Transcript Slide 1

Current Thoughts About
Laparoscopic Fundoplication in
Infants and Children
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, Missouri
Gastroesophageal Reflux
GER – presence of gastroesophageal reflux
GERD – symptomatic gastroesophageal reflux
• Wt loss/FTT
• ALTE (AAP 2006)
• Pulmonary Sxs., RAD
• Esophagitis: pain, stricture, Barrett’s
GERD
Barriers to Mucosal Injury
• LES
• Esophageal IAL
• Angle of His
• Esophageal motility
Barriers to Injury
1.
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)
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
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
Barriers to Injury
4. Esophageal Motility
•
motility, impaired clearance of
gastric refluxate,
mucosal injury
Treatment
• Relieve symptoms
• Heal mucosal injury
• Prevent complications
 ALTE, pneumonia, stricture
Treatment Options
• Medical
• Surgical
• Endoluminal
GERD
SURGICAL
CONSIDERATIONS
Preoperative Evaluation
• 24 hr pH study
• Upper GI contrast study
• Endoscopy
• Endoscopy with biopsy
• 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
• Laparoscopic vs open
• Complete (Nissen) vs Partial (Thal,
Boix-Ochoa, Toupet)
Advantages of Laparoscopy
• Reduced discomfort
• Reduced hospitalization
• Faster return to routine activities
(school, work, play)
• Cosmesis
ISSUES/QUESTIONS
Laparoscopic Fundoplication
1.
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?
Pneumoperitoneum
•
SVR
•
pCO2
•
PVR
•
FRC
•
SV
•
pH
•
CI
•
pO2
•
Venous Return
(Head up)
Proceed With Caution
 VSD with reactive pulmonary HTN
PVR 2o to pCO2, pO2, pH)
 Neonates (in general) with reactive or persistent PHTN
 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
 CAVC – (
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
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
LOS (1.2 vs 2.9 days)
<0.01
Initial Feeds (7.3 vs 27.9 hrs)
<0.01
Full Feeds (21.8 vs 42.9 hrs)
<0.01
Hospital Room ($1290 vs $2847)
Favoring OF
P Value
Op Time (77 vs 91 min)
0.03
0.004
Anesthesia ($389 vs $475)
0.01
Pharmacy ($180 vs $461)
0.01
Operating Suite ($4058 vs $5142)
0.04
Equipment ($1006 vs $1609)
0.003
Central Supply/Sterilization
($1367 vs $2515)
<0.001
Total Charges Similar (LF - $11,449 OF - $11,632)
IPEG 2006
J Lap Endosc Surg Tech 17:493-496, 2007
Laparoscopic Fundoplication
6. Should the esophagus be extensively
mobilized in laparoscopic fundoplication?
Current Thoughts
Technique 2003 -2010
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
93 minutes
Transmigration wrap
15 (12%)
Postoperative dilation
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
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
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
Mean Age (mos)
Group I
Jan 00-March 02
Group II
April 02-Dec 04
117 Pts
102 Pts
P Value
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
6 (6%)
0.159
Wrap
Transmigration
14 (12%)
The relative risk of transmigration of the wrap is
2.03 times greater for Group I than for Group II
Group II
119 Patients
Esophago-Crural Sutures
# Patients Transmigration
%
2 silk sutures
(9, 3 o’clock)
20
5
25%
3 silk sutures
(9, 12, 3 o’clock)
43
1
2.3%
4 silk sutures
(8, 11, 1, 4 o’clock)
56
0
0%
Patients Less Than 24 Months
Group I
Jan 00-March 02
Group II
April 02-Dec 04
104 Pts
93 Pts
P 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
6 (6%)
.226
Wrap
Transmigration
13 (12%)
The relative risk of transmigration of the wrap is 1.94
times greater for Group I than for Group II
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
• APSA, 2010
Evidence Based Studies in MIS
Minimal vs Extensive Esophageal Mobilization
During Laparoscopic Fundoplication
Age (yrs)
Weight (kg)
Neurologically
Impaired (%)
Operating Time
(Minutes)
Extensive Esophageal
Mobilization (N=87)
Minimal Esophageal
Mobilization (N=90)
P-Value
1.9 +/- 3.3
2.5 +/- 3.5
0.30
10.7 +- 11.9
12.6 +/- 18.2
0.44
51.7
54.4
0.76
100 +/- 34
95 +/- 37
0.37
APSA, 2010
Evidence Based Studies in MIS
Minimal vs Extensive Esophageal Mobilization
During Laparoscopic Fundoplication
Extensive
Esophageal
Mobilization (N=70)
Minimal Esophageal
Mobilization (N=90)
PValue
Postoperative Wrap Transmigration (%)
30.0%
7.8%
0.002
Need for Re-do Fundoplication (%)
18.4%
3.3%
0.006
APSA, 2010
Operative Results
Open Operations
Study
# Pts
% Re-op
Herniation
Wrap
Dehiscence
Other
Wheatley
(Michigan)
1974-1989
242
12%
3
14
3
Caniano
(Ohio State)
1976 - 1988
358
16
2
3
Dedinsky
(Indiana)
1975-1985
Fonkalsrud
(UCLA)
1976-1996
Holcomb
(CMH)
2000-2006
(29)
6%
(21)
429
6.7%
29
(29)
7467
7.1%
314
22
21
1
Re-Do Fundoplication
• Jan 00 – March 02
15/130 Pts – 12%
• April 02 – December 06
7/184 Pts – 3.8%
J Pediatr Surg 42:1298-1301, 2007
Re-Do Fundoplication
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
Re-Do Fundoplication
Operative Technique
21/249Pts
Laparoscopic Re-Do – 10
• No SIS –
9
 Open Redo
with SIS - (1)
• SIS
1
Re-Do Fundoplication
Operative Technique
21/249 Pts
Redo 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 al
ASA Meeting, April ‘06
Postoperative Studies
Nissen Fundoplication
•
number and magnitude TLESR 1, 2
• Disruption efferent vagal input to GE
junction with TLESR3
1. Ireland, et al: Gastroenterology 106:1714-1720, 1994
2. Straathof, et al: Br J Surg 88: 1519-1524, 2001
3. Sarani, et al: Surg Endosc 17:1206-1211 2003
Laparoscopic Nissen Fundoplication
Summary
• LNF is an effective approach for surgical
correction of GERD
• Advantages include reduced discomfort,
reduced hospitalization and cosmesis
• Fundoplication appears to work by
decreasing the number and magnitude of
TLESR
Laparoscopic Nissen Fundoplication
Summary
• 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.
QUESTIONS
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