Two Decades of Experience with Laparoscopic Nissen Fundoplication in Infants and Children: A Critical Evaluation of Indications, Technique, and Results
Bibliographic record
Abstract
BACKGROUND: Laparoscopic fundoplication for gastroesophageal reflux disease has become a common procedure performed in infants and children over the last 20 years. This report describes a 20-year experience with nearly 2000 consecutive laparoscopic Nissen fundoplications. SUBJECTS AND METHODS: With Institutional Review Board approval, the data of all patients undergoing fundoplication from 1992 to 2011 were reviewed. Data were kept prospectively from the time of first encounter with each patient. Ages ranged from 5 days to 18 years, and weight ranged from 1.2 to 120 kg. The 2008 fundoplications were performed by or under the direct supervision of a single surgeon. Patients were divided into groups based on age: <6 months, 6-12 months, 1-6 years, and >6 years. Data on indications, surgical demographics, postoperative course including any complications, and long-term follow-up were kept prospectively on each patient. RESULTS: Average operative time dropped dramatically from 109 minutes for the first 30 cases compared with 35 minutes for the last 30. Of the 283 procedures that were redo fundoplications, 85 patients had had previous open surgery, and 198 cases had had previous laparoscopic surgery. Intraoperative and postoperative complication rates were 0.13% and 4.0%, respectively, in the primary group but were 2.2% and 4.2%, respectively, in the redo group. Average time to discharge post-fundoplication for the primary group was 1.1 days. The overall wrap failure rate for primary fundoplications was 4.6% and was highest in the <6-month age group. The failure rate in the redo group was 6.8%. The most common causes of wrap failure were hiatal hernia (46%) and slipped Nissen (34%). CONCLUSIONS: This study shows in a large operative experience over 20 years that laparoscopic fundoplication is safe and effective in the pediatric population. Technical considerations are paramount to improved outcomes, and key points include adequate creation of intraabdominal esophagus, limited hiatal dissection, creation of a tension-free and appropriate orientation, and positioning of the wrap. Clinical results are favorable to the traditional open fundoplication but with a significant decrease in morbidity and hospitalization. Laparoscopic Nissen fundoplication should be considered the gold standard for antireflux procedures.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".