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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).

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The IPEG Annual Congress joins with:

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  1. 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)

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

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

  4. 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

  5. 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

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

  7. Treatment Options • Medical • Surgical • Endoluminal

  8. Preoperative Evaluation • 24 hr pH study • Upper GI contrast study • Endoscopy • Endoscopy with biopsy • Gastric emptying study ? • Esophageal motility study ?

  9. Preoperative EvaluationGastric Emptying Study ?

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

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

  12. ISSUES/QUESTIONS

  13. 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?

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

  15. 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

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

  17. Laparoscopic Fundoplication No

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

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

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

  21. Laparoscopic Fundoplication

  22. The Use of Stab Incisions PAPS 2003 J Pediatr Surg 38:1837-1840, 2003

  23. Cost Savings from Stab Incisions PAPS 2003 J Pediatr Surg 38:1837-1840, 2003

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

  25. Clinical and Financial Analysis of Pediatric Laparoscopic versus Open Fundoplication100 Patients Total Charges Similar (LF - $11,449 OF - $11,632) IPEG 2006

  26. Laparoscopic Fundoplication6.Should the esophagus be extensively mobilized in laparoscopic fundoplication?

  27. Current Thoughts • Less mobilization of esophagus • Keep peritoneal barrier b/w esophagus & crura

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

  29. Laparoscopic FundoplicationCurrent Technique

  30. 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

  31. 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

  32. 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.

  33. 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

  34. 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

  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. 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

  37. Re-Do Fundoplication • Jan 00 – March 02 15/130 Pts – 12% • April 02 – December 06 7/184 Pts – 3.8%

  38. 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

  39. Re-Do FundoplicationOperative Technique21/249Pts Laparoscopic Re-Do – 10 • No SIS – 9 • Open Redo with SIS - (1) • SIS 1

  40. Re-Do FundoplicationOperative Technique21/249 Pts Open Re-Do - 11 • SIS - 7 • No SIS - 4 • 2 required open re-do with SIS

  41. Re-Do Laparoscopic Fundoplication

  42. 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

  43. 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

  44. 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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