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., MBA Children’s Mercy Hospital Kansas City, Missouri

GERD

Barriers 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, 1980

Barriers to Injury

2. IAL Esophagus

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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 Injury

3. Angle of His

• • •

Normally, an acute angle When obtuse, more prone to GER Important consideration following gastrostomy

Treatment Options

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Medical

•

Surgical

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Endoluminal

Preoperative Evaluation

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24 hr pH study

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Upper GI contrast study

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Endoscopy

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Endoscopy with biopsy

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Gastric emptying study ?

•

Esophageal motility study ?

Preoperative Evaluation

Gastric Emptying Study ?

GERD

Fundoplication

Indications for operation



Failure of medical therapy



ALTE/weight loss in infants



Refractory pulmonary symptoms



Neurologically impaired child who needs gastrostomy

Options for Fundoplication

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Laparoscopic vs open

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

ISSUES/QUESTIONS

Laparoscopic Fundoplication

1.

When is it not a good option?

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Significant hx of cardiac disease

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Significant hx of lung disease



BPD



Significant O2 still needed

•

Chronic NICU baby

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Previous upper abdominal operations?

Pneumoperitoneum

• • • • •

SVR PVR SV CI Venous Return (Head up)

• • • •

pCO 2 FRC pH pO 2

Proceed With Caution



VSD with reactive pulmonary HTN

 

CAVC – ( PVR 2 o to pCO 2 , pO 2 , 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 2 o 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 2002 J 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 Incisions Procedure (n) Nissen (209) Nissen (14) Heller Myotomy (7) Appendectomy (102) Meckel’s Diverticulum (2) Pyloromyotomy (77) Cholecystectomy (31) Pullthrough (20) Splenectomy (21) Adrenalectomy (6) UDT (15) Varicocele (5) Ovarian (2) Totals (511) Used/case 1 2 1 2 2 2 2 2 2 2 1 1 1 714 Saved/case 4 3 3 1 1 2 2 1 2 2 2 2 2 1337 PAPS 2003 J Pediatr Surg 38:1837-1840, 2003

Cost Savings from Stab Incisions Procedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) Heller (7) Appy (102) Meckel’s (2) 5,880 / 2,604 2,940 / 1,302 14,280 / 6,324 280/ 124 3,864 / 1,722 1,932 / 861 9,384 / 4,182 184 / 82 Pyloric (77) Chole (31) Pullthrough (20) Spleens (21) 21,560 / 9,548 8,680 / 3,844 2,800 / 1,240 5,880 / 2,604 14,168 / 6,314 5,704 / 2,542 1,840 / 820 3,864 / 1,722 Adrenal (6) UDT (15) Varicocele (5) Ovarian (2) Total = 511 1,680 / 744 4,200 / 1,860 1,104 / 492 2,760 / 1,230 1,400 / 620 920 / 410 560 / 248 368 / 164 $187,180/$82,894 $123,004/$54,817 PAPS 2003 J 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 LOS (1.2 vs 2.9 days) Initial Feeds (7.3 vs 27.9 hrs) Full Feeds (21.8 vs 42.9 hrs) P Value <0.01

<0.01

<0.01

Favoring OF Op Time (77 vs 91 min) P Value 0.03

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 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 Fundoplication Current Technique

Personal Series - CMH Jan 2000 – March 2002 130 Pts No Esophagus – Crural Sutures Extensive Esophageal Mobilization Mean age/weight 21 mo/10 kg Mean operative time Transmigration wrap Postoperative dilation 93 minutes 15 (12%) 0 APSA 2006 J Pediatr Surg 42:25-30, 2007

Personal Series - CMH April 2002 – December 2004 119 Pts Esophagus – Crural Sutures Minimal Esophageal Mobilization Mean age/weight Mean operative time Transmigration wrap Postoperative dilation 27 mo/11 kg 102 minutes 6 (5%) 1 APSA 2006 J 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 Months

Group I Jan 00-March 02 Group II April 02-Dec 04 P Value Mean Age (mos) Mean Wt (kg) Gastrostomy Neuro Impaired Wrap Transmigration 117 Pts 10.26

7.03

47% 71% 14 (12%) 102 Pts 10.95

7.17

46% 61% 6 (6%) 0.650

0.801

0.893

0.118

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 Months

Mean Age (mos) Group I Jan 00-March 02 104 Pts 6.99

Group II April 02-Dec 04 93 Pts 8.15

P Value 0.175

Mean Wt (kg) 6.32

6.46

0.759

Gastrostomy 46% 46% 0.999

Neuro Impairment Wrap Transmigration 73% 13 (12%) 60% 6 (6%) 0.069

.226

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 2 silk sutures (9, 3 o’clock) 3 silk sutures (9, 12, 3 o’clock) 4 silk sutures (8, 11, 1, 4 o’clock) # Patients Transmigration 20 5 43 56 1 0 % 25% 2.3% 0%

Prospective, Randomized Trial

• • •

2 Institutions: CMH, CH-Alabama Power Analysis: 360 Patients Primary endpoint-transmigration rate (12% vs.5%-retrospective data)

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2 Groups: minimal vs. extensive esophageal dissection

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Both groups receive esophago-crural sutures

Re-Do Fundoplication

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Jan 00 – March 02 15/130 Pts – 12%

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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 & 1 st 14.1 (±1.7) mos redo –

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F/U – Minimum -19 mos Mean 34 mos Accepted, J Pediatr Surg

Re-Do Fundoplication Operative Technique 21/249Pts Laparoscopic Re-Do – 10

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No SIS –



Open Redo with SIS - (1)

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SIS 9 1

Re-Do Fundoplication Operative Technique 21/249 Pts Open Re-Do -

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SIS -

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No SIS 11 7 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% (1 o repair) No mesh related complications Oelschlager BK, et al ASA Meeting, April 2006

Postoperative Studies

Nissen Fundoplication

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number and magnitude TLESR 1, 2

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Disruption efferent vagal input to GE junction with TLESR 3 1.

2.

3.

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

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The use of stab incisions for instrument access results in significant financial savings to the patient and institution.

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The incidence of transmigration of the fundoplication wrap has been markedly reduced with the use of esophageal-crural sutures and minimal esophageal mobilization.

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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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