCEDURE

Laparoscopic Nissen fundoplication has replaced open approaches for re fractory gastroesophageal reflux disease (GERD) in many major medical centers. Here we report our preliminary results of the Belsey Mark IV antireflux procedure performed by video-assisted thoracoscopy (VATS-Be lsey). Fifteen patients underwent VATS-Belsey. The indications for sur gery included GERD refractory to medical therapy (n = 10), achalasia ( n = 2), diffuse esophageal spasms (n = 1), epiphrenic esophageal diver ticulum (n = 1), and paraesophageal hernia(n = 1). The median operativ e time was 235 min. There were three conversions to open minithoracoto my (8-10 cm) necessitated by severe adhesions (n = 2) and repair of a, gastric perforation (n = 1). The median hospital stay was 4 days. Post operative complications included persistent air leaks, requiring disch arge with a Heimlich valve in one patient. There were no perioperative deaths. At a median follow-up of 19 months, ten patients (66%) were a symptomatic and were not taking any antacids. One patient who had take n proton pump inhibitors preoperatively required postoperative H(2 )bl ockers for mild heartburn. In three patients, recurrent GERD symptoms (mean follow-up 6 months) led to laparoscopic takedown of the Belsey a nd Nissen fundoplication. One patient with achalasia, who had recurren t dysphagia after 1 year of relief following VATS myotomy and Belsey, underwent esophagectomy. The Belsey Mark IV antireflux procedure is te chnically feasible by VATS with minimal morbidity. However, our prelim inary results suggest that open thoracotomy for Belsey Mark IV should remain the standard operation for GERD with poor esophageal motility w hen a thoracic approach is desired. We have modified our approach to l aparoscopic partial fundoplications (Toupet or Dor) for severe GERD an d poor esophageal motility when an abdominal approach is possible.