الفهرس 
Clinical picture of gastroesophageal reflux
Warning signals requiring investigationOnly 14 pages are availabe for public view
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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.