Comparison of long-term results of total fundoplication gastroplasty and Belsey Mark IV antireflux operations in relation to the severity of oesophagitis.

OBJECTIVE Belsey Mark IV (BM IV) and total fundoplication gastroplasty (TFG) were the standard anti-reflux operations in two consecutive periods in Nottingham City Hospital Thoracic Surgery Unit. The aim of this study was to compare the long-term results obtained by these two procedures emphasizing their relation to the severity of the oesophageal mucosal damage. METHODS Ninety patients (50 females and 40 males with a mean age of 57 years) who had a BM IV operation between 1976 and 1983 and 86 patients (46 females and 40 males, with a mean age of 56.5 years) undergoing a TFG procedure between 1983 and 1986 were evaluated. All patients were assessed preoperatively by means of clinical history, barium meal and endoscopy. In addition, 72 of the patients having a TFG had prolonged pH monitoring and manometric studies. The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to the criteria published by Orringer et al. (Orringer MB, Skinner DB, Belsey RHR. Long-term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25-33). RESULTS In the BM IV group there was one post-operative death (1.1%). The median follow-up was 11 years (range 3-18 years). Overall good results were achieved in 64 patients (71.9%). In patients without oesophagitis (n = 24) the success rate was 91.7% while for grades I (n = 17), II-III (n = 36) and IV (n = 12) oesophagitis this was 76.5, 66.7 and 41.7%, respectively (P = 0.01). The actuarial success rate at 10 through to 18 years was 71.0%. In the TFG group there was no postoperative death. The median follow-up was 10 years (range 2-14 years). Overall good results were achieved in 78 patients (90.7%). In the absence of oesophagitis (n = 10) the success rate was 90.0% and for grades I (n = 12), II-III (n = 26) and IV (n = 38) oesophagitis this was 91.6, 92.3 and 89.4%, respectively. The actuarial success rate at 10 through to 14 years was 90.3%. The differences in the overall success rate (P = 0.002), the success rates forgrades II-III (P = 0.02) and IV (P = 0.001) oesophagitis and the long-term actuarial success rates (P = 0.001) were significant. CONCLUSION These data provide evidence on the superiority of the TFG against the BM IV in achieving long-term relief of reflux symptoms in the presence of severe oesophagitis. We believe that failure of BM IV in this setting is due to obvious or subtle oesophageal shortening.