GERD surgery in non-neurologic patients: Modified Laparoscopic Hill-Snow Repair is a valid alternative to Nissen fundoplication. Results of a 20 years of follow-up
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Nowadays laparoscopic Nissen fundoplication represents the gold standard in surgical treatment of complicated Gastro-Esophageal-Reflux Disease (GERD), above all in cerebral palsy patients. In non-neurological patients without gastrostomy Nissen fundoplication can create some problems (gas bloat syndrome, dysphagia). Laparoscopic Hill-Snow repair is an established surgical alternative, but it is reported only in adult population. We describe our modification of Hill-Snow technique and our experience in a large series of non-neurological children in order to report its effectiveness and applicability in pediatric patients affected by complicated GERD. Between 2000 and 2022, 319 children underwent surgical correction of gastro-esophageal reflux at our Department. All were affected by complicated gastro-esophageal reflux unresponsive to PPI (Proton Pump Inhibitors). 251 underwent laparoscopic Nissen fundoplication; 68 non-neurological patients underwent laparoscopic Hill-Snow repair. Of these 68 children 48 were males (71%) and 20 females (29%); median age was 5years (3 months-11 years). Weight range was 4-37kg.
52 patients (76.5%) presented the following symptoms: retrosternal pain, dysphagia, regurgitation, coughing, failure to thrive, persisting reflux esophagitis. 16 (23.5%) had chronic respiratory problems (aspiration, apneic-spells, dysphagia, coughing, choking, gagging). For 8 (11.8%) symptoms were expression of chronic recurrent gastric volvulus. All underwent modified-laparoscopic-Hill-Snow repair. Contrast study showed sliding hiatal hernia in 55 patients (81%), while endoscopy demonstrated 16 cases of histologically severe esophagitis (23.5%) and 52 of mild esophagitis (76.5%). No intraoperative/postoperative complications were recorded. 60patients had a complete follow-up (range 1-20 years). 60/68 patients were evaluated with barium-swallow-study at 6-12 months; 40/68 patients with upper-gastrointestinal-endoscopy at 12months. No relapse was reported. 50 patients (73.7%) were symptom-free. 18 (26.3%) referred occasional epigastric pain, associated with vomit in 2 cases. 64 (94.1%) referred ability to vomit; 4 temporary difficulty to swallow (average 30 days). All patients reported being able to burp. 3(4.5%) presented episodes of gas-air-bloat during the first 2 months with spontaneous resolution. No case of dumping syndrome was recorded. This technique’s modification yields excellent results in term of relapse and side effects at long-term follow-up. We reported the first and largest pediatric series in non-neurological children with encouraging results.
Maish M, Hagen JA. Laparoscopic fundoplication. Operative Techniq Thoracic Cardiovasc Surg 2004;9:115-128 DOI: https://doi.org/10.1053/j.optechstcvs.2004.05.003
Rothenberg SS. Two decades of experience with laparoscopic Nissen fundoplication in infants and children: a critical evaluation of indications, technique, and results. J Laparoendosc Adv Surg Tech A 2013;23:791–4. DOI: https://doi.org/10.1089/lap.2013.0299
Mauritz FA, Conchillo JM, van Heurn LW, et al. Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study. Surg Endosc 2017;31:1101-1110. DOI: https://doi.org/10.1007/s00464-016-5070-z
Hill LD. An effective operation for hiatal hernia: An eight-year appraisal. Ann Surg 1967;166:681–692. DOI: https://doi.org/10.1097/00000658-196710000-00015
Snow LL, Weinstein LS, Hannon JK. Laparoscopic reconstruction of gastroesophageal anatomy for the treatment of reflux disease. Surg Endosc 1995;9:774–780. DOI: https://doi.org/10.1007/BF00190080
Hill LD, Kozarek RA, Kraemer SJM, et al. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc 1996;44:541–547. DOI: https://doi.org/10.1016/S0016-5107(96)70006-8
Soresi AL. Diaphragmatic hernia: Its unsuspected frequency: Its diagnosis: Technic for radical cure. Ann Surg 1919;69:254–70. DOI: https://doi.org/10.1097/00000658-191903000-00005
Sweet R. Diaphragmatic hernia. In: Thoracic surgery. Sweet R, editor. Philadelphia: WB Saunders, 1950; pp. 316–334.
Allison P. Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 1951;92:419–31.
Nissen R. Gastropexy as the lone procedure in the surgical repair of hiatus hernia. Am J Surg 1956;92:389–92. DOI: https://doi.org/10.1016/S0002-9610(56)80111-6
Dor J, Humbert P, Dor V, Figarella J. L’intérêt de la technique de nissen modifiée dans la prévention du reflux après cardiomiotomie extramuqueuse de heller. Memoires. Academie De Chirurgie 1962;27:877–82.
Toupet MA. Technique d’oesophago-gastroplastic avec phreno-gastropexie appliquee dans la cure radicale des hernies hiatales et comme complement de l’operation de heller dans les cordiospasmes. Mémoires. Académie De Chirurgie 1963;89:394–9.
Park Y, Aye RW, Watkins JR, et al. Laparoscopic Hill repair: 25-year follow-up. Surg Endosc 2018;32:4111-4115. DOI: https://doi.org/10.1007/s00464-018-6150-z
Aye RW, Swanstrom LL, Kapur S, et al. A randomized multiinstitution comparison of the laparoscopic Nissen and Hill repairs. Ann Thorac Surg 2012;94:951-7. DOI: https://doi.org/10.1016/j.athoracsur.2012.04.083
Schneider AM, Aye RW, Wilshire CL, et al. Tri-comparison of laparoscopic Nissen, Hill, and Nissen-Hill hybrid repairs for uncomplicated gastroesophageal reflux disease. J Gastrointest Surg 2017;21:434-440. DOI: https://doi.org/10.1007/s11605-016-3317-6
Rosen R, Vandenplas Y, Singendonk M, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018;66:516-554. DOI: https://doi.org/10.1097/MPG.0000000000001889
Kubiak R, Andews J, Grant HW. Long term outcome of laparoscopic Nissen fundoplication compared with laparoscopic Thal fundoplication in children: a prospective, randomized study. Ann Surg 2011;253:44-49. DOI: https://doi.org/10.1097/SLA.0b013e3181fc98a0
Soyer T, Yalçın S, Demir N, et al. Does Nissen fundoplication improve deglutition in children? Turkish J Pediatr 2017;59:28-34. DOI: https://doi.org/10.24953/turkjped.2017.01.005
Wills VL, Hunt DR. Dysphagia after antireflux surgery. Br J Surg 2001;88:486-499. DOI: https://doi.org/10.1046/j.1365-2168.2001.01662.x
Richter JE. Surgery for reflux disease - reflections of a gastroenterologist. N Engl J Med 1992;326:825-7. DOI: https://doi.org/10.1056/NEJM199203193261209
Monnier P, Ollyo JB, Fontolliet C, Savary M. Epidemiology and natural history of reflux esophagitis. Sem Lap Surg 1995;2:2-9. DOI: https://doi.org/10.1177/155335069500200102
Grande L, Toledo-Pimentel V, Manterola C, et al. Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control. Br J Surg 1994;81:548-550. DOI: https://doi.org/10.1002/bjs.1800810421
Copyright (c) 2023 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.