Current Thoughts About Laparoscopic Fundoplication in Infants and Children

1. Current Thoughts About Laparoscopic Fundoplication in Infants and Children George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. Gastroesophageal Reflux GER – presence of gastroesophageal reflux GERD – symptomatic gastroesophageal reflux • Wt loss/FTT • ALTE • Pulmonary Sxs., RAD • Esophagitis: pain, stricture, Barrett’s

3. GERDBarriers to Mucosal Injury • LES • Esophageal IAL • Angle of His • Esophageal motility

4. Barriers to Injury • LES • Thickened muscle layer, distal esophagus • Imperfect valve, creates pressure gradient • Held in abdomen by phrenoesophageal membrane • Efficacy against GER proportional to: • Length • Pressure • LES relaxes normally with esophageal peristalsis • Inappropriate LES relaxations – Transient LES Relaxations (TLESR)

5. 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

6. 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

7. Barriers to Injury • Angle of His • Normally, an acute angle • When obtuse, more prone to GER • Important consideration following gastrostomy

8. Barriers to Injury • Esophageal Motility • motility, impaired clearance of gastric refluxate, mucosal injury

9. GERD SURGICAL CONSIDERATIONS

10. What Do We Know Now That We Did Not Know in 2000?

11. Preoperative Evaluation • 24 hr pH study – gold standard in many centers • Impedance – acid & alkaline reflux • Upper GI contrast study -reflux seen in 30% • Endoscopy - visualization only not sensitive • Endoscopy with biopsy – probably most sensitive • Gastric emptying study ? • Esophageal motility study - not needed in children?

12. Children’s Mercy Hospital Jan 2000 – June 2007 843 fundoplications ( 3.6% op. vol.) UGI – 656 pts pH study – 379 pts Sensitivity UGI – 30.8% AAP, 2009 J PediatrSurg 4:1169-1172, 2010

13. Children’s Mercy Hospital UGI – 656 pts Abnormality (other than GER) – 30 pts (4.5%) Suspected malrotation – 26 pts (4.0%) AAP, 2009 J PediatrSurg 4:1169-1172, 2010

14. Children’s Mercy Hospital UGI – 656 pts Influences management - 4% Malrotation is the most common finding AAP, 2009 J PediatrSurg 4:1169-1172, 2010

15. Preoperative EvaluationGastric Emptying Study ?

16. GERDFundoplication Indications for operation • Failure of medical therapy • ALTE/weight loss in infants • Refractory pulmonary symptoms • Neurologically impaired child who needs gastrostomy

17. Options for Fundoplication • Laparoscopic vs open • Complete (Nissen) vs Partial (Thal, Boix-Ochoa, Toupet)

18. ISSUES/QUESTIONS

19. pCO2 • FRC • pH • pO2 Effects of Pneumoperitoneum • SVR • PVR • SV • CI • Venous Return (Head up)

20. 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

21. Laparoscopic Fundoplication • Is dysphagia a common problem following laparoscopic Nissen fundoplication in infants and children?

22. Intraoperative Bougie Sizes PAPS, 2002 JPS 37:1664-1666, 2002

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

24. Laparoscopic Fundoplication

25. The Use of Stab Incisions PAPS, 2003 JPS 38:1837-1840, 2003

26. Cost Savings from Stab Incisions PAPS, 2003 JPS 38:1837-1840, 2003

27. Laparoscopic Fundoplication 4. Is there a financial advantage with the laparoscopic approach when compared to the open operation?

28. Clinical and Financial Analysis of Pediatric Laparoscopic versus Open Fundoplication100 Patients Total Charges Similar (LF - $11,449 OF - $11,632) IPEG 2006 J Lap Endosc Surg Tech 17:493-496,2007

29. Laparoscopic Fundoplication5.Should the esophagus be extensively mobilized in laparoscopic fundoplication? Please use this link if you experience problems viewing the video above.

30. Current ThoughtsTechnique 2003 - 2010 • Less mobilization of esophagus • Keep peritoneal barrier b/w esophagus & crura

31. Current Thoughts • Secure esophagus to crura at 8, 11, 1 and 4 o’clock

32. Laparoscopic FundoplicationCurrent Technique - 2010 Please use this link if you experience problems viewing the video above.

33. Why The Change in Technique?

34. 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

35. 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

36. 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.

37. 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 APSA 2006 J Pediatr Surg 42:25-30, 2007

38. Prospective, Randomized Trial • 2 Institutions: CMH, CH-Alabama • Power analysis using retrospective data (12% vs 5%) : 360 patients • Primary endpoint-transmigration rate • 2 groups: minimal vs. extensive esophageal dissection • Both groups received esophago-crural sutures • Stratified for neurological status • UGI contrast study one year post-op • APSA, 2010

39. Minimal vs Extensive Esophageal Mobilization During Laparoscopic Fundoplication Preoperative Demographics

40. Minimal vs Extensive Esophageal Mobilization During Laparoscopic Fundoplication Results APSA, 2010 J PediatrSurg 46:163-169, 2011

41. Current Study • Analysis (80% power,α- 0.05) – 110 patients • Minimal esophageal dissection in all patients • 4 esophago-crural sutures vs. no sutures

42. No Esophago-crural Sutures Please use this link if you experience problems viewing the video above.

43. Operative ResultsOpen Operations

44. Re-Do Fundoplication • Jan 00 – March 02 15/130 Pts – 12% • April 02 – December 06 7/184 Pts – 3.8% J Pediatr Surg 42:1298-1301, 2007

45. Re-Do Fundoplication 22 Pts (2000 – 2006) • 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 J Pediatr Surg 42:1298-1301, 2007

46. Re-Do Fundoplication21/249Pts • SIS – 8: no recurrences • No SIS – 13 4 recurrences (31%)

47. 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 ‘06

48. 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

49. QUESTIONS www.cmhclinicaltrials.com www.cmhmis.com