Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial.
OBJECTIVE
Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial.


METHODS
After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation.


RESULTS
One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006)


CONCLUSIONS
Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.
The Children's Mercy Hospital, Kansas City, MO 64108, USA.
Shawn D
SD
St Peter
Douglas C
DC
Barnhart
Daniel J
DJ
Ostlie
KuoJen
K
Tsao
Charles M
CM
Leys
Susan W
SW
Sharp
Donna
D
Bartle
Tracey
T
Morgan
Carroll M
CM
Harmon
Keith E
KE
Georgeson
George W
GW
Holcomb
D002675:Child, Preschool; D004947:Esophagus / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000453:epidemiology / Q000601:surgery*; D006551:Hernia, Hiatal / Q000601:surgery; D006801:Humans; D007223:Infant; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology / Q000601:surgery; D011446:Prospective Studies; D012086:Reoperation; D016896:Treatment Outcome
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