The IPEG Annual Congress joins with:
Download
1 / 45

The IPEG Annual Congress joins with: - PowerPoint PPT Presentation


  • 108 Views
  • Uploaded on

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).

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'The IPEG Annual Congress joins with:' - nhung


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
The ipeg annual congress joins with

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
GERD Infants and ChildrenBarriers to Mucosal Injury

  • LES

  • Esophageal IAL

  • Angle of His

  • Esophageal motility


Transient les relaxations
Transient LES Relaxations Infants and Children

  • 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 Infants and Children

  • 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 Infants and Children

  • Angle of His

  • Normally, an acute angle

  • When obtuse, more prone to GER

  • Important consideration following gastrostomy


Treatment options
Treatment Options Infants and Children

  • Medical

  • Surgical

  • Endoluminal


Preoperative evaluation
Preoperative Evaluation Infants and Children

  • 24 hr pH study

  • Upper GI contrast study

  • Endoscopy

  • Endoscopy with biopsy

  • Gastric emptying study ?

  • Esophageal motility study ?


Preoperative evaluation gastric emptying study
Preoperative Evaluation Infants and ChildrenGastric Emptying Study ?


Gerd fundoplication
GERD Infants and ChildrenFundoplication

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 Infants and Children

  • Laparoscopic vs open

  • Complete (Nissen) vs Partial (Thal, Boix-Ochoa, Toupet)


Issues questions

ISSUES/QUESTIONS Infants and Children


Laparoscopic fundoplication
Laparoscopic Fundoplication Infants and Children

  • 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

  • pCO Infants and Children2

  • FRC

  • pH

  • pO2

Pneumoperitoneum

  • SVR

  • PVR

  • SV

  • CI

  • Venous Return (Head up)


Proceed with caution
Proceed With Caution Infants and Children

  • 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 Infants and Children

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


Laparoscopic fundoplication2
Laparoscopic Fundoplication Infants and Children

No


Laparoscopic fundoplication3
Laparoscopic Fundoplication Infants and Children

  • Is dysphagia a common problem following laparoscopic Nissen fundoplication in infants and children?


Intraoperative bougie sizes
Intraoperative Bougie Sizes Infants and Children

PAPS 2002

J Pediatr Surg 37:1664-1666, 2002


Laparoscopic fundoplication4
Laparoscopic Fundoplication Infants and Children

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


Laparoscopic fundoplication5
Laparoscopic Fundoplication Infants and Children


The ipeg annual congress joins with

The Use of Stab Incisions Infants and Children

PAPS 2003

J Pediatr Surg 38:1837-1840, 2003


Cost savings from stab incisions
Cost Savings from Stab Incisions Infants and Children

PAPS 2003

J Pediatr Surg 38:1837-1840, 2003


Laparoscopic fundoplication6
Laparoscopic Fundoplication Infants and Children

  • 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


The ipeg annual congress joins with
Laparoscopic Fundoplication versus Open Fundoplication6.Should the esophagus be extensively mobilized in laparoscopic fundoplication?


Current thoughts
Current Thoughts versus Open Fundoplication

  • Less mobilization of esophagus

  • Keep peritoneal barrier b/w esophagus & crura


Current thoughts1
Current Thoughts versus Open Fundoplication

  • Secure esophagus to crura at 8, 11, 1 and 4 o’clock


Laparoscopic fundoplication current technique
Laparoscopic Fundoplication versus Open FundoplicationCurrent Technique


Personal series cmh jan 2000 march 2002
Personal Series - CMH versus Open FundoplicationJan 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 - CMH versus Open FundoplicationApril 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


The ipeg annual congress joins with

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 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.

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 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.

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 II 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.119 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 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.

  • 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 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.

  • Jan 00 – March 02

    15/130 Pts – 12%

  • April 02 – December 06

    7/184 Pts – 3.8%


Re do fundoplication1
Re-Do Fundoplication 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.

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 Fundoplication 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.Operative 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 Fundoplication 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.Operative Technique21/249 Pts

Open Re-Do - 11

  • SIS - 7

  • No SIS - 4

    • 2 required open re-do with SIS


Re do laparoscopic fundoplication
Re-Do Laparoscopic Fundoplication 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.


Sis and paraesophageal hernia repair
SIS and Paraesophageal Hernia Repair 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.

  • 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 Studies 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.Nissen 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 Fundoplication 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.Summary

  • 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.


The ipeg annual congress joins with

? ? ? 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.