BOB in Ped Surg 2023 - PAPSA Winner - Mohamad Mahmoud Qinawy, MD

Nissen fundoplication is the most commonly adopted procedure for GERD all over the world

Post-operative dysphagia and bloating are frequently encountered after Nissen fundoplication, creating the necessity for a more facilitative design

Recurrent GERD has been reported to occur in up to 15% of children requiring re-operation

The study was a prospective single-blinded randomized comparative study conducted from October 2018 to February 2020 including 40 patients divided into two groups

The operative setup is similar between Nissen fundoplication and Hill-Snow procedure

In the Hill-Snow procedure, the first step after crural approximation is excision of the distal abdominal esophagus to the phrenic decision

The Hill-Snow procedure establishes an angle of His by suturing the fundus of the stomach to the distal third of the esophagus with running 2-0 suture

Study inclusion criteria included patients with GERD with failure of medical treatment, symptomatic hiatus hernia, patients presenting with obstruction, and patients with life-threatening symptoms like apnea

Study excluded recurrent cases and giant hiatus hernia

Operative time was significantly longer in the Hill-Snow group when compared to the Nissen group

Early postoperative bloating was found to be lower in the Hill-Snow group: 3 cases versus 15 cases in the Nissen group

Early postoperative dysphagia was found to be lower in the Hill-Snow group: 2 cases versus 7 cases in the Nissen group

Early vomiting was encountered more in the Hill-Snow group: 6 cases versus 2 cases in the Nissen group

The incidence of dysphagia was found to be insignificant in both groups regarding late postoperative assessment, but it was of shorter duration in the Hill-Snow group

No bloating was found in any Hill-Snow patient at late follow-up, while 11 cases from the Nissen group suffered from bloating

Recurrent vomiting and need for drugs was found in 8 cases in the Hill-Snow group versus 6 cases in the Nissen group

There were 3 recurrent Hill-Snow cases versus 2 recurrent Nissen cases

When evaluating reflux disease surgery, you need to differentiate neurologically normal versus neurologically abnormal patients because their responses to surgery are very different

The recurrent cases of Hill-Snow were found in the first 10 cases, which was attributed to the learning curve

Recent literature shows there is no importance of fixation of the esophagus to the crus, and current practice after this study does not use sutures between the esophagus and the crus