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)

George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital 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 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 Angle of His Normally, an acute angle When obtuse, more prone to GER Important consideration following gastrostomy

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 Evaluation Gastric Emptying Study ?

Indications for operation 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)

ISSUES/QUESTIONS

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?

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

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 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 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 PAPS 2003 J Pediatr Surg 38:1837-1840, 2003

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

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

Total Charges Similar (LF - $11,449 OF - $11,632) Clinical and Financial Analysis of Pediatric Laparoscopic versus Open Fundoplication 100 Patients Favoring LF P Value Favoring OF 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) 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) 0.04 <0.001 Total Charges Similar (LF - $11,449 OF - $11,632) IPEG 2006

Laparoscopic Fundoplication 6 Laparoscopic Fundoplication 6. Should the esophagus be extensively mobilized in laparoscopic fundoplication?

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

Current Thoughts 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 Group 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 Months Group I Jan 00-March 02 104 Pts Group II April 02-Dec 04 93 Pts P Value Mean Age (mos) 6.99 8.15 0.175 Mean Wt (kg) 6.32 6.46 0.759 Gastrostomy 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 II 119 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%

Accepted, J Pediatr Surg 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

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 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 al ASA Meeting, April 2006

Postoperative Studies Nissen 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

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.

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