Transhiatal wrap migration is the dominant mode of failure after laparoscopic Nissen fundoplication, with relatively high rates of reoperation reported in large case series [5
]. Prevention of this anatomical failure of the operation is essential to improving outcomes. Most reports in adult general surgery emphasize the importance of complete esophageal mobilization to bring the lower 2 to 3 cm of esophagus into the abdomen [13
]. This operative concept has naturally translated to pediatric surgical practice. However, there may be important differences between adults and children, including differences in the occurrence of esophageal foreshortening. The results of this trial provide compelling evidence that minimal esophageal mobilization can reduce the risk of transhiatal migration and support a different approach in children. It is noteworthy that the clinical symptoms of reflux appeared to be similarly controlled in both groups and that there were no patients who had undergone minimal mobilization who required revision fundoplication for control of symptoms. The natural question will be whether this is an adequate antireflux procedure.
Although the results of this study may contradict historical assumptions about the source of lower esophageal sphincter pressure offered by fundoplication, more recent data shed light on the effectiveness of fundoplications in the MIN group [16
]. Simultaneous combined endoscopic ultrasound/manometry studies have demonstrated that the normal high pressure zone of the lower esophagus is composed of 3 components, 2 of which are smooth muscle intrinsic sphincter components (upper and lower) and the other is the effect of the crural sling [17
]. The proximal intrinsic component is aligned with the crura and moves during respiration, implicating the importance of the phrenoesophageal membrane [18
]. The lower intrinsic component lies at the junction of the gastric cardia and esophagus. Adult patients with reflux have been shown to have an abnormality in the lower intrinsic component [19
]. Pharmacologic manipulation in patients who have undergone Nissen fundoplication has demonstrated that tonic contraction of the gastric smooth muscle in the wrap augments the lower intrinsic component [16
]. Therefore, it would argue against disrupting the anatomical association between the top intrinsic component and the crural sling in patients without a hiatal hernia. Such anatomical disruption was performed in the MAX group. Augmenting the lower intrinsic component with a wrap around the distal esophagus in its native position, as done in the MIN group, should overcome the physiologic deficit while preserving the function and relationship of the 2 upper components. A model for the efficacy of maintaining the anatomical alignment of the esophagus and hiatus while performing an antireflux operation is seen in the emerging endoscopic technologies that have little to no impact on the hiatus [20
The authors recognize the limitation of not having postoperative pH or impedance monitoring to prove equal efficacy of the 2 techniques. The practice at both institutions has been to use these postoperative studies selectively because reflux complications are often readily apparent in children. Furthermore, although pH studies adequately depict risks for peptic complications, they are only a surrogate measure for nonpeptic complications such as failure to thrive, aspiration, and ALTE spells. Because most of the operations were required for complications felt to be secondary to reflux, the follow-up data in suggest that minimal dissection does not compromise the efficacy of the wrap. Most importantly, there is a clear advantage in preventing postoperative complications requiring redo fundoplication.
The rate of transmigration was higher in this study compared with our own historical retrospective data [5
]. This is likely because of the fact that an upper gastrointestinal contrast study at 1 year postoperatively was part of the study protocol. This also likely accounts for the reduced number of redo operations, as not all the patients with transmigration seen on the contrast study were symptomatic. Moreover, the contrast study at 1 year is likely the explanation for the unique finding in this study that rate of transmigration is the same between neurologically normal and neurologically impaired patients.