1. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital
Current Thoughts About Laparoscopic Fundoplication in Infants and Children WOFAPS Meeting
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, Missouri

2. Gastroesophageal Reflux
GER – presence of gastroesophageal reflux
GERD – symptomatic gastroesophageal reflux
Wt loss/FTT
ALTE
Pulmonary Sxs., RAD
Esophagitis: pain, stricture, Barrett’s

3. GERD Barriers to Mucosal Injury
Lower esophageal sphincter (LES)
Esophageal IAL
Angle of His
Esophageal motility

4. Barriers to Injury 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)

5. 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: , 1980

6. 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

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

8. Barriers to Injury Esophageal Motility
motility, impaired clearance of gastric refluxate, mucosal injury

9. What Do We Know Now That We Did Not Know in 2000?

10. Preoperative Evaluation
24 hr pH study – gold standard in many centers
Only measures acid reflux
Impedance – acid & alkaline reflux
Upper GI contrast study -reflux seen in only 30%
Endoscopy - visualization only not sensitive
Endoscopy with biopsy – probably most sensitive
Gastric emptying study ?
Esophageal motility study - not needed in children?

11. Children’s Mercy Hospital
(Jan 2000 – June 2007)
843 fundoplications
( 3.6% op. vol.)
UGI – 656 pts
pH study – 379 pts
Sensitivity UGI – 30.8%
AAP, 2009
J Pediatr Surg 45: , 2010

12. Children’s Mercy Hospital
UGI – 656 pts
Abnormality (other than GER) – 30 pts (4.5%)
Suspected malrotation – 26 pts (4.0%)
Confirmed (16 pts)
No malrotation (6 pts)
Prev. Ladd (4 pts)
AAP, 2009
J Pediatr Surg 45: , 2010

13. Children’s Mercy Hospital
Preoperative UGI – 656 pts
Influences management - 4%
Malrotation is the most common finding
AAP, 2009
J Pediatr Surg 45: , 2010

14. Preoperative Evaluation Gastric Emptying Study ?

15. 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

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

17. Laparoscopic Fundoplication Issues/Questions

18. Effects of Pneumoperitoneum
pCO2
FRC pH
pO2
SVR
PVR SV CI
Venous Return (Head up)

19. 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

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

21. Intraoperative Bougie Sizes
PAPS, 2002
J Pediatr Surg 37: , 2002

22. Laparoscopic Fundoplication
Can stab (3mm) incisions be used rather than cannulas for laparoscopic operations?

23. Laparoscopic Fundoplication

24. The Use of Stab Incisions
PAPS, 2003
JPS 38: , 2003

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

26. 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
J Lap Endosc Surg Tech 17: ,2007

27. Laparoscopic Fundoplication 5) Should the esophagus be extensively mobilized?
Technique

28. Current Thoughts Technique 2003 - 2010
Less mobilization of esophagus
Keep peritoneal barrier b/w esophagus & crura

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

30. Laparoscopic Fundoplication Current Technique - 2010

31. Why The Change in Technique?

32. Personal Series - CMH Jan 2000 – March 2002
Group I 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

33. Personal Series - CMH April 2002 – December 2004
Group II 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

34. Summary
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.

35. Group II 119 Patients Esophago-Crural Sutures
# Patients Transmigration %
2 silk sutures %
(9, 3 o’clock)
3 silk sutures %
(9, 12, 3 o’clock)
4 silk sutures %
(8, 11, 1, 4 o’clock)

36. 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
APSA, 2006
J Pediatr Surg 42:25-30, 2007

37. 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
APSA, 2006
J Pediatr Surg 42:25-30, 2007

38. Prospective, Randomized Trial
2 Institutions: CMH, CH-Alabama
Power analysis using retrospective data (12% vs 5%) : 360 patients
Primary endpoint -- transmigration rate
2 groups: minimal vs. extensive esophageal dissection
Both groups received esophago-crural sutures
Stratified for neurological status
UGI contrast study one year post-op
APSA, 2010

39. Minimal vs Extensive Esophageal Mobilization During Laparoscopic Fundoplication
Preoperative Demographics
177 Patients
Extensive Esophageal Mobilization (N=87)
Minimal Esophageal Mobilization (N=90)
P-Value
Age (yrs)
1.9 +/- 3.3
2.5 +/- 3.5
0.30
Weight (kg)
12.6 +/- 18.2
0.44
Neurologically Impaired (%)
51.7
54.4
0.76
Operating Time (Minutes)
100 +/- 34
95 +/- 37
0.37
APSA, 2010
Accepted, J Pediatr Surg

40. Minimal vs Extensive Esophageal Mobilization During Laparoscopic Fundoplication
Results
177 Patients
Extensive Esophageal Mobilization (N=87)
Minimal Esophageal Mobilization (N=90)
P-Value
Postoperative Wrap Transmigration (%)
30.0%
7.8%
0.002
Need for Re-do Fundoplication (%)
18.4%
3.3%
0.006
APSA, 2010
Accepted, J Pediatr Surg

41. Current Study Analysis (80% power, α- 0.05) – 110 patients
Minimal esophageal dissection in all patients
4 esophago-crural sutures vs. no sutures

42. No Esophago-crural Sutures

43. Operative Results Open Operations

44. Re-Do Fundoplication (Personal Series)
Jan 00 – March 02
15/130 Pts – 12%
April 02 – December 06
7/184 Pts – 3.8%
J Pediatr Surg 42: , 2007

45. Re-Do Fundoplication (Personal Series)
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 mos
J Pediatr Surg 42: , 2007

46. Re-Do Fundoplication 21/249Pts
SIS – 8: no recurrences
No SIS – 13
4 recurrences (31%)

47. 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
Ann Surg 244: , 2006
ASA Meeting, 2006

48. Postoperative Studies Nissen Fundoplication
number and magnitude TLESR 1, 2
Disruption efferent vagal input to GE junction with TLESR3
Ireland, et al: Gastroenterology 106: , 1994
Straathof, et al: Br J Surg 88: , 2001
Sarani, et al: Surg Endosc 17:

49.
Finally, until a more efficacious, more cost effective and more efficient (with regard to health care providers and families) antibiotic regimen is identified, this study supports the use of single day dosing of ceftriaxone/metronidazole as the initial treatment regimen in children with perforated appendicitis. 49