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

GERDBarriers to Mucosal Injury

• LES

• Esophageal IAL

• Angle of His

• Esophageal motility

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

Treatment Options

• Medical

• Surgical

• Endoluminal

Preoperative Evaluation

• 24 hr pH study

• Upper GI contrast study

• Endoscopy

• Endoscopy with biopsy

• Gastric emptying study ?

• Esophageal motility study ?

Preoperative EvaluationGastric Emptying 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)

ISSUES/QUESTIONSISSUES/QUESTIONS

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?

Pneumoperitoneum

• SVR

• PVR

• SV

• CI

• Venous Return (Head up)

• pCO2

• FRC

• pH

• pO2

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

No

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?

Laparoscopic Fundoplication

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?

Current Thoughts

1. Less mobilization of esophagus

2. Keep peritoneal barrier b/w esophagus & crura

Current Thoughts

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

Laparoscopic FundoplicationCurrent Technique

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

• Jan 00 – March 02

15/130 Pts – 12%

• April 02 – December 06

7/184 Pts – 3.8%

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

Re-Do Laparoscopic Fundoplication

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.

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