Belsey Mark IV antireflux procedure for complicated gastroesophageal reflux disease

Background. Over the past 20 years, medical management of gastroesophageal reflux disease has met with increasing success, but a proportion of patients continue to have symptoms or complications requiring surgical treatment. The variety of operations available attests to the general lack of satisfaction with any single procedure. Methods. A retrospective study was conducted of 276 patients who underwent the Belsey Mark IV antireflux procedure at our institution between 1979 and 1995. The indication for operation was gastroesophageal reflux, disease refractory to medical therapy in 137 patients, gastroesophageal reflux disease with symptomatic stricture or Schatzki's ring in 36, achalasia or epiphrenic diverticulum in 74, paraesophageal hernia in 27, and esophageal mass in 2. Fifteen patients (5.4%) had undergone prior antireflux operations. Results. There was one perioperative death (0.4%) resulting from an apparent myocardial infarction in an 87-year-old woman who underwent operation for paraesophageal hernia with volvulus. Two patients had contained leaks diagnosed by routine postoperative contrast studies; both were managed successfully without operation. Two patients required early reoperation for recurrent symptoms: 1 underwent a repeated Belsey Mark IV procedure and the other underwent an esophagogastrectomy. An additional 7 patients experienced late recurrence of symptoms requiring surgical management. The overall complication rate was 10.1%, with minor pulmonary complications (2.1%) and atrial arrhythmias (1.8%) occurring most commonly. Conclusions. The Belsey Mark IV procedure is a safe and effective operation for the management of gastroesophageal reflux disease with complications, and it compares favorably with other antireflux procedures.