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The IPEG Annual Congress joins with:. II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) VII Congress of the Federation of Pediatric Surgical Associations of the South Cone of America (CIPESUR).

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slide1

The IPEG Annual Congress joins with:

  • II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS)
  • VII Congress of the Federation of Pediatric Surgical
  • Associations of the South Cone of America (CIPESUR)
current thoughts about laparoscopic fundoplication in infants and children

Current Thoughts About Laparoscopic Fundoplication in Infants and Children

George W. Holcomb, III, M.D., MBA

Children’s Mercy Hospital

Kansas City, Missouri

gerd barriers to mucosal injury
GERDBarriers to Mucosal Injury
  • LES
  • Esophageal IAL
  • Angle of His
  • Esophageal motility
transient les relaxations
Transient LES Relaxations
  • LES relaxation not related to swallowing
  • Thought to be the primary mechanism for GERD in children

Werlin SL, et al: J Peds 97:244-249, 1980

barriers to injury
Barriers to Injury
  • IAL Esophagus
  • Adults - > 3 cm, 100% LES competency

- 3 cm, 64%

- <1 cm, 20%

  • Important to mobilize intraabdominal esophagus and secure it into abdomen

*DeMeester, et al: Am J Surg 137: 39-46, 1979

barriers to injury1
Barriers to Injury
  • Angle of His
  • Normally, an acute angle
  • When obtuse, more prone to GER
  • Important consideration following gastrostomy
treatment options
Treatment Options
  • Medical
  • Surgical
  • Endoluminal
preoperative evaluation
Preoperative Evaluation
  • 24 hr pH study
  • Upper GI contrast study
  • Endoscopy
  • Endoscopy with biopsy
  • Gastric emptying study ?
  • Esophageal motility study ?
gerd fundoplication
GERDFundoplication

Indications for operation

  • Failure of medical therapy
  • ALTE/weight loss in infants
  • Refractory pulmonary symptoms
  • Neurologically impaired child who needs gastrostomy
options for fundoplication
Options for Fundoplication
  • Laparoscopic vs open
  • Complete (Nissen) vs Partial (Thal, Boix-Ochoa, Toupet)
laparoscopic fundoplication
Laparoscopic Fundoplication
  • When is it not a good option?
  • Significant hx of cardiac disease
  • Significant hx of lung disease
    • BPD
    • Significant O2 still needed
  • Chronic NICU baby
  • Previous upper abdominal operations?
pneumoperitoneum

pCO2

  • FRC
  • pH
  • pO2
Pneumoperitoneum
  • SVR
  • PVR
  • SV
  • CI
  • Venous Return (Head up)
proceed with caution
Proceed With Caution
  • VSD with reactive pulmonary HTN
  • CAVC – ( PVR 2o to pCO2, pO2, pH)
  • Neonates (in general) with reactive or persistent P-HTN
  • Palliated defects with passive pulmonary blood flow (Glenn, Fontan procedures) – Risk is pulmonary flow, reversal of flow thru shunt and clotting of shunt
  • Any defect adversely affected by SVR
    • HLHS
    • CHF (unrepaired septal defects: VSD, CAVC)
    • Risk is acute CHF 2o to afterload & shunting, unbalancing the defect
laparoscopic fundoplication1
Laparoscopic Fundoplication

2. Can a loose, floppy, complete (Nissen) fundoplication be performed without ligation of the short gastric vessels?

laparoscopic fundoplication3
Laparoscopic Fundoplication
  • Is dysphagia a common problem following laparoscopic Nissen fundoplication in infants and children?
intraoperative bougie sizes
Intraoperative Bougie Sizes

PAPS 2002

J Pediatr Surg 37:1664-1666, 2002

laparoscopic fundoplication4
Laparoscopic Fundoplication
  • Can stab (3mm) incisions be used rather than cannulas for laparoscopic operations and is there a financial advantage?
slide22

The Use of Stab Incisions

PAPS 2003

J Pediatr Surg 38:1837-1840, 2003

cost savings from stab incisions
Cost Savings from Stab Incisions

PAPS 2003

J Pediatr Surg 38:1837-1840, 2003

laparoscopic fundoplication6
Laparoscopic Fundoplication
  • Is there a financial advantage with the laparoscopic approach when compared to the open operation?
clinical and financial analysis of pediatric laparoscopic versus open fundoplication 100 patients
Clinical and Financial Analysis of Pediatric Laparoscopic versus Open Fundoplication100 Patients

Total Charges Similar (LF - $11,449 OF - $11,632)

IPEG 2006

slide26
Laparoscopic Fundoplication6.Should the esophagus be extensively mobilized in laparoscopic fundoplication?
current thoughts
Current Thoughts
  • Less mobilization of esophagus
  • Keep peritoneal barrier b/w esophagus & crura
current thoughts1
Current Thoughts
  • Secure esophagus to crura at 8, 11, 1 and 4 o’clock
personal series cmh jan 2000 march 2002
Personal Series - CMHJan 2000 – March 2002

130 Pts

No Esophagus – Crural Sutures

Extensive Esophageal Mobilization

Mean age/weight 21 mo/10 kg

Mean operative time 93 minutes

Transmigration wrap 15 (12%)

Postoperative dilation 0

APSA 2006

J Pediatr Surg 42:25-30, 2007

personal series cmh april 2002 december 2004
Personal Series - CMHApril 2002 – December 2004

119 Pts

Esophagus – Crural Sutures

Minimal Esophageal Mobilization

Mean age/weight 27 mo/11 kg

Mean operative time 102 minutes

Transmigration wrap 6 (5%)

Postoperative dilation 1

APSA 2006

J Pediatr Surg 42:25-30, 2007

slide32
The relative risk of wrap transmigration in patients without esophago-crural sutures and with extensive esophageal mobilization was 2.29 times the risk if these sutures were utilized and if minimal esophageal dissection was performed.
patients less than 60 months
Patients Less Than 60 Months

The relative risk of transmigration of the wrap is 2.03 times greater for Group I than for Group II

patients less than 24 months
Patients Less Than 24 Months

The relative risk of transmigration of the wrap is 1.94 times greater for Group I than for Group II

group ii 119 patients esophago crural sutures
Group II119 PatientsEsophago-Crural Sutures

# PatientsTransmigration%

2 silk sutures 20 5 25%

(9, 3 o’clock)

3 silk sutures 43 1 2.3%

(9, 12, 3 o’clock)

4 silk sutures 56 0 0%

(8, 11, 1, 4 o’clock)

prospective randomized trial
Prospective, Randomized Trial
  • 2 Institutions: CMH, CH-Alabama
  • Power Analysis: 360 Patients
  • Primary endpoint-transmigration rate

(12% vs.5%-retrospective data)

  • 2 Groups: minimal vs. extensive

esophageal dissection

  • Both groups receive esophago-crural

sutures

re do fundoplication
Re-Do Fundoplication
  • Jan 00 – March 02

15/130 Pts – 12%

  • April 02 – December 06

7/184 Pts – 3.8%

re do fundoplication1
Re-Do Fundoplication

22 Pts

  • All but one had transmigration of wrap
  • Mean age initial operation – 12.6 (±5.8) mos
  • 11 had gastrostomy
  • Mean time b/w initial operation & 1st redo – 14.1 (±1.7) mos
  • F/U – Minimum -19 mos

Mean - 34 mos

Accepted, J Pediatr Surg

re do fundoplication operative technique 21 249pts
Re-Do FundoplicationOperative Technique21/249Pts

Laparoscopic Re-Do – 10

  • No SIS – 9
    • Open Redo with SIS - (1)
  • SIS 1
re do fundoplication operative technique 21 249 pts
Re-Do FundoplicationOperative Technique21/249 Pts

Open Re-Do - 11

  • SIS - 7
  • No SIS - 4
    • 2 required open re-do with SIS
sis and paraesophageal hernia repair
SIS and Paraesophageal Hernia Repair
  • Multicenter, prospective randomized trial
  • 108 patients
  • Recurrence: 7% vs 25% (1o repair)
  • No mesh related complications

Oelschlager BK, et al

ASA Meeting, April 2006

postoperative studies nissen fundoplication
Postoperative StudiesNissen Fundoplication
  • number and magnitude TLESR 1, 2
  • Disruption efferent vagal input to GE junction with TLESR3
  • Ireland, et al: Gastroenterology 106:1714-1720, 1994
  • Straathof, et al: Br J Surg 88: 1519-1524, 2001
  • Sarani, et al: Surg Endosc 17:1206-1211 2003
laparoscopic nissen fundoplication summary
Laparoscopic Nissen FundoplicationSummary
  • The use of stab incisions for instrument access results in significant financial savings to the patient and institution.
  • The incidence of transmigration of the fundoplication wrap has been markedly reduced with the use of esophageal-crural sutures and minimal esophageal mobilization.
  • The long-term functional results should be equivalent to the open operation. The major advantages lie in reduced discomfort and hospitalization, faster return to routine activities and cosmesis.
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