Modified Nissen fundoplication: improved results in high-risk children.

A modified Nissen fundoplication was performed in 29 children (26 neurologically impaired and 3 neurologically normal). The modifications to the Nissen 360 degrees wrap were: (1) deliberate crural repair with pledgets; (2) recreation of the angle of His; and (3) anchoring wrap to the diaphragm. Presenting complaints were respiratory in 66%, nutritional in 28%, and for prophylaxis in 2 patients requiring gastrostomy tubes. Prospective follow-up was obtained in 26 of 29 patients for an average of 19 months. Early postoperative complications occurred in 3 patients, none due to recurrent reflux. Six late deaths occurred due to neurological deterioration, pulmonary disease, and medication overdose. Barium swallows were obtained in 20 of 22 available patients postoperatively and all wraps were intraabdominal. We conclude that the modified Nissen prevents wrap herniation and improves postoperative results in the high-risk neurologically impaired child.