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/lp/springer-journals/comparative-study-of-laparoscopic-nissen-fundoplication-versus-hill-WNXCQN9e70
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- Springer Journals
- Copyright
- Copyright © The Author(s) 2022
- eISSN
- 2090-5394
- DOI
- 10.1186/s43159-022-00232-w
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- See Article on Publisher Site
Abstract
Background Gastroesophageal reflux disease (GERD) is a common condition in children. Complete fundoplication provides better reflux control but it results in more dysphagia and gas-bloat symptoms. Antireflux surgery without wrap has fewer adverse effects but a higher failure rate in controlling reflux. Until now, there is little evidence as to whether complete or partial fundoplication is the optimal procedure in this age group. Objective This study aimed to compare the safety and efficacy of laparoscopic Nissen fundoplication versus Hill- Snow procedure among children with GERD. Methods We conducted a randomized, single-blinded, comparative trial that included 40 children with a diagnosis of GERD, who were scheduled to undergo surgery. Children were randomly allocated to undergo laparoscopic Nissen fundoplication or Hill-Snow procedure. Results While the incidence of postoperative dysphagia was similar between both groups, the duration of dysphagia was significantly shorter in the Hill-Snow group. Likewise, the incidence of bloating was significantly lower in the Hill- Snow group than the Nissen group (0% versus 55%, respectively). We found three recurrent Hill-Snow cases versus two recurrent Nissen cases. The operative time was significantly longer in the Hill-Snow procedure (150 ± 52 min) than in the Nissen group (120 ± 48 min). Conclusions The Hill-Snow procedure is an effective alternative to Nissen fundoplication with no bloating and much less dysphagia, leading to faster recovery of ordinary eating patterns. Keywords Laparoscopic Nissen fundoplication, Hill-Snow procedure, Gastroesophageal reflux, Children Background To date, laparoscopic Nissen fundoplication is the sur- gery of choice for GERD management in many surgi- *Correspondence: cal centers, with a reported success rate of 60–90% [1]. Mohamad Mahmoud Qinawy Nonetheless, Nissen fundoplication is associated with a mohamad.qinawy@kasralainy.edu.eg high incidence of dysphagia and gas-bloat symptoms, Department of Pediatric Surgery, Cairo University Children Hospital (Abuelrish Hospital), Dr. Ali Ibrahim Street, Elmounira, Cairo, Egypt leading to a delayed return of normal eating pattern [2]. On the other hand, adult studies proposed the Hill-Snow © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Gad et al. Annals of Pediatric Surgery (2023) 19:8 Page 2 of 7 operation as an effective alternative to the Nissen fun - the inflation of the peritoneum by CO (8–12 cm H O), 2 2 doplication in order to reduce the incidence of postop- left-sided dissection and division of the posterior gas- erative complications [3]. Hill-Snow procedure depends trophrenic attachments anchoring the fundus to the on restoring the angle of His and posterior fixation of the diaphragm was done. The phreno-esophageal ligament gastroesophageal junction (GEJ), leading to augmenta- was dissected toward the anterior wall of the esophagus tion of the intrinsic pressure without wrapping; hence, toward the right crus (Fig. 1). After making a window restoring the normal function of the esophagus [3]. behind the esophagus, a grasping forceps was inserted This comparative trial aimed to compare the safety to expose the hiatus. The crura were approximated using and efficacy of laparoscopic Nissen fundoplication ver - 2/0 non-absorbable sutures. sus Hill-Snow procedure among children with GERD in In the laparoscopic Nissen fundoplication group, a terms of postoperative dysphagia, bloating, and recur- 5-mm hook cautery or Harmonic scalpel was used to rence of symptoms. divide the short gastric vessels. Then, the mobilized fun - dus was passed through the window behind the esoph- Methods agus to the right side. The “shoeshine” maneuvre was The institutional review board (IRB) committee approved performed with the fundoplication around the esophagus the study’s protocol before the patients’ enrolment. All to ensure a loose, floppy, and symmetric fundoplication. study procedures run in compliance with the ethical Then, a 2/0 suture was used in a simple interrupted man - standards of the Declaration of Helsinki [4]. ner to bring the fundus around the esophagus. Another suture was placed to incorporate the wrap to the esopha- Study design and patients gus and crura, 1 cm superior to the first suture. A third We conducted a randomized, single-blinded, compara- suture was sometimes placed inferior to the first one tive trial that recruited children (aged less than 18 years (Fig. 2). old) with a GERD diagnosis that necessitates surgical In the Hill-Snow group, the short gastric vessels were intervention. Patients were recruited from the Pediat- not divided. The distal abdominal esophagus was fixed by ric Surgery Department of Cairo University Specialized suturing the posteromedial wall of the gastroesophageal Pediatric Hospital through the period from October 2018 junction to the crural decussation and tendon just above till April 2020. Patients were included if they exhibited a the origin of the celiac trunk with two simple 2/0 silk poor response to medical treatment, had a symptomatic sutures. Then, the angle of His was reconstructed by fix - hiatus hernia, and/or presented with esophageal stricture ing the fundus to the abdominal esophagus and the dia- or life-threatening symptoms. Exclusion criteria included phragm, thus ensuring that the abdominal esophagus was cases with grade IV hiatus hernia, para-esophageal her- fixed to the abdominal cavity (Fig. 3). nia, or recurrent GERD. Eligible patients were rand- In both groups, the ports were removed, and the inser- omized using web-based software and closed envelopes tion sites were sutured using 3/0 absorbable sutures. All to allocate patients in a 1:1 ratio to undergo either lapa- patients were followed up for 1 year after the operation. roscopic Nissen fundoplication or Hill-Snow technique. Statistical analysis Data collection and operative techniques The analysis was performed using the Statistical Package All patients underwent routine clinical examination and for Social Sciences (SPSS) version 27. Summary statis- investigations, including contrast study and endoscopic tics were used to describe the quantitative and qualita- examination. Patients were instructed to fast for at least tive data. The difference in the qualitative data between 6 hours before the operation. All procedures were done the laparoscopic Nissen fundoplication and Hill-Snow under general anesthesia, and patients were positioned groups was assessed using the chi-square test. In con- in frog-legged and lithotomy positions for small children trast, the association between quantitative data was eval- and larger children, respectively. The table was set in uated using the Mann–Whitney test. A P value of less reversed Trendelenburg position. A 5-mm 30° angled tel- than 5% was considered statistically significant. escope optical trocar was inserted in the umbilicus using the Hasson’s technique. Two working ports were intro- Results duced under vision in the left hypochondrium, and right A total of 40 patients met the inclusion criteria and were hypochondrium at the midclavicular line in both groups. recruited in the present study. The majority of patients Then, a 5-mm grasper was inserted below the left cos - were males (60%), and 12.5% of them had neurological tal margin for the stomach traction. Lastly, the liver was symptoms. The median age was two years old, and the mostly retracted using a 2/0 suture or in grasper intro- mean weight was 10.2 ± 5.9 kg (Table 1). Concerning duced in the epigastrium exposing the hiatus. Following the presentation of the GERD, we found that persistant G ad et al. Annals of Pediatric Surgery (2023) 19:8 Page 3 of 7 vomiting not responding to medical treatment was the most common presenting symptom found in all patients except for two patients who presented with anemia and chest problems. Recurrent chest infection was found in two cases. In nearly all cases, low body weight for age and nutritional deficiency were found (Table 2). About 95% of cases suffered from hiatal hernias. Almost two-thirds of the patients (70%) had type I hiatus hernia, and 25% had type III. In terms of intraoperative data, the operative time (minutes) was significantly longer in the Hill-Snow group (156 ± 52) when compared to the Nissen Group (120 ± 48) (p value = 0.031). Intra-operative complica- tions showed significant differences when comparing the two groups. In the Nissen group, there were two cases with iatrogenic left pleural perforation (10%), which was managed by intercostal tube insertion with no effect on the procedure. In the Hill-Snow group, there were no documented intraoperative complications. The hospital stay time showed no statistical difference when the study groups were compared. The Hill-Snow group patients had a postoperative admission median of 4 days, while in the Nissen group, the median was 6 days (p value = 0.038). In the early postoperative period, both dysphagia and bloating were lower in the Hill-Snow group as in two (10%) and three (15%) cases, respectively. Early bloat- ing was significantly lower in the Hill-Snow group (p value < 0.001). Meanwhile, the Nissen group was as high as 7 (35%) and 15 (75%) cases, respectively. Early postop- erative vomiting was encountered more in the Hill-Snow group, six cases (30%) versus two cases (10%) in the Nis- sen group (Table 3). Although the incidence of postoperative dysphagia was statistically insignificant in both groups, the dura - tion of dysphagia showed a statistically significant shorter duration in the Hill-Snow group compared to the Nis- sen group (p value > 0.001). The duration of dysphagia in the Hill-Snow group showed a median duration of seven days ranging from 0 to 25 days, while in the Nis- sen group, the median duration was as high as 40 days ranging from 10 to 70 days. No patients of the Hill-Snow group suffered from bloating. In contrast, 11 cases from the Nissen group (55% of patients) suffered from bloat - ing to a variable degree throughout their postopera- tive course (p value < 0.001). Mild regurgitation in the follow-up period was reported more frequently in the Hill-Snow group, eight cases (40%) versus six cases (30%) Fig. 1 A Retraction of the liver with a suture passing from abdominal in the Nissen group. The number of patients who had to wall to the diaphragm. B Dissection starting at the gastrophrenic ligament. C Completed esophageal and crural dissection use medications to overcome postoperative regurgitation or dysphagia (as prokinetic drugs or PPIs) was lower in the Nissen group (5 cases) when compared to the Hill- Snow (8 cases). Patients were followed up for a period of Gad et al. Annals of Pediatric Surgery (2023) 19:8 Page 4 of 7 Fig. 2 1 Division of the short gastric vessels. 2 Pulling the fundus behind the esophagus. 3 First suture of the wrap. 4 Wrap completed 12 months. There were three recurrent Hill-Snow cases of our knowledge, this is the first comparative trial that versus two Nissen cases which were related to persis- compared both techniques in the paediatric age group. tent regurgitation. Redo surgery was done for two Hill- Dysphagia is a common complication following surgi- Snow cases while the other cases were controlled on PPIs cal intervention for GERD. It is proposed that early dys- (Table 4). Nissen fundoplication was done for one case phagia is closely related to the postoperative edema, while and redo Hill-Snow procedure for the other. late dysphagia is more likely to reflect improper approxi - mation of the crura or tight wrap [5]. The risk factors for postoperative dysphagia usually include neurological Discussion disorders, such as cerebral palsy [6]. In the present study, GERD is a commonly encountered disorder in the pedi- the Hill-Snow group patients demonstrated a lower inci- atric population, affecting nearly 7–20% of pediatric age dence of early post-operative dysphagia and epigastric group worldwide, and exerts substantial burden on the distension during their post-operative admission. Moving healthcare system. Although the management of GERD to the outpatient follow-up observations, the incidence usually involves lifestyle changes and postural therapy, of postoperative dysphagia was statistically insignificant surgery may be required in the case of life-threatening in both groups, but the duration of dysphagia was signifi - complications. Previous reports showed that the Nissen cantly shorter duration in the Hill-Snow group, highlight- fundoplication is associated with a high incidence of ing the earlier improvement of dysphagia. dysphagia and gas-bloat symptoms, leading to a delayed In the present study, post-prandial epigastric fullness return of normal eating pattern [2]. Thus, Hill-Snow and discomfort; also described as bloating or gas bloat operation was proposed as an alternative to the Nissen syndrome, was not encountered during the follow up of fundoplication in order to reduce the incidence of post- patients after Hill-Snow. In comparison, 55% of Nissen operative complications. This comparative trial aimed fundoplication patients suffered from bloating to a vari - to compare the safety and efficacy of laparoscopic Nis - able degree throughout their postoperative course. sen fundoplication versus Hill-Snow procedure among In terms of recurrence rate in the present study, there children with GERD in terms of postoperative dyspha- were three recurrent Hill-Snow cases versus two Nissen gia, bloating, and recurrence of symptoms. To the best G ad et al. Annals of Pediatric Surgery (2023) 19:8 Page 5 of 7 Table 1 Demographic data of both studied groups Variables Nissen Hill-Snow Count % Count % Gender Males 10 50.0% 14 70.0% Females 10 50.0% 6 30.0% Neurologi- Impaired 4 20.0% 1 5.0% cal status Normal 16 80.0% 19 95.0% Age in Median 25 (10 -132) 18.5 (6 – 144) months (range) Weight in Mean ± 9.9 ± 6.1 10.6 ± 6.1 Kg Table 2 Presentations of GERD in the studied cases Symptoms Number of cases % Anemia, melena 1 2.5% Hematemesis and melena 3 7.5% Vomiting and hematemesis 8 20% Chocking with chest symptoms and feed- 1 2.5% ing problems Dysphagia (esophageal stricture) 3 7.5% Fever and bleeding and vomiting 1 2.5% Hematemesis only 9 22.5% Pulmonary symptoms 1 2.5% Persistent vomiting only 13 32.5% cases. Recurrence occurred about six months postopera- tively. This was confirmed by contrast study and endo - scopic examination. Two Hill-Snow cases required surgical correction due to complete failure of the proce- dure. Recurrent Nissen cases were controlled on PPIs. It is to be noted that recurrent cases of Hill-Snow group were in the first ten cases. This may be attributed to the learning curve that increases gradually. In the current study, Hill-Snow procedure was asso- ciated with significantly longer operative time than in Nissen fundoplication. Such findings run in line with a previous retrospective chart review noting that the mean operative time following Nissen fundoplication was almost 109 min, with dramatic reduction in the opera- tive time with increased learning curve [7]. However, it should be noted that despite the shorter operative time in the Nissen fundoplication group, the rate of intraopera- tive complications was numerically higher in the Nissen group (10% compared to 0% in the Hill-Snow group). The encountered complications were in the form of two cases of iatrogenic left pleural perforation that was suspected by desaturation during anesthesia and confirmed by Fig. 3 1 Posterior esophago-cardiopexy. 2 Accentuation of angle of chest X-ray. In a previous report by Esposito et al., nearly His. 3 Fixation of the gastric fundus to the diaphragm 5% of the patients underwent Nissen fundoplication had intraoperative complications. However, the rate among Gad et al. Annals of Pediatric Surgery (2023) 19:8 Page 6 of 7 Table 3 Early postoperative observations for studied groups Nissen Hill-Snow P value Count % Count % Early dysphagia Yes 7 35.0% 2 10.0% 0.127 No 13 65.0% 18 90.0% Early bloating Yes 15 75.0% 3 15.0% < 0.001 No 5 25.0% 17 85.0% Early vomiting Yes 2 10.0% 6 30.0% 0.235 No 18 90.0% 14 70.0% Table 4 Late postoperative assessment Nissen Hill-Snow P value Count % Count % Dysphagia Yes 5 25.0% 3 15.0% 0.695 No 15 75.0% 17 85.0% Bloating Yes 11 55.0% 0 0.0% < 0.001 No 9 45.0% 20 100.0% Dumping Yes 5 25.0% 1 5.0% 0.182 No 15 75.0% 19 95.0% Vomiting Yes 6 30.0% 8 40.0% 0.507 No 14 70.0% 12 60.0% Ability to blench Yes 12 60.0% 16 80.0% 0.168 No 8 40.0% 4 20.0% Recurrence Yes 2 10.0% 3 15.0% 1 No 18 90.0% 17 85.0% Need for PPIs Yes 5 25.0% 8 40.0% 0.311 No 15 75.0% 12 60.0% Abbreviations infants approached 9.7 to 15.6% in other reports [8]. Of GERD Gastroesophageal reflux disease note, the present study did not observe any case that PPI Proton pump inhibitors needed conversion to open approach. The current litera - Acknowledgements ture indicates that the rate of conversion in the setting of None. GERD range from 0 to 7.5% [9]. The rate of intraoperative complications was reflected on the duration of hospital Authors’ contributions Mohamed Qinawy collected the data and converted the thesis into a manu- stay in the present study which was slightly longer in the script. Mostafa Gad revised the manuscript. Mohamed Elbarbary developed Nissen group. the idea of the research. Osama Abdelazim and Mahmoud Elfiky verified the analytical methods. Sherif Kaddah supervised the project. All authors discussed the results and contributed to the final manuscript. All authors read Conclusions and approved the final manuscript. Based on the present study findings, the Hill-Snow pro - cedure is an effective alternative to Nissen fundoplica - Funding This research did not receive any specific grant from funding agencies in the tion with no bloating and much less dysphagia, leading to public, commercial, or not-for-profit sectors. faster recovery of ordinary eating patterns. Further clini- cal observations are needed to validate these findings and Availability of data and materials All data generated or analyzed during this study are included in this published improve the surgical management of GERD in the paedi- article. atric population. G ad et al. Annals of Pediatric Surgery (2023) 19:8 Page 7 of 7 Declarations Ethics approval and consent to participate The institutional review board committee approved the study’s protocol before the patients’ enrolment. All study procedures run in compliance with the ethical standards of the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Received: 14 June 2022 Accepted: 22 November 2022 References 1. Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-esophageal reflux in chil- dren. Int J Mol Sci. 2017;18(8):1671. 2. Esposito C, Roberti A, Turrà F, Escolino M, Cerulo M, Settimi A, Farina A, Vecchio P, Di Mezza A. Management of gastroesophageal reflux disease in pediatric patients: a literature review. Pediatr Health Med Ther. 2015;6:1. 3. Snow LL, Weinstein LS, Hannon JK. Laparoscopic reconstruction of gas- troesophageal anatomy for the treatment of reflux disease. Surg Endosc. 1995;9(7):774–80. 4. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–4. 5. Allal H, Captier G, Lopez M, Forgues D, Galifer RB. Evaluation of 142 con- secutive laparoscopic fundoplications in children: effects of the learning curve and technical choice. J Pediatr Surg. 2001;36(6):921–6. 6. Lopez M, Kalfa N, Forgues D, Guibal MP, Galifer RB, Allal H. Laparoscopic redo fundoplication in children. Failure causes and feasibility. J Pediatr Surg. 2008;43(10):1885–90. 7. Rothenberg SS. The first decade’s experience with laparoscopic Nissen fundoplication in infants and children. J Pediatr Surg. 2005;40(1):142–7. 8. Esposito C, Montupet P, van Der Zee D, Settimi A, Paye-Jaouen A, Centonze A, Bax NK. Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease. Surg Endosc Other Interv Tech. 2006;20(6):855–8. 9. Lobe TE. The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children. Surg Endosc. 2007;21(2):167–74. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations.
Journal
Annals of Pediatric Surgery – Springer Journals
Published: Feb 7, 2023
Keywords: Laparoscopic Nissen fundoplication; Hill-Snow procedure; Gastroesophageal reflux; Children