Minimally Invasive Surgical Approach for Esophageal Adenocarcinoma in a Patient with Previous Belsey Mark IV Fundoplication: A Case Report

Background: Historically, the management for recurrent or persistent Gastro-esophageal reflux disease included selective vagotomy and fundoplication. Despite these surgical interventions, the risk of Barrett’s esophagus (BE) and subsequent malignant transformation remains, requiring cancer resection surgery. We present a case of a patient with a gastro-esophageal junction (GEJ) adenocarcinoma, who underwent a pediatric thoracotomy and Belsey Mark IV fundoplication, and was successfully treated by Laparoscopic Ivor-Lewis Esophagectomy (LILE). Case Presentation: This 64-year-old gentleman with BE and GEJ adenocarcinoma was previously deemed unsuitable for curative surgery due to clinical staging indicating a tumor length of 10cm and suspected invasion of the left pleura. Further staging by Endoscopic ultrasound indicated no evidence of pleural invasion with the distal esophageal thickening in keeping with his previous Belsey Mark IV fundoplication. He underwent neo-adjuvant chemotherapy and a subsequent LILE with complete laparoscopic reversion of the gastric fundoplication without injury to the gastroepiploic artery or fundus. There was sufficient preservation of conduit length to enable a tension free hand-sewn anastomosis with an uneventful post-operative recovery. Final histopathology confirmed ypT1 ypN0 moderately differentiated adenocarcinoma with R0 resection margins. The patient has completed 24 months of cancer recurrence free surveillance. Conclusion: We describe the successful management of a patient by LILE on a background of previous hiatal fundoplication surgery, previously refused curative surgery. We highlight the importance of EUS as a staging modality for such cases showing invasive disease to increase the final clinical staging accuracy. We suggest a minimally invasive approach may be utilized for successful re-do hiatal dissection as an alternative to a conventional open surgery.

Imre József a magyar nyelőcsősebészet megalapitója

József Imre as a member of Surgical Clinic personnel of Szeged University spent several months at the surgical department of the world-known R. Belsey in Leeds in the 6th decade of the last century. After returning home he introduced such operations in the domestic surgical practice as the Belsey-Mark IV antireflux fundoplication, fundoplication combined with myotomy, diverticulectomy + myotomy in Zenker diverticula, the Belsey type long left colonic graft for replacement of esophageal corrosive strictures and the monofil suture of oesophagal anastomosis. He prepared Tygon prosthesis for palliative oesophagal intubation. J. Imre was the author of the oesophagus chapter in Imre Littman’s monography of surgery. A large number of oesophagus operations was performed in his professional life. He left a total body of work behind. Cut in stone, his exceptional personality is commemorated in the pantheon of Surgical Clinic at Szeged University.

A Case of a Giant Epiphrenic Esophageal Diverticulum

The esophageal diverticula are divided into pharyngoesophageal, parabronchial and epiphrenic. They could also be divided into congenital and acquired, true and false, pulsion and traction. Pulsion diverticula are usually formed in motor disorders of the esophagus, above the place of hypertension and uncoordinated peristalsis. They are pseudo-diverticula caused by increased intramural pressure, leading to herniation of the mucosa and submucosa through the focal areas of the esophageal wall. We present a 65-year-old woman who underwent left-sided transthoracic diverticulectomy, modified Heller esophagocardiomyotomy, and modified Belsey-Mark IV fundoplication due to a huge epiphrenic esophageal diverticulum.

P93 BELSEY MARK IV: STILL A VALID OPTION. SINGLE CENTER EXPERIENCE OF 100 CONSECUTIVE CASES

Aim To share the single-center experience of a tertiary referral center using the Belsey Mark IV operation in the treatment of large primary hiatal hernias (PHH) and recurrent hernias after failed antireflux surgery. Background & Methods We conducted a retrospective analysis of all patients with PHH or recurrent hernia after antireflux surgery operated between May 1, 2012 and December 31, 2016 who received a Belsey-Mark IV antireflux procedure. Data on patient demographics, surgical history, pre-operative work-up, indication, short- and long-term complications graded by the Clavien-Dindo classification (CDC) and recurrence rate, defined as clinical symptoms confirmed with barium swallow test, were collected and analyzed. Results A total of 100 consecutive cases were included in this analysis. Median age at time of surgery was 67 years (range 0 - 86). Seventy-two were female. Indications were: PHH Type I (n = 2), Type II (n = 1); Type III (n = 55), Type IV (n = 3), redo after previous antireflux surgery (n = 39). Median follow-up was 23 months (range 4-80). Major peri-operative short-term morbidity (defined as CDC 3-4) was present in 14 cases, with respiratory complications being the most prevalent. Fundoplication leakage was present in five cases and managed conservatively in three of those. Hernia recurrence rate was 31% in the redo group (12/39) and 10% in the PHH group (6/61). Median time-to-recurrence was 22 months (range 2-78). Post thoracotomy pain syndrome requiring treatment (CDC 2) was present in 12 cases. One patient deceased due to respiratory complications after emergency Belsey Mark IV repair following early recurrence after laparoscopic Nissen fundoplication and two reinterventions. Conclusion The Belsey Mark IV repair is a safe and effective procedure in experienced hands, with well-defined risks and an acceptable recurrence rate, given the nature of the condition and patient’s comorbidities.