By Jill Stein
CHICAGO -- October 15, 2009 -- An open fundoplication technique produces more durable repair and leads to better outcomes than conventional techniques in paediatric gastro-oesophageal reflux disease (GERD), according to a study presented here October 13 at the American College of Surgeons (ACS) 95th Annual Clinical Congress.
Dennis Lund, MD, Division of General Surgery, University of Wisconsin, Madison, Wisconsin, and colleagues described results in 80 patients who underwent primary open fundoplication procedures.
Of the 80 cases, 29 (36%) were 360 degree Nissen fundoplications and 51 (64%) received Toupet fundoplications using a posterior 270 degree wrap. All operations included hiatal closure.
Overall, 71% of the cases were neurologically impaired. "Despite surgical correction of GERD, neurologically impaired patients frequently have persistent gastrointestinal symptoms and require medications," Dr. Lund noted.
Patients who received Nissen fundoplications in this series had a higher incidence of neurological impairment than patients receiving Toupet fundoplications.
At a mean follow-up of 44 months, only 1 patient (1.25%) needed a reoperation for a slipped Nissen fundoplication, and no patient undergoing a Toupet fundoplication needed a reoperation. There were no additional cases of wrap disruption or slippage.
The 2 treatment groups had a similar rate of postoperative use of antireflux medications beyond 3 months and a similar rate of GERD symptoms beyond 1 year.
Dr. Lund pointed out that compared with earlier data from a large multicentre trial, his group's technique resulted in a significantly lower reoperation rate among neurologically impaired patients (1.72% vs 11.81%; P = .0117).
He said he believes that the technique used at his institution contributes to the low need for reoperation, especially in neurologically impaired patients.
He described their procedure as follows: "The operation includes division of the short gastric vessels, a complete dissection of the hiatus and closure of the hiatus without tension around a suitable dilator. Every effort is made to have at least 4 to 5 centimetres of oesophagus anchored below the diaphragm. The decision to create a 270 or 360 degree wrap is determined by the child's neurologic status and likelihood to be fed orally. Children more likely to receive oral feedings predominantly received 270 degrees wraps. Creation of the wrap involves 10 sutures for 270 degree wraps and 15 sutures for 360 degree wraps. After completion of the fundoplication, the anterior wall of the wrap is sutured to the diaphragm to try to pull the wrap forward and create dome angulation. Gastrostomy tubes are used liberally with neurologically impaired children."
[Presentation title: Fundoplication of Children for GERD: The Importance of Technique. Abstract SE120-T]
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