Unilateral Versus Bilateral Wrap Crural Fixation in Laparoscopic Nissen Fundoplication for Children

Abstract

Introduction:Gastroesophageal reflux (GERD) is common in neurologically impaired (NI) children. Fundoplication and gastrostomy have previously been indicated in NI children with GERD who have not responded to medical treatment. The most common reason for fundoplication failure is intrathoracic migration of the wrap.Objective:The aim of the study is to measure the effect of wrap fixation on the final outcome of laparoscopic Nissen fundoplication in NI children.Patients and Methods:A retrospective file review was conducted for all NI children who underwent laparoscopic Nissen fundoplication in 2 tertiary pediatric surgery centers in the United Arab Emirates from February 15, 2006 to February 15, 2013. Redo fundoplication patients were excluded from the study. Patients were divided into 2 groups: group 1 in which the fundoplication wrap was fixed to the right crus only, and group 2 in which the wrap was fixed to the right and left crus simultaneously.Results:The study population included 68 patients; there were 47 male and 21 female children. Mean age at time of surgery was 8.2 years. Recurrent GERD at 1 year postoperatively was 26% versus 7% in group 1 and group 2, respectively, by upper contrast study. Redo surgery was required in 21% versus 3% in group 1 and group 2, respectively.Conclusions:Bilateral fixation of the wrap to diaphragmatic crura significantly reduced recurrent GERD, in laparoscopic Nissen fundoplication for neurologically impaired children, with no increased risk of morbidities. Future prospective studies should be conducted with larger patient populations and longer follow-up periods.

Influence of Wrap Fixation Technique on the Results of Fundoplication

“…In addition, it should decrease the tension on wrap sutures, prevent the wrap from becoming loose with time, and decrease the incidence of recurrent GERD. 21 We chose to perform this in patients with welldeveloped crura of good quality tissue. In cases where this was not feasible, the wrap was fixed to the body of the stomach by placing 2 nodal bilateral sutures.…”

“…We feel that an important advantage of the bilateral fixation of the wrap to crura is the ability to create a more symmetrical wrap. In addition, it should decrease the tension on wrap sutures, prevent the wrap from becoming loose with time, and decrease the incidence of recurrent GERD 21. We chose to perform this in patients with well-developed crura of good quality tissue.…”