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Briggs KB, Svetanoff WJ, Fraser JA, Aguayo P, Fraser JD, HolcombIII GW, St Peter SD. Fundoplication without esophagocrural sutures: Long-term follow-up of a randomized clinical trial. J Pediatr Surg 2022; 57:1499-1503. [PMID: 34980467 DOI: 10.1016/j.jpedsurg.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/14/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We previously conducted a randomized trial that showed a lack of need for esophagocrural (EC) sutures during fundoplication when no esophageal dissection was performed. There was no difference in wrap herniation or other complications in the group without EC sutures at a median 1.5 years of follow-up. In this follow-up study, we aim to evaluate long-term symptom control and complication profiles in these patients. METHODS 106 patients were randomized and participated in the original trial. We were primarily concerned with identification of late complications and persistence of symptoms. Presently, we conducted a retrospective chart review and a telephone follow-up survey at a minimum of 6.5 years after fundoplication. RESULTS 100 patients were alive at late follow-up and 70% of caregivers responded to the telephone survey. 53% of patients were male; 76% were Caucasian. Of these children, 39 (56%) received four EC sutures, while 31 (44%) did not. Follow-up was conducted at a median of 8.7 years [IQR 8.2,9.7] post-fundoplication. Late wrap herniation was not demonstrated radiographically on chart review or caregiver report in either group. The rate of residual reflux symptoms, post-operative hospitalizations for pneumonia, failure to thrive (FTT), and brief resolved unexplained event (BRUE) were also similar between groups. CONCLUSION Long-term follow-up in children who underwent fundoplication without esophagocrural sutures demonstrates no difference in symptom management or subsequent hospitalizations at a minimum of 6.5-year follow-up. LEVEL OF EVIDENCE II (follow-up of a randomized controlled trial).
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Affiliation(s)
- Kayla B Briggs
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - James A Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - George W HolcombIII
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States.
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Till H, Esposito C, Escolino M, Singer G, Gasparella P, Arneitz C. Laparoscopic Treatment of Gastroesophageal Reflux Disease in Children: How We Do It. J Laparoendosc Adv Surg Tech A 2021; 31:1175-1179. [PMID: 34415797 DOI: 10.1089/lap.2021.0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Over decades now, laparoscopic Nissen fundoplication represents the treatment of choice for symptomatic children with gastroesophageal reflux disease (GERD) unresponsive to medication. Although the basic principles of Nissen's technique are still essential today, academic studies of long-term results, complications, and patients benefits have fostered distinct modifications. Identification of surgical factors for wrap migration, dysphagia, and recurrent GERD led to recommendations for "short and floppy" wraps with minimal dissection of the phrenoesophageal membranes. This report summarizes up-to-date information from experts in the field on "how to wrap it right" followed by a critical discussion about long-term benefits for children with GERD and future developments of laparoscopic Nissen fundoplication.
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Affiliation(s)
- Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Ciro Esposito
- Pediatric Surgical Unit, Federico II University of Naples, Naples, Italy
| | - Maria Escolino
- Pediatric Surgical Unit, Federico II University of Naples, Naples, Italy
| | - Georg Singer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Paolo Gasparella
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Christoph Arneitz
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
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Minimal esophagus dissection without approximating the hiatus in laparoscopic fundoplication in pediatric population. North Clin Istanb 2021; 8:222-225. [PMID: 34222801 PMCID: PMC8240242 DOI: 10.14744/nci.2020.10693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 10/07/2020] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE: An important part of laparoscopic Nissen’s fundoplication (LNF) is a proper wrap, which may only be possible with proper dissection of esophagus and hiatus. However, too much dissection of esophagus and hiatus to gain sufficient length of esophagus increases morbidity. The aim of this study is to analyze the effect of minimal esophagus dissection in LNF on recurrence and post-operative hiatal hernia. METHODS: The present study includes the children (0–18 years) who underwent LNF with minimal esophagus dissection and without hiatal closure between 2008 and 2016. The charts of the patients analyzed retrospectively and evaluated in terms of recurrence and post-operative hiatal hernia. RESULTS: There were 143 children. Mean age was 4.5±4.6 year (20 days–17 years). About 54% of the children (n=78) were neurologically impaired. There were two temporary intestinal obstructions which did not require surgery, one esophageal tightness which resolved with one dilatation session and one recurrence with hiatal hernia which required reoperation. CONCLUSION: Minimal esophagus dissection without hiatal closure in LNF avoids dysphagia with no increase in the rate of recurrence and complications.
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Enteral access and fundoplication in children with congenital heart disease. Semin Pediatr Surg 2021; 30:151040. [PMID: 33992312 DOI: 10.1016/j.sempedsurg.2021.151040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Congenital heart disease (CHD) is the most frequently occurring congenital disorder and affects approximately 1% of live births.1,2 Advancements in supportive technology and surgical techniques have allowed many of these children to live into adulthood with reductions in morbidity and mortality.3,4 During infancy, many children with CHD are plagued with co-existing structural anomalies and/or feeding disorders that make adequate oral intake impossible.5 Pediatric surgeons are frequently consulted for enteral access and/or fundoplication to ensure proper growth and development while preventing potential hemodynamic instability caused by significant reflux events. The successful execution of a non-cardiac surgery in a child with significant cardiac risk factors requires the coordination and expertise of multiple providers with a deep understanding of pediatric CHD physiology to ensure a safe outcome. We review critical pre-operative workup, technical operative aspects, and anesthesia considerations in this unique patient population.
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Zain M, Shehata S, Khairi A, Ashour K, Khalil AF, El-Sawaf M, Abouheba M. Role of Wrap-Crural Fixation and Minimal Dissection in Prevention of Transmigration After Laparoscopic Nissen Fundoplication in Children. J Laparoendosc Adv Surg Tech A 2021; 31:484-488. [PMID: 33493406 DOI: 10.1089/lap.2020.0952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Laparoscopic Nissen fundoplication is the gold standard antireflux procedure in pediatric age group. Intrathoracic migration of the fundic wrap is a common cause failure, leading to recurrence of gastroesophageal reflux disease (GERD) symptoms. Objectives: To investigate the impact of wrap-crural fixation and minimal esophageal dissection in prevention of wrap transmigration after laparoscopic Nissen fundoplication in children. Methods: Prospective randomized study of 46 pediatric patients with refractory GERD who underwent laparoscopic Nissen fundoplication divided into two equal groups. In Group A, wrap crural fixation was done, whereas in group B no fixation was done. Minimal esophageal dissection with preservation of the phrenoesophageal ligament was done in both groups. Approval of the Ethics Committee of our Faculty was obtained. Results: There was no difference between both groups regarding operative time, intraoperative complications, or length of hospital stay. Two patients in group B without wrap fixation suffered recurrence of GERD symptoms. On contrast study, they both showed intrathoracic wrap migration. One of them was reoperated. Whereas in group A, no recurrence of symptoms and no wrap transmigration were noticed in follow-up. Conclusion: In laparoscopic Nissen fundoplication, with minimal esophageal dissection and preservation of the phrenoesophageal ligament, there is no additional benefit from wrap-crural fixation in prevention of wrap transmigration.
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Affiliation(s)
- Mostafa Zain
- Department of Pediatric Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Sameh Shehata
- Department of Pediatric Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ahmed Khairi
- Department of Pediatric Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Khaled Ashour
- Department of Pediatric Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ahmed F Khalil
- Department of Pediatrics, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Mohamed El-Sawaf
- Department of Pediatric Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed Abouheba
- Department of Pediatric Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Svetanoff WJ, Dekonenko C, Briggs KB, Fraser J, Oyetunji TA, St. Peter SD. Are Posterior Crural Stitches Necessary in Pediatric Laparoscopic Fundoplication? J Laparoendosc Adv Surg Tech A 2020; 30:1272-1276. [DOI: 10.1089/lap.2020.0646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Charlene Dekonenko
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
- Department of General Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kayla B. Briggs
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - James Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Tolulope A. Oyetunji
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
- Univeristy of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Shawn D. St. Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
- Univeristy of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Holcomb GW, St Peter SD. Error traps and safety steps when performing a laparoscopic Nissen fundoplication. Semin Pediatr Surg 2019; 28:160-163. [PMID: 31171151 DOI: 10.1053/j.sempedsurg.2019.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Quality and safety have come to the forefront of the current healthcare environment over the past 10 years. Although all surgeons feel they perform safe operations with quality outcomes, these variables are being increasingly measured in today's healthcare world. The purpose of this article is to describe our thoughts about the error traps and safety steps when performing a laparoscopic Nissen fundoplication. Hopefully, adherence to these technical points will help prevent the need for a second operative procedure due to transmigration of the fundoplication wrap or the need for esophageal dilation postoperatively.
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Affiliation(s)
- George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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St Peter SD, Poola A, Adibe O, Juang D, Fraser JD, Aguayo P, Holcomb GW. Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial. J Pediatr Surg 2017; 53:S0022-3468(17)30630-9. [PMID: 29103785 DOI: 10.1016/j.jpedsurg.2017.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/05/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures. METHODS Children less than age 7 undergoing laparoscopic fundoplication were randomized to receive four EC sutures or none. Exclusion criteria included an existing hiatal hernia. The primary outcome was transmigration of the fundoplication wrap through the esophageal hiatus into the mediastinum. A contrast study was performed around 1year postoperatively. Telephone follow-up was performed at a minimum of 1.5years. RESULTS 120 patients were enrolled from 2/2010 to 2/2014, and 13 did not survive. One patient was excluded because a hiatal hernia was found at laparoscopy, leaving 52 patients with EC sutures (S) and 54 without EC sutures (NS). Operative time was 20min longer in the S group (P<0.01). Contrast studies were obtained in 62% of S and 68% of NS patients, and there were no wrap herniations in either group. There was one reoperation for wrap loosening in the NS group, none in the S group. Final telephone and clinic follow up was at a median of 4years (IQR 3-4.7). Reflux symptoms and medications were not different at one month, one year, and final follow-up. CONCLUSION When minimal phrenoesophageal dissection is performed, EC sutures offer no advantages and increase operating time. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Shawn D St Peter
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO.
| | - Ashwini Poola
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO
| | - Obinna Adibe
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO
| | - David Juang
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO
| | - Jason D Fraser
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO
| | - Pablo Aguayo
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO
| | - G W Holcomb
- Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO
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Abstract
Despite the frequency with which antireflux procedures are performed, decisions about gastroesophageal reflux disease treatment remain challenging. Several factors contribute to the difficulties in managing gastroesophageal reflux. First, the distinction between physiologic and pathologic gastroesophageal reflux (gastroesophageal reflux disease-GERD) is not always clear. Second, measures of the extent of gastroesophageal reflux often poorly correlate to symptoms or other complications attributed to reflux in infants and children. A third challenge is that the outcome of antireflux procedures, predominately fundoplications, are relatively poorly characterized. All of these factors contribute to difficulty in knowing when to recommend antireflux surgery. One of the manifestations of the uncertainties surrounding GERD is the high degree of variability in the utilization of pediatric antireflux procedures throughout the United States. Pediatric surgeons are frequently consulted for GERD and fundoplication, uncertainties notwithstanding. Although retrospective series and anecdotal observations support fundoplication in some patients, there are many important questions for which sufficient high-quality data to provide a clear answer is lacking. In spite of this, surgeons need to provide guidance to patients and families while awaiting the development of improved evidence to aid in these recommendations. The purpose of this article is to define what is known and what is uncertain, with an emphasis on the most recent evidence.
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Affiliation(s)
- Douglas C Barnhart
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Suite 3800, 100 N Mario Capecchi Dr, Salt Lake City, UT.
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Abstract
PURPOSE OF REVIEW Surgical therapy for gastroesophageal reflux disease (GERD) is controversial with considerable debate ranging from the indications for antireflux surgery to surgical technique. This article will attempt to clarify these issues with the most up-to-date information available on the prevalence, pathophysiology, diagnosis, and surgical treatment of GERD in children. Although laparoscopic Nissen fundoplication (LNF) has become the most popular operation performed for pathologic reflux, its superiority over both open surgery and other types of fundoplication is not well established. RECENT FINDINGS Large retrospective studies suggest LNF has a lower complication rate than open surgery. However, three prospective randomized controlled trials have been published recently which cast doubt on the superiority of LNF and suggest that LNF may have a higher failure rate compared to open fundoplication. Antireflux surgery has higher morbidity and failure rates in infants and in children with neurologic impairment. SUMMARY Based on the best available evidence, LNF may be less morbid, but have a higher rate of failure than open surgery. Pediatric surgeons should be mindful of the risks and benefits of both approaches to best counsel their patients. Larger prospective randomized controlled trials are needed to determine the best treatments for pediatric GERD.
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Hassan ME. Unilateral versus bilateral wrap crural fixation in laparoscopic Nissen fundoplication for children. JSLS 2016; 18:JSLS-D-14-001294. [PMID: 25516705 PMCID: PMC4266228 DOI: 10.4293/jsls.2014.001294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Gastroesophageal reflux (GERD) is common in neurologically impaired (NI) children. Fundoplication and gastrostomy have previously been indicated in NI children with GERD who have not responded to medical treatment. The most common reason for fundoplication failure is intrathoracic migration of the wrap. Objective: The aim of the study is to measure the effect of wrap fixation on the final outcome of laparoscopic Nissen fundoplication in NI children. Patients and Methods: A retrospective file review was conducted for all NI children who underwent laparoscopic Nissen fundoplication in 2 tertiary pediatric surgery centers in the United Arab Emirates from February 15, 2006 to February 15, 2013. Redo fundoplication patients were excluded from the study. Patients were divided into 2 groups: group 1 in which the fundoplication wrap was fixed to the right crus only, and group 2 in which the wrap was fixed to the right and left crus simultaneously. Results: The study population included 68 patients; there were 47 male and 21 female children. Mean age at time of surgery was 8.2 years. Recurrent GERD at 1 year postoperatively was 26% versus 7% in group 1 and group 2, respectively, by upper contrast study. Redo surgery was required in 21% versus 3% in group 1 and group 2, respectively. Conclusions: Bilateral fixation of the wrap to diaphragmatic crura significantly reduced recurrent GERD, in laparoscopic Nissen fundoplication for neurologically impaired children, with no increased risk of morbidities. Future prospective studies should be conducted with larger patient populations and longer follow-up periods.
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12
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Desai AA, Alemayehu H, Dalton BG, Gonzalez KW, Biggerstaff B, Holcomb GW, St. Peter SD. Review of the Experience with Re-Operation After Laparoscopic Nissen Fundoplication. J Laparoendosc Adv Surg Tech A 2016; 26:140-3. [DOI: 10.1089/lap.2015.0273] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amita A. Desai
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Hanna Alemayehu
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Brian G. Dalton
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | | | | | - George W. Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
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14
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Desai AA, Alemayehu H, Holcomb GW, St Peter SD. Minimal vs. maximal esophageal dissection and mobilization during laparoscopic fundoplication: long-term follow-up from a prospective, randomized trial. J Pediatr Surg 2015; 50:111-4. [PMID: 25598105 DOI: 10.1016/j.jpedsurg.2014.10.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE We have previously conducted a prospective randomized trial (PRT) comparing circumferential phrenoesophageal dissection and esophageal mobilization (MAX) to minimal dissection/mobilization (MIN). The MIN group had a decreased incidence of postoperative wrap herniation and need for reoperation. This study provides long-term follow-up of the patients from our center who participated in the PRT. METHODS Parents of patients in the PRT were queried regarding symptoms, medication use, postoperative complications, and additional procedures. Medical records were reviewed. Student's t-test was used for continuous variables. Fisher's exact and chi-square with Yates correction were used where appropriate. RESULTS Of patients from our center, 75.4% MAX and 72.5% MIN patients were contacted. Median time to follow-up was 6.5 years. A rise in the incidence of herniation was noted in both groups (22.7% to 36.5% MAX vs 2.8% to 12.2% MIN). Time to diagnosis of hernia was significantly longer in the MIN group (14.7±9.5 months MAX vs 30.2±23.6 months MIN, P=0.04). There was no significant difference between MIN and MAX group in reflux symptoms or medication use. CONCLUSION Long-term follow-up demonstrates an increase in incidence of herniation in both groups. Previously demonstrated higher risk of wrap herniation with maximal esophageal dissection during laparoscopic fundoplication remains supporting original findings.
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Affiliation(s)
- Amita A Desai
- The Children's Mercy Hospital, Kansas City, MO, United States
| | - Hanna Alemayehu
- The Children's Mercy Hospital, Kansas City, MO, United States
| | - G W Holcomb
- The Children's Mercy Hospital, Kansas City, MO, United States
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Fever after redo Nissen fundoplication with hiatal hernia repair. J Surg Res 2014; 190:594-7. [PMID: 24948540 DOI: 10.1016/j.jss.2014.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 02/18/2014] [Accepted: 05/07/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Fevers often arise after redo fundoplication with hiatal hernia repair. We reviewed our experience to evaluate the yield of a fever work-up in this population. METHODS We performed a retrospective review of children undergoing redo Nissen fundoplication with hiatal hernia repair between December 2001 and September 2012. Temperatures and fever evaluations of those children receiving a mesh repair were compared with those without mesh. A fever defined as temperature ≥38.4°C. RESULTS Fifty one children received 46 laparoscopic, 4 open, and 1 laparoscopic converted to open procedures. Biosynthetic mesh was used in 25 children whereas 26 underwent repair without mesh. A fever occurred in 56% of those repaired with mesh compared with 23.1% without mesh (P = 0.02). A fever evaluation was conducted in 32% of those with mesh compared with 11.5% without mesh (P = 0.52). A urinary tract infection was identified in one child after mesh use and an infection was identified in two children without mesh, one pneumonia and one wound infection (P = 1). In those repaired with mesh, there was no significant difference in maximum temperature. CONCLUSIONS Fever is common after redo Nissen fundoplication with hiatal hernia repair and occurs more frequently, and with higher temperatures in those with mesh. Fever work-up in these patients is unlikely to yield an infectious source and is attributed to the extensive dissection during the redo procedure.
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A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children. J Pediatr Surg 2013; 48:1306-11. [PMID: 23845623 DOI: 10.1016/j.jpedsurg.2013.03.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/08/2013] [Indexed: 11/23/2022]
Abstract
AIM The objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children. METHODS After Institutional Review Board approval (5100277), data for children under 18 years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo. Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence. RESULTS There were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years). Factors associated with redo were: younger age at first fundoplication, (p=0.002), hiatal dissection (p<0.001), and male gender (p=0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45-29.11), retching, OR: 3.59 (95% CI: 1.56-8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97-0.98). CONCLUSION The incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.
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Hill SJ, Wulkan ML. Cardiaplication as a Novel Antireflux Procedure for Infants: A Proof of Concept in an Infant Porcine Model. J Laparoendosc Adv Surg Tech A 2013; 23:74-7. [DOI: 10.1089/lap.2012.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sarah J. Hill
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Mark L. Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Maheshkumar GS, Jani K, Madhankumar MV, Palanivelu C. Laparoscopic redo fundoplication for intrathoracic migration of wrap. J Minim Access Surg 2011; 3:111-3. [PMID: 19789668 PMCID: PMC2749186 DOI: 10.4103/0972-9941.37195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 03/16/2007] [Indexed: 11/04/2022] Open
Abstract
Laparoscopic fundoplication is fast emerging as the treatment of choice of gastro-esophageal reflux disease. However, a complication peculiar to laparoscopic surgery for this disease is the intrathoracic migration of the wrap. This article describes a case of a male patient who developed this particular complication after laparoscopic total fundoplication. Following a trauma, wrap migration occurred. The typical history and symptomatology is described. The classical Barium swallow picture is enclosed. Laparoscopic redo fundoplication was carried out. The difficulties encountered are described. Postoperative wrap migration can be suspected clinically by the presence of a precipitating event and typical symptomatology. Confirmation is by a Barium swallow. Treatment is by redo surgery.
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Affiliation(s)
- G S Maheshkumar
- Department of Minimal Access Surgery, GEM Hospital, 45A, Pankaja Mill Road, Coimbatore - 641 045, India
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19
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St. Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW, Bartle D, Morgan T, Harmon CM, Georgeson KE, Holcomb GW. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg 2011; 46:163-8. [PMID: 21238659 PMCID: PMC3097032 DOI: 10.1016/j.jpedsurg.2010.09.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial. METHODS After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation. RESULTS One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006) CONCLUSIONS Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.
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Affiliation(s)
- Shawn D. St. Peter
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA,Corresponding author. Department of Surgery, Center for Prospective Clinical Trials, Children’s Mercy Hospital, Kansas City, MO 64108, USA. Tel.: +1 816 983 3575; fax: +1 816 983 6885. S.D. St. Peter
| | | | | | - KuoJen Tsao
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | | | - Susan W. Sharp
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Donna Bartle
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
| | - Tracey Morgan
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-69. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Margaron FC, Oiticica C, Lanning DA. Robotic-Assisted Laparoscopic Nissen Fundoplication with Gastrostomy Preservation in Neurologically Impaired Children. J Laparoendosc Adv Surg Tech A 2010; 20:489-92. [DOI: 10.1089/lap.2009.0367] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Franklin C. Margaron
- Division of Pediatric Surgery, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Claudio Oiticica
- Division of Pediatric Surgery, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - David A. Lanning
- Division of Pediatric Surgery, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Curtis JL, Wong G, Gutierrez I, Gollin G. Pledgeted mattress sutures reduce recurrent reflux after laparoscopic Nissen fundoplication. J Pediatr Surg 2010; 45:1159-64. [PMID: 20620312 DOI: 10.1016/j.jpedsurg.2010.02.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 02/22/2010] [Indexed: 01/08/2023]
Abstract
INTRODUCTION In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction. METHODS We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with chi(2), logistic regression, and Kaplan-Meier analysis. RESULTS A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures (P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods. CONCLUSIONS The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.
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Affiliation(s)
- Jennifer L Curtis
- Division of Pediatric Surgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
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Laparoscopic fundoplication for gastroesophageal reflux disease in infants and children. Surg Today 2010; 40:393-7. [PMID: 20425539 DOI: 10.1007/s00595-009-4149-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 04/30/2009] [Indexed: 10/19/2022]
Abstract
The number and types of minimally invasive surgical procedures being performed in children have increased exponentially in the last 15 years. Laparoscopic fundoplication is commonly performed for gastroesophageal reflux disease (GERD), although the population of patients who undergo this procedure is different in adults and children. In Japan, laparoscopic fundoplication has become a standard procedure, even for children with neurological impairment; however, its indications remain controversial. In this article we review the status of laparoscopic antireflux surgery for infants and children, looking at its indications, the procedures available, the complications, and the training required to perform the procedure safely and effectively.
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Ostlie DJ, Holcomb GW. Reiterative laparoscopic surgery for recurrent gastroesophageal reflux. Semin Pediatr Surg 2007; 16:252-8. [PMID: 17933667 DOI: 10.1053/j.sempedsurg.2007.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Laparoscopic Nissen fundoplication is successful in preventing reflux in more than 95% of patients. However, over time, there appears to be failure of the fundoplication either with wrap breakdown and/or transmigration of the wrap through the esophageal hiatus in 5% to 10% of patients. It is unlikely that medical management will be successful in controlling the reflux symptoms following either wrap breakdown and/or transmigration. Thus, operative repair for control of recurrent symptoms is required in most cases. This article outlines the etiology for recurrent gastroesophageal reflux disease, presentation of the patient with wrap failure or transmigration, steps which the authors have taken to help prevent these complications from developing, and our approach for those patients who require re-operation.
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Affiliation(s)
- Daniel J Ostlie
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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St Peter SD, Ostlie DJ, Holcomb GW. The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication. J Pediatr Surg 2007; 42:1298-301. [PMID: 17618902 DOI: 10.1016/j.jpedsurg.2007.03.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There are a number of reports in the literature describing the need for a redo fundoplication in patients who have previously undergone open fundoplication. However, these data are not well characterized in our current era of laparoscopic surgery. The purpose of this report is to document the management of patients requiring a redo fundoplication who originally underwent a laparoscopic Nissen fundoplication. METHODS After internal review board approval, the senior surgeon performed a retrospective chart review on all patients undergoing laparoscopic fundoplication between January 2000 and April 2006. Data collected included the patient's age, sex, neurologic impairment, need for gastrostomy, time interval between the initial and redo fundoplication, operative approach for the redo fundoplication, use of a biologic patch for the redo procedure, and length of follow-up. RESULTS Two hundred seventy-three patients underwent laparoscopic Nissen fundoplication by the senior author during this time interval. Twenty-one patients have required a redo fundoplication and repair of the enlarged hiatus after laparoscopic fundoplication. No patient has undergone a redo procedure without the development of transmigration of the fundoplication wrap. A redo operation was performed without mesh in 13 patients, of which there were 4 recurrences (31%). The other 8 cases were repaired with Surgisis (Cook, Inc, Bloomington, Ind), and none of these have recurred, with a minimum of 11 months' follow-up and a mean follow-up of 26 months. In the 4 patients requiring a second redo procedure, the enlarged esophageal hiatus was reinforced with Surgisis, and none of these cases have recurred, with a minimum of 3 years' follow-up. CONCLUSIONS Our data support the use of a biosynthetic mesh to reinforce the crural closure during the repair of iatrogenic hiatal hernias in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA
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