Are Posterior Crural Stitches Necessary in Pediatric Laparoscopic Fundoplication?

Abstract

Introduction:

Minimal esophageal mobilization during laparoscopic fundoplication decreases the rate of wrap transmigration, and previous study has shown that placement of esophageal-crural sutures does not offer any advantages in preventing wrap migration. Our aim was to determine the need for posterior crural sutures during laparoscopic fundoplication.

Methods:

This was a retrospective review of patients >1 month old who underwent a primary laparoscopic fundoplication from 2010 to 2019. Demographic, surgical, and outcome data were recorded. Primary outcome was transmigration of the fundoplication wrap. Analysis was performed using STATA^® (StataCorp, College Station, TX); P value <.05 was significant.

Results:

There were 181 patients included. The median age was 7.2 months (interquartile range [IQR] 3.7, 17.0) with 59% being male patients. Sixty-one (34%) patients received posterior crural stitches and 120 (66%) did not receive stitches according to staff preference. The stitch group had a median of 1 (IQR 1, 1) posterior crural stitches placed. There was no difference in the incidence of wrap migration, the number of patients requiring a workup for recurrent symptoms, or reoperation between the two groups (Table 1). A significantly higher percentage of patients in the no-stitch group underwent concurrent procedures; when controlled for this, there was no difference in the median operative time between the groups (P = .18).

Conclusion:

The placement of crural sutures, including the posterior crural suture, does not prevent wrap migration and may not be necessary for prevention of wrap herniation in pediatric fundoplication.

Introduction

Gastroesophageal reflux (GER) is one of the most common indications for surgical intervention in children.¹ Laparoscopic fundoplication is the current standard of treatment for refractory GER.² Fundoplications are quite successful in preventing reflux by reducing all parameters of esophageal acid exposure, including total acid exposure time and total number of reflux episodes.^1,3,4

Current literature has demonstrated that laparoscopic fundoplication is comparable with open fundoplication in terms of failure rates and complications, but with benefits, including shorter hospital stay and better cosmesis.¹ However, the failure rate of a laparoscopic fundoplication still ranges between 3% and 37%, with the most common reason cause of failure being wrap transmigration.^5–11 Subsequently, fundoplication technique has been scrutinized to identify areas where improvement might lead to a decreased recurrence rate or wrap failure. Previous study has shown that minimal esophageal mobilization without violation of the phrenoesophageal membrane and placement of esophagocrural sutures significantly decreased the rate of transhiatal wrap migration without compromising the efficacy of the wrap, even at 5 years of follow-up.^7,11,12 After this technique modification, a prospective randomized trial at our institution was conducted to determine if placement of esophagocrural sutures was even necessary.¹³ With a median of 4 years of follow-up, the study concluded that the esophagocrural sutures were not required if the phrenoesophageal membrane remained intact, and placement of these sutures only added to the operating time without influencing rates of wrap transmigration or postoperative recurrent/persistent reflux symptoms.¹³

However, during the randomized trial, a posterior crural suture was still being placed before formation of the wrap. This posterior stitch was thought to be necessary to prevent the crura from widening and allowing the wrap to transmigrate into the chest. The aim of this study was to further define the optimal technique for performing a laparoscopic Nissen fundoplication in the pediatric population by determining the need for posterior crural suture placement.

Methods

After approval was obtained by our institutional review board with a waiver of informed consent (IRB #14080337), a retrospective chart review of patients >1 month old who had undergone a primary laparoscopic fundoplication from 2010 to 2019 was performed. The indication for fundoplication was based on clinical symptoms: patients who showed signs of reflux with aspiration, failure to thrive, or bradycardia/apnea episodes with improvement after a change to transpyloric feeds were considered candidates for fundoplication.

Operative technique

The patient was placed under general anesthesia and peritoneal access was obtained through the umbilicus. The fundoplication was performed using a 5-port technique.¹¹ The short gastric vessels were divided to identify the left crus and the gastrohepatic ligament was divided to identify the right crus. Minimal dissection was made at the esophagocrural junction with the phrenoesophageal membrane left intact; no esophagocrural sutures were placed. As our center has progressively decreased the amount of dissection in this region, the performance of a posterior crural suture, the most recent change in our fundoplication technique, had been eliminated since 2014. The fundoplication is then performed with an appropriately sized bougie based on the patient's weight placed in the esophagus using 2–0 silk sutures; the superior suture also incorporates the esophagus.^3,13 Postoperatively, feedings were initiated on the day of surgery and discharge was determined based on the patient's underlying comorbidities and medical needs.

Statistical analysis

Demographics, surgical/intraoperative, and outcome data, including complications, were recorded. Follow-up data points included recurrent or persistent symptoms, imaging workup for symptoms and indications for and performance of redo surgery both at 1 year after initial fundoplication and at last follow-up during the data collection period. The primary outcome was need for redo fundoplication due to transmigration of the fundoplication wrap, with secondary outcomes, including complication rate and operative time. Patients who underwent fundoplication and received a posterior crural suture were compared with those who did not receive a posterior crural suture at the time of fundoplication. Analysis was performed using STATA^® (StataCorp, College Station, TX). Continuous variables are reported in median with interquartile range (IQR) and categorical data are presented in absolute numbers and percentages. The Wilcoxon rank sum test was used for comparison of nonparametric continuous variables and chi-square test was used to compare percentages. A P value <.05 was considered statistically significant.

Results

There were 181 patients included in the study, with 61 patients (34%) receiving posterior crural sutures and 120 patients (66%) who did not receive posterior crural sutures at the time of fundoplication according to staff preference. Fifty-eight patients who underwent the same fundoplication technique as part of a recent study were also included in the follow-up analysis.¹³ The suture group had a median of 1 (IQR 1, 1) posterior crural sutures placed. The median age for all patients was 7.2 months (IQR 3.7, 17.0) at the time of surgery; 59% were male. There was no difference in demographics characteristics or preoperative symptoms between groups (Table 1). Intraoperatively, the median operative time [74 minutes (IQR 60, 108) versus 63 minutes (IQR 49, 86), P = .03] was significantly longer in the no-suture group compared with the suture group; however, a significantly larger percentage of patients in the no-suture group underwent concurrent procedures at the time of fundoplication (61% versus 37%, P = .003). Interestingly, the percentage of patients who received a gastrostomy tube at the time of fundoplication was similar between groups (71% versus 65%, P = .45). When controlled for the performance of concurrent procedure, there was no difference in the median operative time between groups (P = .18).

Table 1.

Demographic and Preoperative Symptom Comparison Between Patients Who Received a Posterior Crural Suture at the Time of Fundoplication and Those Who Did Not

	Crural sutures (n = 61)	No crural sutures (n = 120)	P
Demographics
Age at surgery (months)	7.1 (3.3, 16.0)	7.3 (4.3, 17.4)	.47
Height (meters)	0.65 (0.55, 0.72)	0.64 (0.58, 0.77)	.31
Weight (kilograms)	6.30 (4.16, 8.9)	6.38 (4.77, 10.57)	.35
BMI	15 (13.1, 16.8)	15.5 (14.3, 16.9)	.07
Male gender	33 (54%)	74 (61%)	.30
Preoperative symptoms
Retching episodes	13 (21%)	35 (29%)	.25
Reactive airway disease	9 (16%)	12 (10%)	.24
Pneumonia	9 (16%)	27 (22.5%)	.31
Failure to thrive	29 (47.5%)	54 (45%)	.75
ALTEs	8 (13%)	29 (24%)	.08

No difference was found between groups. All continuous variables are expressed as medians with IQRs.

ALTE, acute life-threatening event; BMI, body mass index; IQR, interquartile range.

One month, 1 year, and final follow-up outcome data between the suture and no suture group are shown in Table 2. The total length of follow-up was significantly shorter for the no suture group compared with the suture group (35.1 months versus 45.1 months, P = .03), which correlates with foregoing the use of posterior crural sutures being our most recent technique change. Although up to 15% of patients still experienced symptoms of reflux at 1 year and up to 30% had symptoms at the end of follow-up, there was no difference in the number of patients requiring a workup for recurrent symptoms, the incidence of wrap migration, or need for reoperation between the two groups either at 1 year or long-term follow-up (Table 2). Fourteen patients died during the follow-up period at a range of 3 months to 7 years after fundoplication: two had cyanotic congenital heart defects, 3 died due to respiratory infections, 4 due to neurological disorders/seizure disorder/genetic disorders, 2 patients had an unknown cause of mortality, 1 patient died with bronchopulmonary dysplasia and pulmonary arterial hypertension, and 1 patient was diagnosed with juvenile myelomonocytic leukemia and developed respiratory failure.

Table 2.

Short- and Long-Term Outcome Comparisons Between Patients Who Received and Who Did Not Receive Posterior Crural Sutures

	Crural sutures	No crural sutures	P
1 month follow-up
Number of patients	58 (95%)	119 (99%)	.09
Retching episodes	16 (28%)	22 (18%)	.13
Reactive airway disease	4 (7%)	14 (12%)	.31
Pneumonia	4 (7%)	7 (6%)	.80
Failure to thrive	4 (7%)	15 (13%)	.23
ALTEs	1 (2%)	6 (5%)	.34
1 year follow-up
Number of patients	57 (93%)	97 (81%)	.03
Retching episodes	3 (5%)	15 (15%)	.06
Reactive airway disease	3 (5%)	14 (14%)	.08
Pneumonia	6 (10.5%)	4 (4%)	.11
Failure to thrive	5 (9%)	12 (12%)	.57
ALTEs	4 (7%)	2 (2%)	.12
Height (meters)	0.77 (0.72, 0.84)	0.81 (0.75, 0.91)	.05
Weight (kilograms)	9.55 (8.2, 11)	10.5 (9.2, 13.4)	.01
BMI	16 (15.0, 17.5)	16.5 (15.3, 17.7)	.27
Repeat workup for symptoms	12 (21%)	35 (36%)	.05
Upper GI endoscopy	30 (53%)	39 (40%)	.12
Wrap transmigration	0 (0%)	0 (0%)	1.0
Reoperation within 1 year	1 (2%)	6 (6%)	.25
Time from initial fundoplication to reoperation (months)	4.6	11.4 (10.0, 13.0)	.13
Mortality	2 (3%)	3 (2.5%)	.85
Last follow-up
Number of patients	51 (84%)	93 (77.5%)	.31
Median follow-up (months)	45.1 (26.6, 56.4)	35.1 (20.7, 50.6)	.02
Retching episodes	10 (20%)	9 (10%)	.09
Reactive airway disease	16 (31%)	18 (19%)	.10
Pneumonia	6 (12%)	3 (3%)	.03
Failure to thrive	6 (12%)	13 (14%)	.74
ALTEs	2 (4%)	7 (7.5%)	.41
Height (meters)	1.01 (0.91, 1.08)	0.95 (0.88, 1.1)	.28
Weight (kilograms)	16.2 (14, 18.8)	14.1 (12.2, 17.7)	.10
BMI	16.2 (15.1, 17.4)	16.0 (14.2, 17.3)	.44
Workup for recurrent symptoms	31 (61%)	52 (56%)	.56
Wrap transmigration	0 (0%)	1 (1%)	.48
Total reoperation rate	1 (2%)	7 (7.5%)	.17

The bold values indicate comparisons that are statistically significant.

All continuous variables are expressed as medians with IQRs.

ALTE, acute life-threatening event; BMI, body mass index; IQR, interquartile range.

Discussion

In this study, we further defined the components needed to perform a successful laparoscopic fundoplication. Patients who underwent a laparoscopic fundoplication without placement of posterior crural stitches had a similar recurrence rate of symptoms, wrap transmigration, and need for redo surgery both in short-term (1 month) and long-term (3–4 years) follow-up. Thus, with the addition of these results to the current body of literature, the most effective technique in creating a successful fundoplication in a patient without a hiatal hernia includes ligating the short gastric vessels, performing minimal esophageal mobilization, keeping the phrenoesophageal membrane intact, and performing a 360° wrap.^7,10–12,14 Neither the use of esophagocrural stitches or posterior crural stitches are needed for acceptable results.¹³

The body's natural antireflux barrier includes the lower esophageal sphincter, the angle of His, the length of intra-abdominal esophagus, and esophageal peristalsis.¹⁵ The phrenoesophageal membrane is also thought to play an integral part in maintaining the function of the lower esophageal sphincter.⁷ This may be why minimal hiatal dissection without disruption of the phrenoesophageal membrane has led to fewer recurrences and a lower incidence of wrap transmigration.^7,10–12,14

However, in patients where this natural antireflux barrier is unable to function properly, a surgical fundoplication can attempt to restore this natural design. A multicenter study of patients who underwent a laparoscopic Nissen fundoplication with mainly respiratory complaints (recurrent pneumonia, asthma, and reactive airway disease) but confirmed reflux, 92% found relief from respiratory symptoms with a significant improvement in quality of life.¹⁶ Similarly, a retrospective analysis looking at patients in the neonatal intensive-care unit who underwent fundoplication found that all patients were free from acute life-threatening events, were able to stop antireflux medication and were able to gain weight.¹⁷ A prospective study was conducted to examine the outcomes between patients who underwent fundoplication and were considered neurologically normal compared with those considered neurologically impaired.¹⁸ Although hospital length of stay was longer in the neurologically impaired group, there was no difference in long-term relief of symptoms. Vomiting, regurgitation, meal discomfort, and pulmonary infections were significantly reduced after the performance of a fundoplication, and when surveyed during the 4-year follow-up, 90% of all parents claimed that performing the fundoplication improved the child's condition and quality of life with a significant reduction in preoperative symptoms.¹⁸

Few studies have looked at the actual technical nuances of performing a fundoplication nor has there been extensive analyzation into whether the technique of performing a fundoplication that was learned for adults should be altered for the pediatric population. Although a systematic review performed by the American Pediatric Surgical Association's (APSA) Outcomes and Evidence-Based Practice committee was able to show similar outcomes between laparoscopic and open fundoplication and between partial and complete wraps, no identification was made about whether different technical aspects of the fundoplication made a difference in outcomes.¹ Through a series of retrospective and prospective studies, including randomized trials,^7,11–13 our institution has been able to objectively delineate the important steps for performing a successful fundoplication in the pediatric patient and have found that minimal disruption of the patient's natural anatomic antireflux barriers with reinforcement where needed has provided successful relief of symptoms with minimal long-term complications and recurrences.

Despite these advances, the fundoplication has been found to have a progressive failure rate over time with most redo fundoplications performed within the first 3 years after initial surgery.^5,9 Wrap transmigration is the most common cause of failed fundoplication,^1,19 with partial or full dissemble of the wrap also causing recurrent symptoms.^2,20 The failure rate of the initial fundoplication ranges from 3% to 37%,^5–11 with a time to redo fundoplication lasting between 14 and 30 months in most studies.^{5,7–9,11,20,21} In a multicenter study aimed at identifying predictors associated with a need for a redo fundoplication, hiatal dissection during the primary fundoplication, retching, and a younger age at primary fundoplication were all found to be independent predictors of recurrence.^5,8 Patient factors that lead to a high risk of recurrence include a history of esophageal atresia, chronic neurological pathology, and need for esophageal dilations postoperatively.^8,15,22,23 Technical nuances that can increase the recurrence rate of transmigration or lead to wrap failure include dividing the phrenoesophageal membrane and performing extensive esophageal mobilization.¹⁴ As such, we have continued to change our group's practice based on available evidence.

Limitations of this article include its retrospective nature and single institution design. Follow-up was based on the last contact within our hospital system; therefore, there might be some patients who have received workup and subsequently underwent a redo fundoplication at another institution. Future study should focus on validating these results with a prospective trial. As it is believed that fundoplications have a progressive failure rate over time,⁹ another area of interest is looking at the recurrence and wrap transmigration rate over the course of development as these children who undergo surgery as infants or toddlers become adolescents and adults.

Conclusion

The placement of crural sutures, including the posterior crural suture, does not prevent wrap migration and may not be necessary for prevention of wrap herniation in the pediatric fundoplication technique.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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