for and Related Diseases 11 (2015) e19–e20

Online case report Modification of Belsey (Mark IV) fundoplication in the management of hiatal and gastroesophageal reflux disease after sleeve : a case report Wei-Tao Liang, MDa,b, Ji-Min Wu, MDa,*, Zhong-Gao Wang, MDa,b aCenter for GERD, The Second Artillery General Hospital of Chinese People’s Liberation Army, Beijing, P.R. China bDepartment of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, P.R. China Received November 7, 2014; accepted November 23, 2014

Keywords: Laparoscopic ; Belsey Mark IV; Gastroesophageal reflux disease;

Gastroesophageal reflux disease (GERD) is a condition manometry demonstrated a hypotensive lower esophageal seen commonly in the population. sphincter (LES, pressure, 4.0 mm Hg) with normal relax- Although some operations, such as Roux-en-Y gastric ation and normal peristalsis of the esophageal body. bypass, are known to be associated with a reduced After the patient was referred to our center for GERD, a incidence of reflux postoperatively, the prevalence of modified laparoscopic Belsey (Mark IV) fundoplication GERD after laparoscopic sleeve gastrectomy (LSG) may with hiatal was performed. The patient was be increased by 2.1% 34.9% [1]. In addition, it is still endotracheally intubated in the supine position using 5 controversial for the treatment of medication-refractory laparoscopic ports under general anesthesia. After dissect- GERD after LSG. Here, we report the surgical management ing the gastrohepatic ligament with harmonic scalpel, a of a patient, suffering from acid reflux, heartburn, and widow was created behind the lower . Then, the vomiting, with a modified laparoscopic Belsey (Mark IV) diaphragmatic crura were dissected carefully, and the distal fundoplication 2 years after a successful LSG operative for esophagus was mobilized about 5 cm while the mediastinal obesity. structures, including pleura, pericardium, vagus nerves and aorta, were identified and preserved. The size of hernia Case presentation defect was measured as approximate 4cm, and then secured with 2 interrupted 2-0 nonabsorbable sutures. A 60-year-old woman with a history of obesity had Because of stapling too close to the angle of His in the undergone LSG at another hospital 4 years ago. The surgery previous LSG, the remnant of gastric fundus could not be provided good control of weight and resulted in a 40-kg utilized for fundoplication. After dissecting the adhesions weight loss. She did well until one year before referral, from the previous operation, one horizontal mattress 2-0 when she began to experience symptoms of acid reflux, nonabsorbable suture was secured between the left wall of heartburn, and vomiting, which severely limited the quality esophagus and the wall of gastric fundus for reconstructing of her life. The hiatal hernia and were diagnosed the angle of His. Afterwards, 5 horizontal mattress sutures by esophagogastroduodenoscopy, and esophageal were placed 1.5–2 cm from the esophagogastric junction between and esophagus to create a nearly 2001 * Correspondence: Center for GERD, The Second Artillery General wrap, and the second row of sutures was placed 1–1.5 cm Hospital of Chinese People’s Liberation Army, No. 16 Xinjiekouwai Street, Xicheng District, Beijing 100088. China. Phone: þ86 010- proximally so as to include the diaphragm. A bougie was 62015718. Fax: þ86 010-62015718. not necessary for this anterior and partial fundoplication E-mail: [email protected] surgery if the diaphragmatic hiatus after repairing was not http://dx.doi.org/10.1016/j.soard.2014.11.020 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). e20 W. -T. Liang et al. / Surgery for Obesity and Related Diseases 11 (2015) e19–e20 smaller than normal. Finally, the ports were removed under are needed to definitely assess the value of a modified direct vision, and the abdomen was desufflated. laparoscopic Belsey (Mark IV) fundoplication in GERD The patient was discharged on the 7th postoperative day patients after LSG. tolerating a liquid diet without reflux or . Two year later, she is still well and does not have dysphagia or Conclusion any other symptoms of GERD. A modified laparoscopic Belsey (Mark IV) fundoplica- Discussion tion for medication-refractory GERD appears to be a feasible and efficacious approach. It is a successful treat- Laparoscopic sleeve gastrectomy has become a standard ment option for the GERD patients with good control of bariatric surgical procedure [2]. Although it has an accept- weight after LSG. able complication profile and amount of weight loss, one of the most distressing complications to the patient is reflux Disclosures postoperatively. It is reported that hiatal hernia repair concurrently with LSG could result in a 47.5% decrease The authors have no commercial associations that might in GERD prevalence postoperative at 12 months if one is be a conflict of interest in relation to this article. detected intraoperatively [3]. However, it is controversial for the treatment of patients with medication-refractory Appendix GERD after LSG, especially for these patients with hiatal hernia. Supplementary data Although laparoscopic with hiatal hernia repair is thought to be a gold standard of antireflux Supplementary data cited in this article is available online procedure [4], the remnant of fundus can not be used for at http://dx.doi.org/10.1016/j.hrthm.2014.12.023. fundoplication in these patients after LSG. The transthoracic Belsey (Mark IV) operation has been used for management of hiatal hernia for over 40 years [5]. Based on the basic References technique, a modified Belsey (Mark IV) fundoplication with hiatal hernia repair was performed under in this [1] Laffin M, Chau J, Gill RS, Birch DW, Karmali S. Sleeve gastrectomy patient after LSG. It provides a partial fundoplication on the and gastroesophageal reflux disease. J Obes 2013;2013:741097. anterior of esophagus with using the anterior gastric wall. [2] Gibson SC, Le Page PA, Taylor CJ. Laparoscopic sleeve gastrectomy: Kotak et al. [6] reported that primary hiatal hernia review of 500 cases in single surgeon Australian practice. ANZ J Surg. repairing in GERD patients after LSG was a well- Epub 2013 Dec 5. [3] Daes J, Jimenez ME, Said N, Daza JC, Dennis R. Laparoscopic sleeve tolerated and effective operation. Clapp [7] also reported gastrectomy: symptoms of gastroesophageal reflux can be reduced by that the use of a prosthetic bioabsorbable mesh to repair a changes in surgical technique. Obes Surg 2012;22:1874–9. hiatal hernia could be a more effective operation after LSG. [4] Ielpo B, Martin P, Vazquez R, et al. Long-term results of laparoscopic Comparing with primary hiatal hernia repairing with or Nissen fundoplication with or without short gastric vessels division. – without using mesh, however, fundoplication with hiatal Surg Laparosc Endosc Percutan Tech 2011;21:267 70. [5] Markakis C, Tomos P, Spartalis ED, et al. The Belsey Mark IV: an hernia repair would provide a better and long-term control operation with an enduring role in the management of complicated of reflux in GERD patients after LSG. Although Roux-en-Y hiatal hernia. BMC Surg 2013;24. gastric bypass (RYGB) is a feasible and efficacious treat- [6] Kotak R, Murr M. Recurrent hiatal hernia repair after sleeve gastrectomy. ment option for GERD patients after LSG [8], it is optimal Surg Obes Relat Dis 2013;9:1027–8. [7] Clapp B. Prosthetic bioabsorbable mesh for hiatal hernia repair during for the GERD patient with weight regain after LSG. – fi fi sleeve gastrectomy. JSLS 2013;17:641 4. It is the rst time to perform a modi ed Belsey (Mark IV) [8] Abdemur A, Fendrich I, Rosenthal R. Laparoscopic conversion of operation under laparoscopy in patients after LSG. There- laparoscopic sleeve gastrectomy to gastric bypass for intractable fore, large scale, long-term follow-up and randomized trials gastroesophageal reflux disease. 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