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George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

Current Thoughts About Laparoscopic Fundoplication in Infants and Children Guangzhou Children’s Hospital. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri. Gastroesophageal Reflux. GER – presence of gastroesophageal reflux

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George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

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  1. Current Thoughts About Laparoscopic Fundoplication in Infants and ChildrenGuangzhou Children’s Hospital 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 • Lower esophageal sphincter (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. What Do We Know Now That We Did Not Know in 2000?

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

  11. 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 Pediatr Surg 45:1169-1172, 2010

  12. Children’s Mercy Hospital UGI – 656 pts Abnormality (other than GER) – 30 pts (4.5%) Suspected malrotation – 26 pts (4.0%) AAP, 2009 J Pediatr Surg 45:1169-1172, 2010

  13. Children’s Mercy Hospital Preoperative UGI – 656 pts Influences management - 4% Malrotation is the most common finding AAP, 2009 J Pediatr Surg 45:1169-1172,2010

  14. Preoperative EvaluationGastric Emptying Study ?

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

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

  17. Laparoscopic Fundoplication Issues/Questions

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

  19. 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

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

  21. Intraoperative Bougie Sizes PAPS, 2002 J Pediatr Surg 37:1664-1666, 2002

  22. Laparoscopic Fundoplication • Can stab (3mm) incisions be used rather than cannulas for laparoscopic operations?

  23. Laparoscopic Fundoplication

  24. The Use of Stab Incisions 2000-2002 PAPS, 2003 JPS 38:1837-1840, 2003

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

  26. 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

  27. Laparoscopic Fundoplication5)Should the esophagus be extensively mobilized? Technique 2000 - 2002

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

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

  30. Laparoscopic FundoplicationCurrent Technique - 2010

  31. Why The Change in Technique?

  32. Personal Series - CMHJan 2000 – March 2002 Group I - 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

  33. Personal Series - CMHApril 2002 – December 2004 Group II - 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

  34. Summary 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.

  35. 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)

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

  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 177 Patients APSA, 2010 Accepted, J Pediatr Surg

  40. Minimal vs Extensive Esophageal Mobilization During Laparoscopic Fundoplication Results 177 Patients APSA, 2010 Accepted, J Pediatr Surg

  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

  43. Operative ResultsOpen Operations

  44. Re-Do Fundoplication(Personal Series) • 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(Personal Series) 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 Ann Surg 244:481-490, 2006 ASA Meeting, 2006

  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.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com

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