IPEG - Fundoplication without Esophagocrural Sutures- Long-term Follow-up from a Randomized Trial - Kayla Briggs

So next up we have Dr. Kayla Briggs from Children's Mercy Hospital with her presentation, fun application without esophageal cl sutures, the long-term follow-up from a randomized trial. And then following Dr. Bethany Slater from the University of Chicago will start our discussion. Thank you for allowing me to present our work. We have no disclosures. Our institution has performed a series of trials focusing on refining the fundoplication technique to minimize wrap transmigration and need for redo surgery. First was a randomized trial which demonstrated minimal esophageal mobilization resulted in fewer wrap transmigrations and need for repeat operation. Second was another RCT which evaluated the need for esophageal curl sutures with minimal esophageal mobilization, which showed that esophageal curl sutures were not needed if minimal esophageal mobilization was utilized. Most recently, a retrospective review demonstrated no difference in wrap transmigration between those who did and did not have posterior curl sutures. We sought to attain long-term follow-up from the children included in the second RCT that either got four esophago curl sutures or no esophago curl sutures. Children were included in the study if they were less than seven years of age undergoing primary fundoplication. Retrospective chart review and a telephone follow-up to assess long-term symptom control was performed a minimum of six and a half years post-operatively. 106 children participated in the original RCT with 101 alive at late follow-up. 70 caregivers responded to a telephone follow-up call. 39 children had four EC sutures while 31 children had no sutures placed. Follow-up was conducted at a median of 8.7 years post-operatively and children were a median of 9.5 years of age at the time of follow-up. Of those available for telephone follow-up, there was no difference in sex, race, age at fundoplication, rate of G2 placement during fundoplication or neurologic impairment at the time of operation. No child had wrap transmigration in either group. One child required a repeat operation, which was for wrap disons. This was performed 140 days after the original operation. At telephone follow-up, there was no difference in current reflux symptoms, antacid use, persistent retching, need for GJ tube placement or post-operative hospitalizations between groups. In conclusion, there was no difference in wrap transmigration, symptom control or subsequent hospitalizations between those who did and did not have esophago curl sutures placed during laparoscopic fundoplication with minimal esophageal mobilization at late follow-up. Thank you. I'd be happy to take any questions. Well, first of all, go IPeg, and then second of all, thanks so much for having me. Uh Dr. Briggs, that was a great presentation and I really applaud you and all the co-authors for both a randomized control study as well as a long-term follow-up. I think that the technical aspects of an is really important both for outcomes and for um reoperation etc. I was curious to know if you guys had done a subanalysis for the patients with neurologic impairment in the two groups. We did not specifically perform a subgroup analysis of those that had neurologic impairments. Okay. And I appreciate you being here today and being our commentator. Great. Um in your institution, do you tend to get most of the patients back to your hospital if there are issues with um recurrent symptoms or do you tend to see people go into other hospitals, etc. That is a really great question. Um and that was one thing that we definitely felt like was a potential weakness of this study. We have a huge catchment area both in Kansas City, Missouri proper, Kansas City, Kansas and all throughout the region. And, you know, sometimes if people have those complications, they're not always super willing to come back for further care. Um, we do find that kind of antinote when anyone does have complications, our referring facilities are not necessarily afraid to contact us. The kind of bigger issue that we were wondering is that in our hospital just as we were talking about, you know, surgeons owning the common bile duct as opposed to GI is that typically our GI colleagues here really dominate the post-operative care in these children with the fundlications in terms of continuing medications, choosing when to discontinue those. And so that was really a question of ours is should we be having more involvement with these children post-operatively to perhaps be a little bit more aggressive and getting off antacids if their symptoms are controlled instead of just going with the status quo. But that was definitely a concern of ours with as large as our catchment area and the presence of some other bigger children's hospitals there around us that might have taken care of these children if there were any issues. Great, thank you. Uh my last question for you is does everyone in your group now forego the extra switches? They do. And that um Dr. Wendy Spinoff um posted kind of the most recent iteration of this which was examining the posterior curl suture necessity and um recently published that data. So I anticipate that there will be a long-term follow-up kind of with this very minimal approach, minimal mobilization, no EC sutures, no PC sutures, you know, here in the coming years. Wonderful. Dr. Polsky, are there other questions in the chat? So, uh let me not in the chat yet. So I want to invite people to start commenting uh about this and I may have missed something. Uh also for the panelists, I don't know if Samir uh or anyone else here has a comment to make. Yeah, I do actually. I I I'm glad that you brought that up. So, um uh just I'm curious. I haven't done any cruel stitches in probably a decade now. So uh out of curiosity like you know, there's a few of us on this call here. Who actually still does those? The posterior. When you say cruel stitch, do you mean esophago curl or a Yeah the EC. The EC. Not I only do the PC if there's a hital hernia. If there's no hital hernia, they're not getting one and uh with all due respect to the senior colleagues, I do not skeletonize everything because why break it up if it's already there. So I I'll I'll answer your question. Um I got uh bashed by Tim Kane because we asked, you know, who still does it and I was the only one that raised my hand and Tim's like, Todd, like, hey dummy, uh look at the data. Stop like being old school and doing what you were taught. So I am slowly trying to break my habit and I do realize it makes no sense to do it anymore. Dad, you were going to say something? Yeah, we'll get to fix these in years to come. You're providing material for the older surgeons to do. I love it. That's great. Well, I mean, can I count it as a charitable contribution? Yes, absolutely. it. Want to keep your skills sharp, sir. That's that's what we want to do. It's too late for me. We are here to aim we aim to please you. That's what we're here for. It's a you know, this will always be such a great area of controversy. Um so uh it looks like we have uh about a minute left. If anyone has other comments. Uh if not, um pediatric surgeons are doing all your operations without sutures. You're fixing hernias, you know, with per strings internally. this is great security for us in the future. There was one question in the chat about how many in the study had a hital hernia associated during on imaging. That's a great question. So we specifically did not include children that had a concurrent hital hernia. And I actually did have a question for some of the senior authors too in terms of the number of fundos that you guys do a year now because we've definitely seen our volume drop off at children's as medical management has gotten better. You know. That is a great question and it is a very sore topic for me because I left this operation and uh unfortunately it is dwindling rapidly. And um what what I find in some of our GI folks, they have such a hatred towards this operation because they don't understand the floppy nature of the operation. They don't understand the minimal dissection and they have this affinity for this GJ2 business that keeps on getting dislodged and blocked and needs multiple anesthetic exposures and so yeah, um if you want to partner and write something up about that, I'm in. That's an easy study to I was just thinking Samir, terrible minds think alike. I I was just uh thinking the same thing, that's an easy study to do. It would be but then remember the I know the bell rang, I'm going. The pendulum swings, the pendulum swings and especially on functional surgery. Anytime you're doing functional surgery, we can't figure out how to do it and we do a lot, we do a little. I was doing six a day with Rothberg when I trained and now, right, right Bethany? And now, you know, I haven't done one in a super long time because we just don't do them anymore. Um so final comments from anyone before we go to the next? Great job, Kayla. That was awesome. Uh and great discussion. Thank you for this opportunity. Yeah, awesome discussion. And and let me just be be very clear. I will not be partial to IPeg in the in the next couple couple of hours. I will be unbiased uh and not partial, okay? IPeg doesn't need anybody to be biased. We're going to win it with 10 eight rounds anyway. So, you know. You're calling it in 10 you're calling it in eight or 10. We're with 10 eight rounds. Like all the rest are getting eight, we're getting 10. It is what it is. It's a knockout. Oh, I see. All right. You know. All right, got it. All right. Knockout in knockout in eight.