الفهرس | Only 14 pages are availabe for public view |
Abstract Surgical treatment is indicated for children with gastroesophageal reflux disease in whom medical treatment fails, or accompanied by some other indications. Various surgical techniques produce a long term control of reflux with low mortality and few complications. Two different concepts govern the most commonly used operative procedures, in the first, a tight valve is constructed as in Nissen fundoplication, while the other concept aims at correcting the abnormal anatomy to enable the biologic antireflux mechanism to become effective as in Thal procedure. In Nissen fundoplication, the gastric fundus of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia. In Thal-Ashcraft procedure, the lower 2 cm of distal esophagus is freed then lifted upward and to the left allowing the placement of a figure of eight suture in the esophageal hiatus to close an enlarged hiatus in a posterior direction, a partial 180 degree anterior wrap is then constructed. The aim of this study was to compare between Nissen and Thal fundoplication a surgical treatment of GERD.This study was conducted on thirty six patients with gastroesophageal reflux and indicated for antireflux surgery. All patients were subjected to history taking, clinccal examination, laboratory and radiological investigations. Twenty four cases had Nissen fundoplication, while 12 cases had Thal procedure. Follow up findings of cases for disappearance or recurrence of symptoms and complications were recorded clinically and radiologically, also comparison between the two procedures was done regarding operating time, time of initial feeding and period of hospital stay. Improvement was noticed in 18 cases of Nissen group(75%), and in 9 cases in Thal group(75%), one case did not improve in Nissen group (4.2%), while partial improvement was noted in 4 cases in Nissen’s fundoplication (16.7%), and was observed in 3 cases with Thal’s procedure (25%), another case of Nissen group showed improvement but with medication (4.2%). Dysphagia in Nissen group was observed in 4 cases(16.7%), vomiting was observed in 4 cases of Thal group (33.3%), wound gapping was only in one case of Nissen group (4.2%). Cases without complications were 19 in Nissen group (79.2%), and were 8 (66.7%) in Thal group.Using barium study follow up, we had one case of failed Nissen repair (4.2%) and and another failed Thal procedure (8.3%), normal caliber and patency was observed in 18 cases of Nissen group (75%), and in 9 cases of Thal group (75%), reflux was found in 2 cases of Thal group (16.7%) while stenosis was observed in 2 cases of Nissen group (8.3%). Regarding recurrence of symptoms, we found that 18 cases among Nissen group were completely symptom free (75%), while in Thal procedure, 9 caess were symptom free (75%). Operative time in Nissen ranged from 80-130 minutes, with mean value 95.41 and in Thal procedure ranged from 60-80 minutes, with mean value 72.08. In Nissen’s fundoplication, the initial feeding sarted after a period ranged 2-5 days with mean value of 3.20 and in Thal procedure ranged 2-4 with mean value 3.08. Post-operative hospital stay ranged 3-15 days with mean value 6.75 in Nissen fundoplication and in Thal procedure it ranged 5-8 days with mean value 6. There was no statistically significant difference between the two studied procedures regarding post-operative clinical picture, barium study follow up, recurrence of symptoms, post-operative time of feeding and hospital stay. Nissen fundoplication had lower incidence of post-operative complications than in Thal procedure, while Thal fundoplication had lower mean operative time than Nissen fundoplication. Further and longer term studies are needed to assess, compare and decide which procedure is better. |