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Prosthetic patch stabilization of crural repair in antireflux surgery in children
B Simpson1, R R Ricketts, P M Parker
1Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Insights
Reinforcing Nissen fundoplication repairs with a prosthetic patch significantly reduces recurrent gastroesophageal reflux and wrap herniation in children, especially those with neurological impairments or prior failed surgeries.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Surgical Innovation
Background:
- Nissen fundoplication is a common surgical treatment for pediatric gastroesophageal reflux.
- Reoperation rates for failed fundoplication are high, particularly in neurologically impaired children (25%).
- Recurrent reflux and wrap herniation are significant postoperative complications.
Purpose of the Study:
- To evaluate a modified Nissen fundoplication technique using a prosthetic patch for crural repair.
- To reduce the incidence of postoperative gastroesophageal reflux recurrence and wrap herniation.
Main Methods:
- A modified Nissen fundoplication was performed in 38 children between 1993 and 1995.
- A horseshoe-shaped Dacron patch was used for tension-free crural repair posterior to the esophagus.
- A standard 360-degree Nissen wrap was constructed after crural repair.
Main Results:
- 56% of patients were neurologically impaired; 18% underwent reoperation for prior failed fundoplication.
- One patient experienced dysphagia requiring esophageal dilatation due to stenosis.
- After a 15-month mean follow-up, all patients were free of symptomatic reflux and radiographic evidence of recurrence or herniation.
Conclusions:
- Tension-free crural repair with a prosthetic patch appears effective in decreasing postoperative reflux and wrap herniation.
- This modified technique may be particularly beneficial for neurologically impaired children and those requiring reoperation.
Abstract:
Nissen fundoplication is a frequently performed procedure by pediatric surgeons for the treatment of gastroesophageal reflux. Reoperation for failed fundoplication is necessary in 10 per cent of children and in 25 per cent of neurologically impaired children. In an attempt to reduce the postoperative recurrence of gastroesophageal reflux and wrap herniation, we have modified our Nissen fundoplication by reinforcing the crural repair with a horseshoe-shaped prosthetic patch. Between 1993 and 1995, 38 children underwent a Nissen fundoplication with prosthetic patch crural repair. Tension-free crural repair was performed over an esophageal dilator by suturing a horseshoe-shaped Dacron patch posterior to the esophagus. After crural repair, the standard Nissen 360 degrees wrap was constructed. Of the 38 children, 56 per cent (n = 21) were neurologically impaired. In 18 per cent of patients, the operation was performed for recurrent reflux due to wrap herniation after a Nissen fundoplication without prosthetic patch repair. One child required esophageal dilatation postoperatively for dysphagia related to esophageal stenosis. After a mean follow-up of 15 months, all patients were without symptomatic reflux or had no radiographic evidence of recurrent reflux or wrap herniation. Tension-free crural repair with a prosthetic patch may decrease postoperative reflux and wrap herniation, particularly in neurologically impaired children and in children requiring reoperation for recurrent reflux.