Skip to main content
SpringerLink
Log in

Transthoracic fundoplication using the Belsey Mark IV technique versus Nissen fundoplication: A systematic review and meta-analysis

  • Review Article
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Nissen fundoplication is considered the cornerstone surgical treatment for hiatal hernia repair. Belsey Mark IV (BMIV) transthoracic fundoplication is an alternative approach that is rarely utilized in today’s minimally invasive era. This study aims to summarize the safety and efficacy of BMIV and to compare it with Nissen fundoplication.

Methods

We searched MEDLINE, Scopus, and Cochrane Library databases for single arm and comparative studies published by March 31st, 2022, according to PRISMA statement. Inverse-variance weights were used to estimate the proportion of patients experiencing the studied outcome and random-effects meta-analyses were performed.

Results

17 studies were identified, incorporating 2136 and 638 patients that underwent Belsey Mark IV or Nissen fundoplication, respectively. A total of 13.8% (95% CI: 9.6–18.6) of the patients that underwent fundoplication with the BMIV technique had non-resolution of their symptoms and 3.5% (95% CI: 2.0–5.4) required a reoperation. Overall, 14.8% (95% CI: 9.5–20.1) of the BMIV arm patients experienced post-operative complications, 5.0% (95% CI: 2.0–9.0) experienced chronic postoperative pain and 6.9% (95% CI: 3.1–11.9) had a hernia recurrence. No statistically significant difference was observed between Belsey Mark IV and Nissen fundoplication in terms of post-interventional non-resolution of symptoms (odds ratio [OR]: 1.49 [95% Confidence Interval (95%CI):0.6–4.0]; p = 0.42), post-operative complications (OR:0.83, 95%CI: 0.5–1.5, p = 0.54) and in-hospital mortality (OR:0.69, 95%CI: 0.13–3.80, p = 0.67). Belsey Mark IV arm had significantly lower reoperation rates compared to Nissen arm (OR:0.28, 95%CI: 0.1–0.7, p = 0.01).

Conclusions

BMIV fundoplication is a safe and effective but technically challenging. The BMIV technique may offer benefits to patients compared to the laparoscopic Nissen fundoplication. These benefits, however, are challenged by the increased morbidity of a thoracotomy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

HH:

Hiatal Hernia

BMIV:

Belsey Mark IV

NHLBI:

National Heart, Lung, and Blood Institute

VATS:

Video-assisted thoracoscopy

References

  1. Kim J, Hiura GT, Oelsner EC, Yin X, Barr RG, Smith BM, Prince MR (2021) Hiatal hernia prevalence and natural history on non-contrast CT in the Multi-Ethnic Study of Atherosclerosis (MESA). BMJ Open Gastroenterol 8:e000565. https://doi.org/10.1136/BMJGAST-2020-000565

    Article  PubMed  PubMed Central  Google Scholar 

  2. Kohn GP, Price RR, Demeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD (2013) Guidelines for the management of hiatal hernia. Surg Endosc 27:4409–4428. https://doi.org/10.1007/S00464-013-3173-3/TABLES/4

    Article  PubMed  Google Scholar 

  3. Richards K, Fisher K, Flores J, Christensen BJ (1996) Laparoscopic Nissen fundoplication: cost, morbidity, and outcome compared with open surgery. Surg Laparosc Endosc 6:140–143

    Article  CAS  PubMed  Google Scholar 

  4. Frazzoni M, Piccoli M, Conigliaro R, Frazzoni L, Melotti G (2014) Laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 20:14272–14279. https://doi.org/10.3748/WJG.V20.I39.14272

    Article  PubMed  PubMed Central  Google Scholar 

  5. Gyawali CP, Fass R (2018) Management of gastroesophageal reflux disease. Gastroenterology 154:302–318. https://doi.org/10.1053/J.GASTRO.2017.07.049

    Article  PubMed  Google Scholar 

  6. Nissen R (1970) Reminiscences-reflux esophagitis and hiatal hernia. Rev Surg 27:3071–3114

    Google Scholar 

  7. Skinner BD, Belsey RHR, Russel PS (1967) Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 53:33–55

    Article  CAS  PubMed  Google Scholar 

  8. Cooke DT (2013) Belsey mark IV repair. Oper Tech Thorac Cardiovasc Surg 18:215–229. https://doi.org/10.1053/j.optechstcvs.2013.10.001

    Article  Google Scholar 

  9. Stylopoulos N, Rattner DW (2005) The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg 241:185–193. https://doi.org/10.1097/01.SLA.0000149430.83220.7F

    Article  PubMed  PubMed Central  Google Scholar 

  10. Laan DV, Agzarian J, Harmsen WS, Shen KR, Blackmon SH, Nichols FC, Cassivi SD, Wigle DA, Allen MS (2018) A comparison between Belsey Mark IV and laparoscopic Nissen fundoplication in patients with large paraesophageal hernia. J Thoracic Cardiovasc Surg 156:418–428. https://doi.org/10.1016/j.jtcvs.2017.11.092

    Article  Google Scholar 

  11. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wohlin C (2014) Guidelines for snowballing in systematic literature studies and a replication in software engineering. In: Proceedings of the 18th International Conference on Evaluation and Assessment in Software Engineering (EASE ’14). ACM, New York, NY, USA, Article 38, 1–10

  13. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13. https://doi.org/10.1186/1471-2288-5-13

    Article  PubMed  PubMed Central  Google Scholar 

  14. Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:135. https://doi.org/10.1186/1471-2288-14-135

    Article  PubMed  PubMed Central  Google Scholar 

  15. Study Quality Assessment Tools | NHLBI, NIH. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed 17 Jul 2022

  16. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hróbjartsson A, Kirkham J, Jüni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Schünemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JP (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919. https://doi.org/10.1136/BMJ.I4919

    Article  PubMed  PubMed Central  Google Scholar 

  17. Zhu ZJ, Chen LQ, Duranceau A (2008) Long-term result of total versus partial fundoplication after esophagomyotomy for primary esophageal motor disorders. World J Surg 32:401–407. https://doi.org/10.1007/s00268-007-9385-8

    Article  PubMed  Google Scholar 

  18. Sillin LF, Gordon RE, Wilson SD, Worman LW (1979) Effective surgical therapy of esophagitis. Arch Surg 114:536–541

    Article  CAS  PubMed  Google Scholar 

  19. Coosemans W, de Leyn P, Deneffe G, van Raemdonck D, Lerut T (1997) Laparoscopic antireflux surgery and the thoracic surgeon: what now? Eur J Cardio-Thoracic Surg 12(5):683–693

    Article  CAS  Google Scholar 

  20. Alexiou C, Beggs D, Salama FD, Beggs L, Knowles KR (2000) A tailored surgical approach for gastro-oesophageal re¯ux disease: the Nottingham experience. Eur J Cardio-Thoracic Surg 17(4):389–395

    Article  CAS  Google Scholar 

  21. Dilling EW, City O, Oklahoma MD, Peyton O, City OJP, Cannon O, Paul J, Kanaly O, Ronald C, Elklns O (1977) Comparison of Nissen Fundoplication and Belsey Mark IV in the Management of Gastroesophageal Reflux. Am J Surg 134(6):730–733

    Article  CAS  PubMed  Google Scholar 

  22. Perez AR, Moncure AC, Rattner DW (2001) Obesity adversely affects the outcome of antireflux operations. Surg Endosc 15:986–989. https://doi.org/10.1007/s004640000392

    Article  CAS  PubMed  Google Scholar 

  23. Laycock WS, Oddsdottir M, Franco A, Mansour K, Hunter JG (1995) Laparoscopic Nissen fundoplication is less expensive than open Belsey Mark IV. Surg Endosc 9:426–429

    Article  CAS  PubMed  Google Scholar 

  24. Berry WB (1978) Surgical correction of refractory reflux esophagitis using the standard unmodified Belsey Mark IV technique. Ann Thorac Surg 26:102–106. https://doi.org/10.1016/S0003-4975(10)63649-1

    Article  CAS  PubMed  Google Scholar 

  25. Donnelly RJ, Deverall PB, Watson DA (1973) Hiatus hernia with and without esophageal stricture: experience with the Belsey Mark IV repair. Ann Thorac Surg 16:301–307. https://doi.org/10.1016/S0003-4975(10)64997-1

    Article  CAS  PubMed  Google Scholar 

  26. Maziak DE, Todd TRJ, Pearson FG (1998) Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 115:53–62

    Article  CAS  PubMed  Google Scholar 

  27. Fenton KN, Miller JI, Lee RB, Mansour KA, Whitehead JB (1997) Belsey Mark IV antireflux procedure for complicated gastroesophageal reflux disease. Ann Thoracic Surg 64(3):790–794

    Article  CAS  Google Scholar 

  28. Singh SV (1980) Present concept of the Belsey mark IV procedure in gastro-oesophageal reflux and hiatus hernia. Br J Surg 67:26–28. https://doi.org/10.1002/bjs.1800670108

    Article  CAS  PubMed  Google Scholar 

  29. Migliore M, Arcerito M, Vagliasindi A, Puleo R, Basile F, Deodato G (2003) The place of Belsey Mark IV fundoplication in the era of laparoscopic surgery. Eur J Cardio-Thoracic Surg 24(4):625–630

    Article  CAS  Google Scholar 

  30. Bais JE, Horbach JMLM, Masclee AAM, Smout AJPM, Terpstra JL, Gooszen HG (2000) Surgical treatment for recurrent gastro-oesophageal reflux disease after failed antireflux surgery. Br J Surg 87:243–249. https://doi.org/10.1046/j.1365-2168.2000.01299.x

    Article  CAS  PubMed  Google Scholar 

  31. Markakis C, Tomos P, Spartalis ED, Lampropoulos P, Grigorakos L, Dimitroulis D, Lachanas E, Agathos A (2013) The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia. BMC Surg 13:1–6

    Article  Google Scholar 

  32. Orringer MB, Skinner DB, Belsey RHR (1972) Long-term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 63(1):25–33

    Article  CAS  PubMed  Google Scholar 

  33. Scheffer RCH, Samsom M, Hebbard GS, Gooszen HG (2006) Effects of partial (Belsey Mark IV) and complete (Nissen) fundoplication on proximal gastric function and esophagogastric junction dynamics. Am J Gastroenterol 101:479–487. https://doi.org/10.1111/j.1572-0241.2006.00498.x

    Article  PubMed  Google Scholar 

  34. Alexiou C, Salama FD, Beggs D, Brackenbury ET, Knowles KR (1999) Comparison of long-term results of total fundoplication gastroplasty and Belsey Mark IV antireflux operations in relation to the severity of oesophagitis 1. Euro J Cardio-Thoracic Surg 15(3):320–326

    Article  CAS  Google Scholar 

  35. Nguyen NT, Schauer PR, Hutson W, Landerneau R, Weigel T, Ferson PF, Keenan RJ, Luketich JD (1998) Preliminary results of thoracoscopic Belsey Mark IV antireflux procedure. Surg Laparosc Endosc 8:185–188

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

None

Funding

The authors have not disclosed any funding.

Author information

Author notes

  1. Benjamin E. Haithcock and Jason M. Long have share senior authorship.

Authors and Affiliations

  1. Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA

    Panagiotis Tasoudis, Benjamin E. Haithcock & Jason M. Long

  2. Surgery Working Group, Society of Junior Doctors, Athens, Greece

    Evangelos Vitkos

Authors
  1. Panagiotis Tasoudis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Evangelos Vitkos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Benjamin E. Haithcock
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jason M. Long
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Panagiotis Tasoudis.

Ethics declarations

Disclosure

Drs. Panagiotis Tasoudis, Evangelos Vitkos, Benjamin E. Haithcock and Jason M. Long have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 5133 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tasoudis, P., Vitkos, E., Haithcock, B.E. et al. Transthoracic fundoplication using the Belsey Mark IV technique versus Nissen fundoplication: A systematic review and meta-analysis. Surg Endosc 37, 4123–4130 (2023). https://doi.org/10.1007/s00464-023-09931-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-023-09931-w

Keywords

Search

Navigation