Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial

Infographic · Oct 2018 · 1 min read

In brief

Randomized trial of 106 children found that esophagocrural sutures during laparoscopic fundoplication added 20 minutes to operative time without reducing wrap herniation or improving outcomes when minimal esophageal dissection was performed. Results suggest EC sutures can be safely omitted in this surgical approach.

Esophagocrural sutures added 20 minutes to operative time without reducing wrap herniation when minimal esophageal dissection was performed
Zero wrap herniations occurred in either group (with or without EC sutures) at 1-year contrast study follow-up
Reflux symptoms and medication use were equivalent between groups at 1 month, 1 year, and 4-year follow-up
EC sutures can be safely omitted during laparoscopic fundoplication when minimal phrenoesophageal dissection technique is used
Study of 106 pediatric patients (age <7) demonstrates EC sutures offer no clinical advantage in this surgical approach

Written by the GCMD Library team from the infographic.

Side-by-side comparison layout with teal panels showing anatomical illustrations of the stomach and esophagus. Left panel shows four sutures indicated, right panel shows sutures crossed out with a red prohibition symbol. Center panel displays blacked-out outcome data. Both surgical approaches are illustrated with identical stomach diagrams.

Purpose

Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures.

Methods

Children less than age 7 undergoing laparoscopic fundoplication were randomized to receive four EC sutures or none. Exclusion criteria included an existing hiatal hernia. The primary outcome was transmigration of the fundoplication wrap through the esophageal hiatus into the mediastinum. A contrast study was performed around 1 year postoperatively. Telephone follow-up was performed at a minimum of 1.5 years.

Results

120 patients were enrolled from 2/2010 to 2/2014, and 13 did not survive. One patient was excluded because a hiatal hernia was found at laparoscopy, leaving 52 patients with EC sutures (S) and 54 without EC sutures (NS). Operative time was 20 min longer in the S group (P < 0.01). Contrast studies were obtained in 62% of S and 68% of NS patients, and there were no wrap herniations in either group. There was one reoperation for wrap loosening in the NS group, none in the S group. Final telephone and clinic follow up was at a median of 4 years (IQR 3–4.7). Reflux symptoms and medications were not different at one month, one year, and final follow-up.