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

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.