Adult Chest Surgery

Chapter 30. Belsey-Mark IV Fundoplication/Collis Gastroplasty 

The management of gastroesophageal reflux disease (GERD) and hiatal hernia has been an evolving topic in both general and thoracic surgery over the last century. While the introduction of improved medical management in the form of H2-blockers and proton pump inhibitors (PPIs) has reduced the overall volume of patients presenting for surgical management, there remains a definite role for surgery in the circumstances of medical failure or fixed anatomic abnormality. Beginning in the late 1950s with the work of Belsey, Nissen, Hill, and Collis and continuing to the present day, there has been much debate regarding the optimal surgical approach for the correction of reflux disease and repair of hiatal hernia. Most recently, minimally invasive approaches have gained favor. However, the traditional techniques of open hiatal hernia repair and fundoplication still may be preferred in selected patient groups. This chapter concerns the current application of the transthoracic Collis-Belsey repair of hiatal hernia with an eye toward appropriate patient selection and evaluation.


The operation now attributed to Belsey evolved from a series of surgical modifications spanning over a decade of clinical investigation. Belsey's original intent was to create a general approach to the management of reflux disease, and the procedure underwent several iterations before the present Mark IV operation.1 Working in the same era, Collis also sought to answer the question of surgical management of reflux disease. He focused on obtaining an adequate length of intraabdominal esophagus that would permit a tension-free acute angle of esophageal entry into the stomach. Looking for ways to achieve this, he published the first description of tubularization of a section of the lesser curvature of the stomach for use as a distal esophageal equivalent in 1957.2 In 1971, Pearson and colleagues published a series of 24 patients with peptic stricture of the distal esophagus who were treated with a combination Collis gastroplasty and Belsey hiatal hernia repair.3 They reported excellent results, achieving either resolution of stricture or improvement in symptoms of dysphagia in all patients treated in this fashion.

The Collis-Belsey operation, as described by Pearson, gained widespread support as an approach to hiatal hernia repair and a viable antireflux procedure. However, in recent years, minimally invasive approaches to the surgical treatment of GERD have limited application of the Collis-Belsey procedure to a relatively specific subset of patients with foreshortened esophagus. The operation also has a defined role for hiatal hernia repair in the obese patient, when pressure on the abdominal viscera and omentum limits visualization with an intraabdominal approach.

A transthoracic approach to paraesophageal hernia also may be indicated in the reoperative setting in patients who have had a prior abdominal approach. Additionally, patients with impaired esophageal motility benefit from the improved esophageal clearance provided by the partial fundoplication of the Belsey procedure as compared with the "tighter" circumferential wrap described by Nissen. In the setting of incarcerated paraesophageal hernia with gastric volvulus, when an urgent operation is indicated to prevent gastric necrosis or bleeding, it may not be known whether the patient has normal motility or a foreshortened esophagus. A Collis-Belsey operation will address both concerns.


Thorough assessment of the patient is of paramount importance in determining the appropriate surgical approach. A detailed history of symptoms and prior interventions can give an accurate impression of the severity of the reflux disease process. All patients should undergo esophagogastroduodenoscopy (EGD) to assess both the anatomic relationship of the gastroesophageal junction (GEJ) with the diaphragm and the degree of esophagitis or stricture. EGD also can define the size and degree of organoaxial volvulus of a paraesophageal hernia. A barium swallow is helpful to further assess esophageal length and the anatomy of the paraesophageal hernia. A foreshortened esophagus will produce tension on the hiatal repair or fundoplication, and these patients benefit greatly from an esophageal lengthening procedure. Peptic stricture of the distal esophagus is indicative of a transmural inflammatory process, which as it heals causes a cicatricial scar that binds the mucosa and submucosa to the muscularis. Fibrosis involving the inner circular muscle layer produces the luminal stricture, whereas involvement extending to the outer longitudinal muscle layer leads to esophageal shortening.

An assessment of esophageal motility with a manometric pressure catheter is also essential. This allows for appropriate characterization of intrinsic esophageal function, which, if abnormal, may mandate a partial fundoplication to avoid significant dysphagia postoperatively. A complete evaluation also will include quantification of the extent of reflux with 24-hour pH monitoring and correlation of symptoms with periods of decreased distal esophageal pH.

Occasionally, a hiatal hernia may be detected incidentally on plain chest radiographs (Fig. 30-1). It may manifest as a retrocardiac air-fluid level. If a paraesophageal hernia is causing symptoms of postprandial pain, retching, and/or early satiety, an abdominal CT scan may reveal the abnormally positioned intrathoracic stomach (Fig. 30-2).

Figure 30-1.


Standard plain film shows a soft tissue density at the retrocardiac and the right heart border. This density represents a large paraesophageal hernia.


Figure 30-2.


Abdominal CT scan done for epigastric and substernal pain reveals an incarcerated stomach with organoaxial volvulus.

Once the patient is deemed an appropriate surgical candidate, a careful evaluation of pulmonary function and cardiac health should be undertaken both by the surgeon and by the anesthesiologist. We routinely recommend preoperative anesthesia consultation both to achieve this goal and to discuss airway management, thoracic epidural placement, and other strategies for postoperative pain control.


We are indebted to Pearson's excellent description of the Collis-Belsey procedure in the chapter on open gastroplasty in his textbook of esophageal surgery.4


An epidural catheter and arterial line are placed in the preoperative holding area. After induction of general anesthesia, a double-lumen tube is placed for optimal lung isolation. The anesthesiologist also will assist with placement of the esophageal bougie to aid proper sizing of the gastroplasty.

Positioning and Incision

An upper endoscopy may be performed at the outset of the procedure to assess for the presence of stricture or other pathology prior to commencing the fundoplication and gastroplasty. This would not be obligatory in the setting of an elective repair, when all the preoperative data have been obtained, but when gastric volvulus and the threat of gastric necrosis necessitate an urgent trip to the operating room, it is prudent to inspect endoscopically before incision. Upper endoscopy is performed most easily while the patient is still supine.

When the operative procedure begins, the patient should be in the left thoracotomy position with pressure points padded appropriately. After securing the patient properly, the operating bed should be flexed to open the left interspaces for maximal exposure. A generous sixth or seventh interspace posterolateral thoracotomy is created, dividing the latissimus dorsi muscle but sparing the serratus anterior. Occasionally, a rib will need to be "shingled" posteriorly to achieve better exposure, but this is not common if the interspace is opened widely to allow gentle rib spreading.

Dissection of the Esophagus and Stomach

The inferior pulmonary ligament is divided with electrocautery to permit the lung to retract into the upper hemithorax and to expose the esophagus, which lies anterior to the descending aorta and posterior to the pericardium. There may be a large hernia sac above the hiatus. Whether this is present or not, the initial circumferential dissection of the esophagus should be at the level of the inferior pulmonary vein to permit identification of both vagus nerves. Beginning the dissection at this level enables one to mobilize a sufficient length of esophagus to facilitate the gastroplasty and a tension-free return to the abdomen. A Penrose drain is passed around the esophagus and used for gentle retraction.

Attention is turned to the hiatus. The hiatal hernia sac, which consists of parietal pleura, phrenoesophageal membrane, and peritoneum, should be dissected from the hiatus circumferentially. By dividing the hernia sac, the serosa of the stomach is exposed, and the abdomen may be entered (Fig. 30-3). The crura should be dissected free during this stage. To freely deliver the stomach into the chest, the gastrohepatic omentum, which tethers the cardia below the diaphragm, is divided at this point. To more fully mobilize the fundus, the highest two or three short gastric vessels may be ligated and divided (Fig. 30-4). These maneuvers are especially useful in situations of intrathoracic gastric volvulus to ensure that proper orientation of the stomach is maintained once it is returned to the abdomen. Three to five crural closure sutures (0 braided polyester) are placed but left untied.

Figure 30-3.


View of the incarcerated stomach from left thoracotomy after dissection of hiatal hernia sac.


Figure 30-4.


The fundus is shown retracted by a Babcock clamp.

The GEJ is identified with its overlying fat pad. Dissection of the fat pad off the GEJ commences at its posterolateral aspect, just to the left of the posterior (right) vagus. As the fat pad is dissected anteriorly, the left (anterior) vagus should be mobilized with the fat pad. Small vessels coursing between the fat pad and gastric wall may need to be electrocauterized or ligated during this dissection.

Creation of the Gastric Tube (Esophageal Lengthening)

A gastric tube is created from the cardia of the stomach (Fig. 30-5A). The anesthetist passes a 48F–50F bougie into the stomach, guided by the surgeon to avoid inadvertent malpositioning or perforation. The fundus is retracted, and a thick tissue stapler is placed alongside the bougie and fired to add 4–5 cm of extra length to the esophagus (Fig. 30-5B). This permits the neogastroesophageal junction to lie without tension below the diaphragm. However, since this neoesophagus (gastric tube) will not retain normal esophageal motility, segments longer than 4–5 cm are not advised. We oversew the gastroplasty staple line with 3-0 polypropylene suture, taking care not to narrow the gastric tube.

Figure 30-5.


Collis gastroplasty for esophageal lengthening. A. The fundus is retracted with a Babcock clamp. B. A thick tissue stapler is placed at the angle of His alongside a 48F–50F esophageal bougie. A 4- to 5-cm staple line is created (Inset). The staple line is subsequently oversewn with 3-0 polypropylene suture (not shown).

Fundoplication and Return to the Abdomen

The fundoplication is a partial wrap of 270 degrees created with three rows of horizontal mattressed, double-armed 2-0 or 3-0 braided polyester or silk sutures. The sutures should be placed partial thickness (seromuscular) but must be deep enough to permit apposition of the fundus to the esophagus without tearing out. The middle suture of each row should straddle the staple line used to create the gastric tube (Fig. 30-6A). The other two sutures of each row, therefore, are 135 degrees left and right of the middle suture. The sutures are placed in horizontal mattress fashion. The next row then is spaced 1.5 cm from the fold created by tying down the sutures in the previous row (Fig. 30-6B). The last row of sutures is not tied down after placement; rather, the needles are passed into the abdomen via the hiatus and then back up through the diaphragm (Fig. 30-6C). A malleable retractor or sterile spoon can be used to protect the abdominal viscera during this maneuver. The transdiaphragmatic sutures should continue the 270-degree spacing of the fundoplication. The GEJ, with its fundoplication in place, then is returned to the abdomen, and the transdiaphragmatic sutures are tied down to anchor the wrap to the underside of the diaphragm anteriorly (Figs. 30-7 and 30-8). The crural sutures are then tied down, reestablishing an adequate length of the posterior aspect of the hiatus. When tied, the reconstructed hiatus still should be lax enough to admit a finger alongside the esophagus. A completion flexible endoscopy also may be of assistance in ensuring that the fundoplication and crural repair are appropriate.

Figure 30-6.


Fundoplication. A. Initial middle suture is placed in mattress fashion on either side of oversewn gastroplasty staple line to begin fundoplication. Left and right mattress sutures then are placed 135 degrees to either side of this initial middle suture for this row. B. The first-row sutures have been tied down, and the middle row of the next suture is placed next row's middle suture is placed, again straddling the staple line. Note that the sutures are placed 1.5 cm away from the fold created by the first row of sutures. Again, sutures will be placed to the left and right of this middle suture to continue to create the 270-degree fundoplication. C. Finally, the last row is placed in similar fashion but not tied down until the needles are passed through the diaphragm and the gastroesophageal junction and fundoplication are returned to the abdomen.


Figure 30-7.


Appearance of the fundoplication just before placement of the third and final row of sutures. Note the presence of the untied crural sutures.


Figure 30-8.


The GEJ and fundoplication have been returned to the abdomen, and the transdiaphragmatic sutures have been tied. Note also that the crural sutures also have been tied at this stage.

A nasogastric tube is placed with guidance by the surgeon at the field. The chest is irrigated, and a flexible or standard chest drain is placed. The chest is closed in standard fashion after ensuring good lung reexpansion. The patient is extubated in the OR.


In the recovery room, the patient is assessed for adequacy of analgesia. A chest radiograph is obtained to check the appearance of the lungs and positions of the chest and nasogastric tubes. The patient should be positioned in the bed with 20–30 degrees of head elevation. Maintenance IV fluid is provided, but fluid overload should be avoided both to prevent pulmonary dysfunction and to minimize bowel edema, which might contribute to ileus or narrowing of the fundoplicated neo-GEJ junction. By postoperative day 1, ambulation and significant time out of bed should be a mandatory goal for all patients.

Perioperative antibiotics are continued for 24 hours. Prophylactic subcutaneous heparin and lower extremity pneumatic compression boots are used.

The chest tube usually is discontinued by postoperative day 1, provided that daily output is less than 200–300 mL. The nasogastric tube is discontinued on postoperative day 1 or 2 with adequate recovery of bowel function. After the nasogastric tube has been removed, a barium swallow may be done both to ensure that edema at the level of the fundoplication does not cause temporary dysphagia, and to check for occult leak from the gastroplasty staple line or at the sites of the esophageal or gastric sutures. If the swallow study is unremarkable, the patient's diet is advanced to sips of liquids and then clear liquids as tolerated. The next day, soft solid food may be introduced, and the patient will be discharged on this diet. Pills may be taken orally when required, but if there is a liquid alternative (e.g., oral liquid narcotic analgesia), it should be used to avoid the potential for pills to become impacted at the level of the fundoplication. At the postoperative follow-up visit, more substantial food may be reintroduced as long as the patient has no significant dysphagia. The hospital length of stay typically is 4–5 days.



Dysphagia represents the most common immediate and delayed complication of the procedure. In almost all cases, this is related to stricture of the distal esophagus, usually present at the time of the operation. Treatment should be approached endoscopically with bougie dilation. In many cases, postoperative esophageal edema may be the etiology of dysphagia, although repeated dilations may be necessary in some patients.

Gastric Leak

Suture-line breakdown at the site of the gastroplasty also has been described in the perioperative period.5 Should a leak be suspected, the diagnosis can be made definitively with a contrast fluoroscopic study. The vast majority of these leaks will respond to expectant management strategies if there is no obvious extraluminal collection. If an extraluminal collection is present, it must be drained. The patient is kept nothing by mouth and nourished with total parenteral nutrition or distal enteral feedings (if access is available). The swallow study should be repeated in 2–3 weeks to assess for persistence of a leak. In rare cases, operative exploration and repair may be required. Exploration is best approached through an abdominal incision so as not to disrupt the diaphragmatic repair. By reinforcing the gastroplasty staple line at the time of the initial operation, the rate of leak at this site is reduced.


Some authors have reported erosive esophagitis associated with shallow-based bleeding ulcers following operative repair.5 Interestingly, these ulcers were found proximal to prior sites of stricture. Initial characterization and, if possible, management with upper endoscopy is preferred in this situation. Transfusion of blood products may be needed if the degree of bleeding is significant. In Orringer and Sloan's series,5 acid-suppression therapy led to cessation of bleeding in all patients.

Recurrent Reflux

Persistent or recurrent reflux symptoms are seen in a subset of patients treated with Collis gastroplasty and Belsey fundoplication. These symptoms can result from delayed gastric emptying (i.e., from vagus nerve injury during the esophageal or hiatal dissection) or they may demonstrate a failure of the reconstructed GEJ to act as a physiologic barrier. A gastric emptying study using technetium-labeled food products can determine the contribution of relative gastroparesis to the reflux symptom complex. In fact, this study is part of the routine preoperative evaluation in some centers, especially if the contemplated antireflux procedure is a reoperation. In patients with delayed gastric emptying, addition of a promotility agent (e.g., metoclopramide, erythromycin) often will ameliorate symptoms. Long-term use may not be required. In patients with normal gastric motility, reflux symptoms usually can be well controlled with the addition of PPIs to the postoperative medication regimen.


The efficacy and safety of the Belsey fundoplication have been well documented since Skinner and Belsey published their series of 1030 patients in 1967 showing 85% of patients to be free of reflux symptoms at a minimum follow-up of 5 years.1 When combined with a gastroplasty procedure to yield further esophageal length, good to excellent symptomatic relief has been shown in up to 80% of patients in several studies.3,6–8 Pearson and colleagues reported on 24 patients in their initial description of the combined procedure and found only two patients to have residual acid reflux symptoms, although these were improved in comparison with the preoperative condition.3 They also found residual, although improved, dysphagia in 7 of the 24 patients. In a longitudinal study of this patient cohort, Pearson and colleagues followed 25 patients treated with Collis gastroplasty and Belsey fundoplication over a period of at least 5 years from their operation. Excellent clinical results were achieved in 24 of these patients and were confirmed objectively with upper endoscopy and barium swallow.6

The success of the combined operation stems from the decrease in tension on the fundoplication, particularly at the buttress sutures of the hiatal repair, which constitute a common site of recurrence in patients undergoing Belsey fundoplication alone. Manometric study of the procedure in vivo both intraoperatively and postoperatively demonstrates reconstitution of the distal esophageal high-pressure zone at the level of the gastroplasty tube.7 Postprocedure reflux, as documented by pH monitoring, also has been shown to return to normal levels.8 In a longitudinal study, Pearson and Henderson showed the operation to be effective in the treatment of stricture, with patients remaining free of dysphagia at 5 years.6


With the development of minimally invasive operations to treat reflux disease and paraesophageal hernia, the Collis-Belsey procedure no longer represents first-line treatment in most patients. However, the operation remains an important option for patients with foreshortened esophagus and distal esophageal stricture or impaired esophageal motility. In this difficult subset, an excellent long-term result may be achieved. A thorough preoperative evaluation is essential in the selection of appropriate candidates, with careful attention paid to the anatomy and physiology of the distal esophagus. Patients undergoing the operation should be made aware that further interventions may be necessary in the course of their postoperative care, and the surgeon should aggressively pursue endoscopic evaluation of patients with persistent symptoms of reflux or dysphagia postoperatively.


Thorough understanding of all surgical approaches to the management of the esophagus is critical for practicing thoracic surgeons who have the training to approach the GEJ from the abdomen or the chest based on their patient's need. These days, the Belsey or Pearson-Belsey operation is best suited for cases where a laparoscopic approach is not possible due to scarring or other anatomical constraints. This is a complex procedure best learned from an experienced practitioner. In cases of re-operation after a Nissen fundoplication, the left lateral segment is almost always adhesed to the wrap or stomach. It can be bluntly dissected to avoid the risk of entering the liver rather than the stomach. The bleeding usually stops with packing for a few minutes. Whenever there is a doubt as to the length of the esophagus, it is best in my opinion to perform the Collis extension. Newer laparoscopic staplers may be more convenient for the Collis portion of the procedure.



1. Skinner DB, Belsey RH: Surgical management of esophageal reflux and hiatus hernia: Long-term results with 1030 patients. J Thorac Cardiovasc Surg 53:33–54, 1967.[PubMed: 5333620]

2. Collis JL: An operation for hiatus hernia with short esophagus. J Thorac Surg 34:768–73; discussion 774–8, 1957. 

3. Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus hernia repair: An operation for the management of peptic stricture with acquired short esophagus. J Thorac Cardiovasc Surg 61:50–63, 1971.[PubMed: 5540462]

4. Pearson FG: Gastroplasty/open gastroplasty. In Pearson FG (ed): Esophageal Surgery, 2d ed. Philadelphia, Churchill-Livingston, 2002:373–98.

5. Orringer MB, Sloan H: Complications and failings of the combined Collis-Belsey operation. J Thorac Cardiovasc Surg 74:726–35, 1977.[PubMed: 916712]

6. Pearson FG, Henderson RD: Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty, and Belsey hiatus hernia repair. Surgery 80:396–404, 1976.[PubMed: 960006]

7. Cooper JD, Gill SS, Nelems JM, Pearson FG: Intraoperative and postoperative esophageal manometric findings with Collis gastroplasty and Belsey hiatal hernia repair for gastroesophageal reflux. J Thorac Cardiovasc Surg 74:744–51, 1977.[PubMed: 916714]

8. Orringer MB, Sloan H: Collis-Belsey reconstruction of the esophagogastric junction: Indications, physiology, and technical considerations. J Thorac Cardiovasc Surg 71:295–303, 1976.[PubMed: 1246155]

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