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
George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital
Kansas City, Missouri
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, 1980Werlin SL, et al: J Peds 97:244-249, 1980
Barriers to Injury2. 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*DeMeester, et al: Am J Surg 137: 39-46, 1979
Barriers to Injury
• Normally, an acute angle
• When obtuse, more prone to GER
• Important consideration following gastrostomy
3. Angle of His
Preoperative Evaluation
• 24 hr pH study
• Upper GI contrast study
• Endoscopy
• Endoscopy with biopsy
• Gastric emptying study ?
• Esophageal motility study ?
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
• Laparoscopic vs open
• Complete (Nissen) vs Partial (Thal,
Boix-Ochoa, Toupet)
Laparoscopic Fundoplication
• Significant hx of cardiac disease
• Significant hx of lung disease
BPD
Significant O2 still needed
• Chronic NICU baby
• Previous upper abdominal operations?
1. When is it not a good option?
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 Fundoplication
2. Can a loose, floppy, complete (Nissen)
fundoplication be performed without
ligation of the short gastric vessels?
Laparoscopic Fundoplication
3. Is dysphagia a common problem
following laparoscopic Nissen
fundoplication in infants and
children?
Intraoperative Bougie Sizes
PAPS 2002PAPS 2002
J Pediatr Surg 37:1664-1666, 2002J Pediatr Surg 37:1664-1666, 2002
Laparoscopic Fundoplication
4. Can stab (3mm) incisions be used rather than cannulas for laparoscopic operations and is there a financial advantage?
The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4
Nissen (14) 2 3
Heller Myotomy (7) 2 3
Appendectomy (102) 2 1
Meckel’s Diverticulum (2) 2 1
Pyloromyotomy (77) 1 2
Cholecystectomy (31) 2 2
Pullthrough (20) 2 1
Splenectomy (21) 2 2
Adrenalectomy (6) 2 2
UDT (15) 1 2
Varicocele (5) 1 2
Ovarian (2) 1 2
Totals (511) 714 1337
PAPS 2003PAPS 2003J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) 5,880 / 2,604 3,864 / 1,722 Heller (7) 2,940 / 1,302 1,932 / 861 Appy (102) 14,280 / 6,324 9,384 / 4,182 Meckel’s (2) 280/ 124 184 / 82 Pyloric (77) 21,560 / 9,548 14,168 / 6,314 Chole (31) 8,680 / 3,844 5,704 / 2,542 Pullthrough (20) 2,800 / 1,240 1,840 / 820 Spleens (21) 5,880 / 2,604 3,864 / 1,722 Adrenal (6) 1,680 / 744 1,104 / 492 UDT (15) 4,200 / 1,860 2,760 / 1,230 Varicocele (5) 1,400 / 620 920 / 410 Ovarian (2) 560 / 248 368 / 164 Total = 511 $187,180/$82,894 $123,004/$54,817
PAPS 2003PAPS 2003J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
Laparoscopic Fundoplication
5. 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
Favoring LF P Value Favoring OF P Value
LOS (1.2 vs 2.9 days) <0.01 Op Time (77 vs 91 min) 0.03
Initial Feeds (7.3 vs 27.9 hrs)
Full Feeds (21.8 vs 42.9 hrs)
<0.01
<0.01
Hospital Room ($1290 vs $2847)
Pharmacy ($180 vs $461)
Equipment ($1006 vs $1609)
0.004
0.01
0.003
Anesthesia ($389 vs $475)
Operating Suite ($4058 vs $5142)
Central Supply/Sterilization ($1367 vs $2515)
0.01
0.04
<0.001
Total Charges Similar (LF - $11,449 OF - $11,632)IPEG 2006IPEG 2006
Laparoscopic Fundoplication
6. Should the esophagus be extensively mobilized in laparoscopic fundoplication?
Personal Series - CMHJan 2000 – March 2002
130 PtsNo Esophagus – Crural Sutures
Extensive Esophageal Mobilization
Mean age/weight 21 mo/10 kg
Mean operative time 93 minutes
Transmigration wrap 15 (12%)
Postoperative dilation 0APSA 2006 APSA 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
Personal Series - CMHApril 2002 – December 2004
119 PtsEsophagus – 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 APSA 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
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 MonthsGroup I
Jan 00-March 02
117 Pts
Group II
April 02-Dec 04
102 Pts
P Value
Mean Age (mos) 10.26 10.95 0.650
Mean Wt (kg) 7.03 7.17 0.801
Gastrostomy 47% 46% 0.893
Neuro Impaired 71% 61% 0.118
Wrap Transmigration
14 (12%) 6 (6%) 0.159
The relative risk of transmigration of the wrap is 2.03 times greater for Group I than for Group II
Patients Less Than 24 MonthsGroup I
Jan 00-March 02
104 Pts
Group IIApril 02-Dec 04
93 PtsP Value
Mean Age (mos) 6.99 8.15 0.175
Mean Wt (kg) 6.32 6.46 0.759
Gastrostomy 46% 46% 0.999
Neuro Impairment
73% 60% 0.069
Wrap Transmigration 13 (12%) 6 (6%) .226
The relative risk of transmigration of the wrap is 1.94 times greater for Group I than for Group II
Group II119 Patients
Esophago-Crural Sutures
# Patients Transmigration %
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
• 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
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 SurgAccepted, J Pediatr Surg
Re-Do FundoplicationOperative Technique
21/249Pts
Laparoscopic Re-Do – 10
• No SIS – 9
Open Redo with SIS - (1)
• SIS1
Re-Do FundoplicationOperative Technique
21/249 Pts
Open Re-Do - 11
• SIS - 7
• No SIS - 4
2 required open re-do with SIS
SIS and Paraesophageal Hernia Repair
• Multicenter, prospective randomized trial
• 108 patients
• Recurrence: 7% vs 25% (1o repair)
• No mesh related complications
Oelschlager BK, et alOelschlager BK, et alASA Meeting, April 2006ASA Meeting, April 2006
Postoperative StudiesNissen Fundoplication
• number and magnitude TLESR 1, 2
• Disruption efferent vagal input to GE junction with TLESR3
1. Ireland, et al: Gastroenterology 106:1714-1720, 19942. Straathof, et al: Br J Surg 88: 1519-1524, 20013. Sarani, et al: Surg Endosc 17:1206-1211 2003
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.