gastroesophageal reflux ( gor ) affects a large number of infants and children . for the majority ,
the condition is self - limiting and most patients improve spontaneously over the first years of life .
medical therapy is the first line treatment of choice , but surgery remains an option if this fails to control reflux adequately .
indications for surgical treatment include failed medical therapy , the presence of reflux - related respiratory complications , or failure to thrive . in older children ,
in whom reflux is unlikely to resolve spontaneously , there is generally a reluctance to accept lifelong proton pump inhibitors ( ppis ) and quality of life issues become more prominent .
the recognition that the placement of gastrostomy tubes for feeding significantly increases the risk of gor , together with evidence that reflux may play an important role in the occurrence of apnoeic or bradycardic episodes , sudden death , recurrent chest infections , and chronic reactive airway disease , has also resulted in a large increase in antireflux surgery .
laparoscopic antireflux surgery is now firmly established as a useful tool in the management of gor in children , as it is associated with less morbidity and a more rapid recovery , particularly in children with neurological impairment [ 46 ] .
several antireflux procedures have been described , but which of these techniques offer the best outcomes in children has been open to debate .
nissen 's fundoplication was established prior to the advent of laparoscopic surgery , so this technique was the first to be adapted for laparoscopic surgery and , consequently , has been the most widely used by laparoscopic surgeons [ 79 ] .
nevertheless , a high incidence of mechanical side effects has been reported , such as dysphagia , an inability to belch or vomit , and gas bloating , all of which are likely due to the establishment of a supercompetent gastrooesophageal sphincter by the 360-degree wrap . as a result
, alternative fundoplication techniques have been developed by boix - ochoa , toupet , and others . however , which of these techniques offer the best outcomes in children is still under debate .
one of the modifications of the laparoscopic nissen technique , using a partial anterior wrap , was described by watson in 1991 .
this method is associated with reduced mechanical side effects in adults , but its efficacy in children has not yet been firmly established .
the aim of this study was to evaluate the short- and long - term outcomes of laparoscopic watson fundoplication in children and infants in terms of durability and the incidence of mechanical complications , especially in those children with neurological impairment .
this was a prospective observational study of 76 children and infants who had laparoscopic watson fundoplication performed by a single surgeon at the royal aberdeen children 's hospital and the royal alexandra children 's hospital in brighton between 1995 and 2014 .
demographic data , investigations , operative technique , and all reported complications were collected and analysed using microsoft excel .
all patients were investigated with barium swallow and 89% had preoperative endoscopy ( see table 1 ) . where necessary , the degree of reflux was clarified by oesophageal ph and manometry studies , where acid reflux was defined by a demeester score > 14.72 .
all patients received a single dose of 25  mg / kg co - amoxiclav ( or 30  mg / kg cefotaxime if allergic to penicillin ) .
laparoscopy utilised a four - port technique with an additional epigastric stab incision to accommodate a nathanson liver retractor .
a 10  mm port was used in older children and a 5  mm port in small children and infants , to accommodate either a 0-degree or 30-degree laparoscope .
once pneumoperitoneum was established , two instrument ports were placed either side of the umbilicus for triangulation using either 5  mm or 3.5  mm ports for older or younger children , respectively .
a further 5  mm or 3.5  mm port was placed near the left anterior axillary line to retract the gastrooesophageal junction . in children ,
spatial restrictions necessitate accessing the hiatus by dissection of the lesser omentum in the initial instance .
adhesions between the oesophagus and right crus were then released and the inferior oesophagus mobilised by extended dissection into the posterior mediastinum .
the phreno - oesophageal ligament was divided anteriorly before the oesophagus was brought down into the peritoneum , taking care to avoid damage to the anterior vagus nerve .
next , the fundus was drawn over to the patient 's right with division of phreno - fundal adhesions to release the left crus .
a nylon tape was then used as a sling and held via the left anterior axillary port . once 4 - 5  cm of tension - free oesophagus
was brought down into the peritoneum , the crural repair was performed with two or three 2/0 ethibond sutures .
the angle of his was recreated by suturing the fundus to the left anterior oesophageal hiatal rim .
further fundal tissue was then rolled over the anterior oesophagus and sutured to the mid portion and right angle of the anterior hiatal rim to create a 180-degree anterior wrap .
finally , three sutures were passed from the rolled - over fundus through the right oesophageal wall to the right crural repair .
half circle needles were used in younger children and infants and  ski needles  in older children .
postoperatively , patients were allowed clear fluids via oral or gastrostomy routes on the same day as surgery and allowed feeds the following day .
follow up included standard post - operative outpatient appointments at 6 weeks , 3 months and , where possible , at least one annual review .
treatment failure was defined as the continued or renewed dependence on ppis , histamine h2 receptor antagonists , or regular antacids for reflux symptoms as well as wrap failure with reoperation .
thirty - three ( 34.2% ) were neurologically impaired , one suffered from cystic fibrosis , and 6 were born with oesophageal atresia + / tracheooesophageal fistula .
fifteen patients ( 19.7% ) had previously undergone abdominal or thoracic surgery or percutaneous endoscopic gastrostomy ( peg ) placement .
one child had previously undergone nissen fundoplication by a nonpaediatric specialist and represented with recurrent symptoms and a further patient underwent a failed boix - ochoa fundoplication by a paediatric surgeon .
contrast studies in these patients confirmed failure of the wrap and recurrence of hiatus hernia .
the majority of children ( n = 68 ; 89.4% ) also underwent upper gastrointestinal endoscopy and 44 ( 57.9% ) patients had ph studies .
median postoperative stay was 2 days ( mean 3 days ; range 119 days ) .
of the 76 patients undergoing surgery , 21 ( 27.6% ) had a gastrostomy placed at the same time .
immediate complications included 4 minor liver injuries ( 5.25% ) , 6 minor bleeds ( 7.9% ) , and 1 bleed requiring a postoperative transfusion . in the short- to medium - term
, one patient developed a wound infection and one had an early port site hernia .
postoperatively , dysphagia was reported in 9 cases ( 11.8% ) , 5 of whom had confirmation of relative narrowing at the cardiooesophageal junction at the level of the wrap on barium swallow .
the median duration of follow - up was 30 months ( range 043 months ) .
one child developed late dysphagia and was found to have a recurrent stricture proximal to the wrap on barium swallow , requiring endoscopic balloon dilatation .
reflux symptoms ( arching , postfeed cough , or vomiting ) were reported in 14 cases ( 18.4% ) , but only 2 had acid reflux confirmed by ph studies .
two cases developed a small hiatus hernia managed medically , 3 cases suffered recurrent retching again managed medically , and a high risk older cerebral palsy patient with respiratory compromise had a gastrojejunostomy placed for breakthrough chest aspiration after spinal surgery .
a patient who had undergone a tracheooesophageal fistula ( tof ) repair as a neonate and who had been listed for fundoplication due to frequent apnoeas , thought to be reflux - related , continued to experience apnoeas postoperatively , but at a reduced frequency .
laparoscopic fundoplication for the management of gor in infants and children has become one of the most frequently performed operations in paediatric surgery , as its effectiveness and safety have been well established .
nissen 's technique remains the most commonly performed antireflux operation in children . in adult practice ,
laparoscopic anterior fundoplication appears to be associated fewer adverse events , especially mechanical complications , than nissen fundoplication [ 1517 ] .
the advantages should , in theory , apply to paediatric practice as well . to date , however , only a limited number of patients series with children or infants undergoing anterior fundoplication have been published [ 14 , 1821 ] .
comparison of complications and treatment failures are hampered by the lack of precise definitions of symptoms , such as  gas bloat  and  early dysphagia . 
even  treatment failure  is variously defined as wrap breakdown on contrast swallow , recurrence of symptoms , persistent or recurrent reflux on ph studies , and reinstitution of medical therapy or reoperation . in our unselected consecutive series of patients ,
postoperative dysphagia is seen in approximately 12% of cases , but it is nearly always transient and rarely requires oesophageal dilatation . although 18.4% reported ongoing or recurrent reflux , this figure appears to be satisfactory relative to other reports [ 1217 ] .
furthermore , the incidence of early dysphagia in our series falls between that reported by other authors for nissen fundoplication [ 10 , 17 ] , although there are marked differences in study design . over a third of the children in our series had neurological comorbidities .
the outcome of antireflux surgery in children with neurological impairment is known to be inferior to that of neurologically intact children [ 46 ] .
many of these children are accepted for surgical intervention on the basis of vomiting or failure to thrive , which may be due to causes other than reflux .
more thorough preoperative investigations and distinction of centrally induced retching from true reflux might have altered the decision to proceed to surgery in some of our patients . indeed , in adults , most surgeons would now be reluctant to perform antireflux surgery without convincing evidence of high volume reflux on endoscopy , contrast swallow , and/or ph - manometry studies . despite the fact that reliable ph studies are difficult to perform in children , especially in those unable to self - report symptom events
, consideration should be given to obtaining such objective evidence prior to surgery , especially if the indications are nonspecific .
this study confirms that the technique of laparoscopic watson fundoplication is safe in infants and children , including those with significant neurological disability .
adverse events , although relatively common , were generally very mild and tended to be transient .
 gastroesophageal reflux ( gor ) affects 28% of children over 3 years of age and is associated with significant morbidity . 
 the disorder is particularly critical in neurologically impaired children , who have a high risk of aspiration . 
 traditionally , the surgical antireflux procedure of choice has been nissen 's operation 
 . however , this technique has a significant incidence of mechanical complications and has a reoperation rate of approximately 7% , leading to the development of alternative approaches . 
 watson 's technique of partial anterior fundoplication has been shown to achieve long - lasting reflux control in adults with few mechanical complications , but there is limited data in the paediatric population . 
 we present here short- and long - term outcomes of laparoscopic watson fundoplication in a series of 76 children and infants , 34% of whom had a degree of neurological impairment including severe cerebral palsy and hypoxic brain injury . 
 the overall complication rate was 27.6% , of which only 1 was classified as major . 
 to date , we have not recorded any incidences of perforation and no revisions . in our experience 
 , watson 's laparoscopic partial fundoplication can be performed with minimal complications and with durable results , not least in neurologically compromised children , making it a viable alternative to the nissen procedure in paediatric surgery . 