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Pledgeted mattress sutures reduce recurrent reflux after laparoscopic Nissen fundoplication
Jennifer L Curtis1, Grace Wong, Ivan Gutierrez
1Division of Pediatric Surgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
Insights
Modifying laparoscopic Nissen fundoplication with pledgeted sutures for crural closure and wrap construction significantly reduces recurrent reflux and reoperation rates in children. This technique improves outcomes compared to simple sutures.
Area of Science:
- Pediatric Surgery
- Gastrointestinal Surgery
- Surgical Techniques
Background:
- Recurrent reflux after laparoscopic Nissen fundoplication prompted a technique modification.
- The modified technique incorporates pledgeted, horizontal mattress sutures for crural closure and wrap construction.
Purpose of the Study:
- To assess the impact of using pledgeted sutures versus simple sutures for crural closure and wrap construction in pediatric laparoscopic Nissen fundoplication.
- To evaluate the effect of this technical modification on recurrent reflux rates and other outcomes.
Main Methods:
- Retrospective review of 384 children undergoing laparoscopic fundoplication between 1997 and 2007.
- Comparison of outcomes between patients receiving simple sutures versus pledgeted, horizontal mattress sutures for crural closure and wrap construction.
- Statistical analysis including chi-squared, logistic regression, and Kaplan-Meier analysis.
Main Results:
- A total of 384 subjects were analyzed; 77% had neurologic deficits.
- Patients receiving simple sutures had significantly higher cumulative incidences of recurrent reflux, gagging/retching, wrap failure, and reoperation compared to those with pledgeted sutures.
- Kaplan-Meier analysis confirmed a significantly lower probability of recurrent reflux with pledgeted sutures.
Conclusions:
- The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication is associated with reduced rates of recurrent reflux.
- This technical modification may be beneficial in improving surgical outcomes for pediatric patients undergoing Nissen fundoplication.
Introduction:
In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction.
Methods:
We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with chi(2), logistic regression, and Kaplan-Meier analysis.
Results:
A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures (P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods.
Conclusions:
The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.
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