Background: Laparoscopic anti-reflux surgery has become firmly established in the management of gastro-oesophageal reflux in children. The Nissen remains the most widely used anti-reflux procedure, but its success is frequently compromised by mechanical complications. Several modifications, such as partial wraps, have been described. It is not known whether the advantages of partial fundoplication translate into paediatric surgical practice, and the aim of this paper is to evaluate the medium term results in a series of largely anterior Watson laparoscopic fundoplications.
Methods: Prospective observational study of 70 children and infants who underwent laparoscopic fundoplication for gastro-oesophageal reflux disease.
Results: Between 01/1997 and 07/2007 a total of 70 laparoscopic fundoplications in 2 separate institutions were performed by the senior author. Sixty three had the Watson procedure with the remainder having had a Nissen fundoplication. Thirty six percent of patients in this series were neurologically compromised, age ranged from 2 months to 18 years (mean 7.52) with 10 patients having had previous abdominal procedures (8 PEG placements, 1 VP shunt, 1 previous failed Nissen fundoplication by adult surgeon).
Three patients in the initial 2 years of this experience, 2 with port site hernia and 1 with bolus obstruction were taken back to theatre within 72 hours of surgery. Nine patients suffered early dysphagia and 2 cases with Hellers myotomies and anterior fundoplication required dilatations. In a mean follow up of 2.29 and1.93 years respectively for the 2 institutional experience, no patients had come to redo surgery although several with confirmed intact wraps (11 cases) are back on medical treatment. Overall there were 3 mortalities of which 1 was perioperative(15 days) and all were attributable to co-morbidity. Overall, 21 patients in this cohort required PEG placement on completion of fundoplication and there were no conversions to the open technique despite difficult local conditions from previous surgery, extensive perioesophagitis or associated hiatal hernia (14 cases). Median post operative stay for the whole series was 2 days (range 1-19 days) although the subset with neurological compromise requiring PEG placement stayed longer with a median stay of 4 days.
Conclusion: From this study it would appear that the advantages of partial fundoplication pertain to paediatric practice as it does in adults. Encouragingly, neither conversion nor redo surgery were necessary. This series also confirms the safety and efficacy of the laparoscopic anterior fundoplication in children and infants but to establish its superiority over Nissen fundoplication would require further study.
Program Number: P275