Laparoscopic Nissen Fundoplication in Children. A Modified Technique to Reduce Recurrent Reflux

Abstract Background Gastroesophageal reflux disease is very common in children and adolesents. In cases of severe neurologic deficits and reflux symptoms fundoplication procedure is also required together with gastrostomy for feeding purposes. The most popular operation is laparoscopic Nissen fundoplication with the efficiency of about 90%. However in certain cases reoperations are needed. The recurrence rate varies in a wide range making 3–40% and is one of the most acute problems in GERB surgery. In our study we introduce the new technique of laparoscopic Nissen procedure which may reduce the incidence of recurrent reflux. Methods 345 children form 1 month to 18 years old underwent laparoscopic Nissen fundoplications, with were divided into two groups. Group I (181 patients)—The wrap was made according to our adjusted technique with constructing the wrap by suturing the stomach wall through all the layers. Group II (164 patients)—the wrap was made in the traditional way. The patients with recurrent reflux were divided into Group I-R (n = 14) and Group II-R (n = 30) depending on the operation technique used. The patients were followed up at 3, 6, 12 months and then once a year after the operation. Results A total of redo fundoplication was 52 in both groups. The recurrence rate in Group I was 8% and in Group II 19%. The incidence of hiatal hernia in both groups was equal (15%), however in redo operations it raised up to 57–64%. Peptic esophageal strictures were also higher in children with recurrent reflux 14–20% comparing to 7–9% of those who were operated on once. The main cause of symptoms recurrence was wrap failure (47–56%), wrap migration and telescoping was present in 19–28% of cases. Conclusion The use of sutures through all the layers of the stomach wall to construct the fundoplication wrap lowers the recurrence rate from 19% to 8% and reduces wrap migration from 28% to 19% comparing to the traditional technique of laparoscopic Nissen procedure. Hiatal hernia and peptic esophageal strictures are the risk factors for redo operations.