A review of laparoscopic Nissen fundoplication in children weighing less than 5 kg

Association of Age at Duodenal Atresia Repair With Outcomes: A Pediatric NSQIP Analysis

PURPOSE

Neonates with duodenal atresia (DA) are often born prematurely and undergo repair soon after birth, while others are delayed to allow for growth until closer to term corrected gestational age (cGA). Premature infants have been demonstrated to experience worse outcomes, but it is unclear whether delaying surgery mitigates the increased morbidity. This study evaluates the association of timing of DA repair with postoperative morbidity.

METHODS

We retrospectively evaluated neonates undergoing DA repair from the National Surgical Quality Improvement Program-Pediatric database (2015-2020). A multivariable regression analyzed factors associated with composite morbidity, including cGA and age in days of life (DOL) at surgery. A propensity score matched analysis was completed in premature neonates born at ≤35 weeks gestation to compare outcomes at similar birth gestational ages (bGA) and birth weight who underwent early (<7 DOL) versus delayed (≥7 DOL) repair.

RESULTS

809 neonates were included with a median bGA of 36 weeks (IQR 34-38), birth weight of 2.46 kg (IQR 1.96-2.95), and DOL at surgery of 2 (IQR 1-5). Infants born ≤35 weeks represented 35.23% of the cohort. On multivariable analysis, increasing cGA at surgery was associated with decreased morbidity (OR: 0.91, CI [0.84, 0.99]), and increasing DOL at surgery was associated with increased morbidity (OR: 1.02, CI [1.00, 1.04]). On propensity score matched analysis, delayed repairs were associated with increased postoperative ventilation (6 days vs. 2 days, p < 0.05); however, there were no differences in composite or surgical morbidity between early and delayed repairs.

CONCLUSIONS

Morbidity after DA repair in neonates ≤35 weeks cGA is primarily driven by non-surgical causes, but delaying surgery does not appear to mitigate the risks associated with prematurity. It seems reasonable to consider repair in neonates around 33-34 weeks gestation without prohibitive risk factors. Optimal timing of DA repair requires a delicate balance between these factors.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective Cohort Study.

Fluorescence-Guided Surgery (FGS) during a Laparoscopic Redo Nissen Fundoplication: The First Case in Children

We present the first case of fluorescence-guided surgery (FGS) using indocyanine green (ICG) in a pediatric redo-Nissen fundoplication. The patient is a 17-year-old male with recurrent gastroesophageal symptoms who underwent primary antireflux surgery at 10 months of age. During the redo fundoplication, ICG was intravenously administered to help the visualization during the adhesiolysis between liver, stomach and right crus of the diaphragm and to spare small oesophageal vessels and the left gastric artery. In this case, FGS made the surgery easier than usual and likely reduced the risk of intra-operative complications. Therefore, we believe that this new technology should be regularly used in these types of complex intra-abdominal redo operations.

Outcomes of laparoscopic nissen fundoplications in children younger than 2-years: single institution experience

BACKGROUND

Variation exists in the diagnostic testing for gastroesophageal reflux (GER) in infants and in the application of surgical therapy. There has been an increase in antireflux surgery (ARS) since the development of laparoscopy but the outcomes in high-risk infants is unclear. This study examines the results of laparoscopic fundoplication in infants less than 2 years.

METHODS

The results of infants less than 2 years undergoing laparoscopic Nissen fundoplication (Lap-F) from 2012 to 2015 were retrospectively reviewed and outcomes were followed until 2017.

RESULTS

There were 106 patients, median gestational age 32.50 weeks ± 6.35 SD and non-corrected age at operation 23.0 weeks ± 19.0 SD, mean weight of 4.81 kg ± 2.10 SD. One of the most common reasons for surgical consultation was improvement in respiratory status after insertion of nasoduodenal feeding tube. Of the Lap-F, 100 were with gastrostomy tube (GT). There were no conversions to open or intraoperative complications. The complication rate was 4.71%, and the reoperation rate was 5.66%, one fundoplication revision and the others gastrostomy revisions. The median time for feeds and to reach goal were 1 (1-14) and 4 (2-279) days, respectively. The 30-day mortality was 0.9% and long-term it was 4.71%. The long-term mortality was related to the underlying medical problems. The median follow-up was 113 (3-286) weeks. One patient required revision of the fundoplication and none required esophageal dilatation during the follow-up period.

CONCLUSION

Fundoplication is effective for relief of symptoms of GER in children younger than 2 years. The procedure has a low morbidity and mortality in this population.

Safety of laparoscopic fundoplication in children under 5 kg: a comparative study

BACKGROUND

Laparoscopic fundoplication in children under 5 kg is still debated. Our objective was to evaluate the safety and efficacy of laparoscopic fundoplication (LF) in children under 5 kg.

METHODS

We reviewed the cases of 96 children treated by laparoscopic fundoplication between 2005 and 2014. Thirty-five patients had a weight of 5 kg or less at the time of LF (Low Weight Group) and 61 patients had a weight between 5.1 and 10 kg (High Weight Group). The pre-operative, peri-operative, post-operative data regarding surgery and anesthesia were compared between groups.

RESULTS

Mean weight was 3.9 ± 0.8 kg in the LWG and 7.8 ± 1.5 kg in the HWG. Children in the LWG were more prone to pre-operative respiratory management (40% mechanical ventilation and 42.9% oxygen therapy). The operating times (82 ± 28 min for LWG and 85 ± 31 min for HWG) and respiratory parameters during the procedure (PCO₂) were comparable between groups. Post-operative complications were 1 gastric perforation with peritonitis and 1 small bowel obstruction in the LWG, 2 cases of gastric perforation with peritonitis in the HWG. Mean follow-up was 67 ± 44 months. Significant recurrence of GERD requiring a redo fundoplication was noted in 3 patients in the LWG and 1 patient in the HWG.

CONCLUSION

Laparoscopic fundoplication is a safe procedure in infants ≤ 5 kg without increase of post-operative complications, recurrence, or mean operative time.

Gastroesophageal reflux disease in children

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.

Laparoscopic Toupet Fundoplication using an Air Seal Intelligent Flow System and Anchor Port in a 1.8-kg infant: A Technical Report

INTRODUCTION

We report a case of a 1.8-kg infant who had laparoscopic Toupet fundoplication (LTF) using the AirSeal Intelligent Flow System and Anchor Port (AP).

MATERIALS AND SURGICAL TECHNIQUE

Our case had severe gastroesophageal reflux in association with genetic and cardiac anomalies. Despite the patient being continuously fed, persistent vomiting caused failure to thrive, and LTF was performed at 4 months of age when he weighed 1.8 kg. The AirSeal Intelligent Flow System is a novel laparoscopic CO2 insufflation system that improves the visual field by constantly evacuating smoke and providing a more stable pneumoperitoneum. The AP is a recently developed, stretchable, elastomeric, low-profile cannula. Three 5-mm AP were inserted: one subumbilically for the scope and one in both the right and left upper abdomen for the surgeon. A 5-mm AirSeal trocar was inserted in the left lower abdomen for the assistant. The gastrosplenic ligament was dissected free, and the intra-abdominal esophagus was prepared. A posterior hiatoplasty was performed, followed by the 270° fundoplication. During the fundoplication, the esophagus was fixed to the crus and then the right and left wraps were fixed to the esophagus. Pneumoperitoneum was maintained stably throughout the LTF procedure, with optimal operative field. Total operating time for LTF was 90 min. Body temperature dropped from 37.4°C to 35.7°C during pneumoperitoneum but resolved once pneumoperitoneum was ceased. Postoperative progress was uneventful, and an upper gastrointestinal study on postoperative day 2 showed no residual gastroesophageal reflux.

DISCUSSION

We believe the AirSeal Intelligent Flow System and AP contributed to the successful completion of LTF in a 1.8-kg infant.

Anti-gastroesophageal reflux surgery in infants with severe bronchopulmonary dysplasia

Gastroesophageal reflux may exacerbate lung disease in infants with bronchopulmonary dysplasia (BPD). Anti-reflux surgery may therefore reduce the severity of this disease in some infants. We report a retrospective series of 22 infants with severe BPD who underwent anti-reflux surgery. Our experience indicates that these procedures can be safely performed in this population and that early post-operative initiation of gastric feeds is well tolerated. Modest post-operative reductions in required oxygen and median respiratory rate were observed.

A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age

AIMS

The surgery of gastroesophageal reflux disease (GERD) is common in modern pediatric surgical practice. Any differences in perioperative and long-term clinical outcomes following laparoscopic (LN) or open Nissen (ON) fundoplication have not been comprehensively described in young children. This randomized, prospective study examines outcomes following LN versus ON in children<2 years of age.

METHODS

Four surgeons at a single institution enrolled patients under 2 years of age that required surgical management of GERD, who were then randomized to LN or ON between 2005 and 2012. A universal surgical dressing was employed for blinding. Analgesia and enteral feeding pathways were standardized. The primary outcome was postoperative length of stay. Perioperative outcomes and long-term follow up were collected as secondary outcomes and used to compare groups.

RESULTS

Of 39 enrolled patients, 21 were randomized to ON and 18 to LN. Length of postoperative hospital stay, time of advancement to full enteral feeds, and analgesic requirements were not significantly different between treatment cohorts. The LN group experienced longer median operating times (173 vs 91 min, P<0.001) and higher surgical charges ($4450 vs $2722, P=0.002). The incidence of post-discharge complications did not differ significantly between the groups at last follow-up (median 42 months).

CONCLUSIONS

This randomized trial comparing postoperative outcomes following LN vs ON did not detect statistically significant differences in short- or long-term clinical outcomes between these approaches. LN was associated with longer surgical time and higher operating room costs. The benefits, risks, and costs of laparoscopy should be carefully considered in clinical pediatric surgical practice.

Laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease in infants

INTRODUCTION

Data on laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease (GERD) in infants remain limited. We describe our experience with this operation in children and in particular, infants younger than 12 months old.

MATERIALS AND METHODS

Medical records of all paediatric patients who had laparoscopic fundoplication done for GERD from 1998 to 2013 were reviewed. Patients were divided into two groups based on age: group I: 0-12 months, and group II >12 months. Data on indications, patient's demographics, operative time, blood loss, conversions, complications, recurrences and duration of hospitalization were studied.

RESULTS

A total of 86 patients were reviewed (group I, n = 21; group II, n = 65). While the mean age and body weight for group I were 8 ± 2.99 months and 6 ± 1.96 kg, the values for group II were 98 ± 65 months and 18 ± 9.6 kg, respectively. All patients had concurrent laparoscopic gastrostomy for feeding difficulties. The mean operative time was shorter in group I (157 ± 55 vs 169 ± 52 min, p = 0.66). Both groups had minimal blood loss only. The surgical outcomes in both groups were comparable in terms of recurrence (0 vs 3 %, p = 0.105) and complications (9.5 vs 6 %, p = 0.275). The median follow-up duration for group I and group II was 23 and 40 months, respectively. Sixteen (76 %) patients in group I and 45 (67 %) patients in group II did not develop pneumonia post fundoplication.

CONCLUSION

Laparoscopic Nissen fundoplication can be safely performed in infants with outcomes comparable to older patients and a shorter operative duration. Low recurrence rate (up to 3 %) is shown by our long term follow-up data. We recommend laparoscopic Nissen fundoplication to be considered in managing infants with GERD.

Minimal invasive surgery in the newborn: current status and evidence

The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.

Laparoscopic antireflux surgery in infants with single ventricle physiology: a review

Laparoscopic fundoplication and gastrostomy tube placement have grown in popularity within the pediatric population for treatment of gastroesophageal reflux disease and failure to thrive, respectively. One population that has an increased need for gastric surgery in infancy is patients with congenital heart defects, especially those with "single ventricle physiology." The most common defect included in this population is hypoplastic left heart syndrome (HLHS). Because of the abnormal physiology present in this condition, there are concerns with regard to the use of laparoscopic procedures for gastric surgery in patients treated with a three-staged reconstruction. We review the staged reconstruction of infants with HLHS, address safety concerns of interstage noncardiac procedures on this patient population, and review the current literature regarding outcomes of laparoscopic gastric surgery on patients with single ventricle physiology.

Thirty-day outcome in children randomized to open and laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is considered by some to be superior to open Nissen fundoplication (ONF). To test this hypothesis, we compared early results after LNF and ONF in a randomized trial.

METHODS

All children accepted for antireflux surgery for gastroesophageal reflux disease were offered enrollment. Ethical approval and parental consent were obtained. Anesthesia, surgical methods, and postoperative treatment were standardized. Patient demographics, length of hospital stay (LOS), and complications occurring the first 30 postoperative days were registered.

RESULTS

Eighty-eight children were randomized to LNF (n = 44) or ONF (n = 44). The groups were comparable with regard to age, weight, and comorbidity. Duration of surgery was 150 ± 34 minutes for LNF and 89 ± 25 minutes for ONF (P < .001). Median LOS was 7.0 days (range, 3-57 days) and 7.5 days (range, 2-20 days) after LNF and ONF, respectively (P = .74). Postoperative complications occurred in 48 patients, 24 in both groups. Twenty-four patients (LNF: n = 12, ONF: n = 11) were readmitted to hospital because of complications occurring after discharge.

CONCLUSIONS

This study failed to show that LNF is superior to ONF when surgery duration, LOS, and complications occurring during the first postoperative month were compared. Apart from surgery duration, the results were surprisingly similar.

Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

Pediatric gastroesophageal reflux disease

This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.

Association of feeding modality with interstage mortality after single-ventricle palliation

OBJECTIVE

Interstage mortality has been reported in 10% to 25% of hospital survivors after single-ventricle palliation. The purpose of this study was to examine the impact of feeding modality at discharge after single-ventricle palliation on interstage mortality.

METHODS

We conducted a retrospective review of all neonates undergoing single-ventricle palliation from January 2003 to January 2010. A total of 334 patients (90%) survived to hospital discharge, comprising the study group. Preoperative, operative, and postoperative variables were examined, including feeding method at discharge. Multivariate Poisson regression models were constructed to estimate the relative risk of interstage mortality.

RESULTS

Of 334 patients, 56 (17%) underwent gastrostomy tube ± Nissen. There was a statistically significant increase in interstage mortality for patients who underwent gastrostomy tube ± Nissen compared with patients who did not (relative risk, 2.38; 95% confidence interval, 1.05-5.40; P = .04]). Of the 278 patients who were not fed via a gastrostomy tube ± Nissen, 190 (68%) were fed with nasogastric feedings and 88 (32%) were fed entirely by mouth. There was no difference in interstage mortality between these 2 groups (relative risk, 0.92; 95% confidence interval, 0.31-2.73; P = .89).

CONCLUSIONS

Neonates undergoing single-ventricle palliation who require gastrostomy tube ± Nissen are at an increased risk of interstage mortality. The need for gastrostomy tube ± Nissen in this population may be a marker for other unmeasured comorbidities that place them at an increased risk of interstage mortality. Discharge with nasogastric feeds does not increase the risk of interstage mortality.

Minimally invasive surgery in the neonate

The advent of minimally invasive surgical techniques in the neonate has been delayed due to the limited working space and the unique physiology of the newborn. In the last decade, with the introduction of new instruments and techniques, many of the initial problems have been solved making minimally invasive surgery feasible for a variety of indications in the neonate and a favored approach in specialized centers around the world. Although an increasing number of reports document the feasibility of this exciting technique, data demonstrating its benefit compared to conventional surgery is limited. This review focuses on recent developments in minimally invasive surgery in neonates and the evidence for its use.

Laparoscopic or laparoscopic-assisted pelvic surgery in small infants: our experience

OBJECTIVE

The objective of this study was to review our experience of laparoscopic (LA) or laparoscopic-assisted pelvic surgery (LAPS) in small infants.

MATERIALS AND METHODS

The medical records of 35 patients who underwent an LA or LAPS between January 2007 and June 2010 were studied and 21 patients who were younger than 1 year or whose weight was less than 10  kg were included. Indications, procedures, results, and complications were analyzed.

RESULTS

The indications of surgery and procedures done were impalpable undescended testes (7 cases--3 single-stage orchidopexy and 4 Fowler Stephen stage I ligation of testicular vessels), Hirschsprung's disease (HD; 5 cases--all laparoscopic-assisted transanal pull-through), anorectal malformation (ARM; 3 cases--all laparoscopic-assisted pull-through), disorders of sexual differentiation (3 cases--1 herniotomy and 2 gonadal biopsy), sacrococcygeal teratoma (1 case--laparoscopic mobilization of pelvic component and posterior sagittal excision), and ovarian mass (2 cases; laparoscopic oophorectomy). There were 14 males, 4 females, and 3 of indeterminate sex. All procedures could be successfully completed without conversion. There was no anesthesia-related complication or need for postoperative ventilatory support. There were no immediate procedure-related complications. One female child with ARM had rectal mucosal prolapse; 1 HD case had rectovaginal fistula that healed following fecal diversion. The major advantages of laparoscopy in different indications were magnified access into the depth of pelvis and early frozen section biopsies in HD, accurate placement of neoanus in the center of muscle complex in ARM, early ligation of vessels and avoidance of laparotomy in sacrococcygeal teratoma, ease of decision making and better mobilization of vessels in undescended testes, and diagnostic accuracy and therapeutic procedure in ambiguous genitalia.

CONCLUSION

Laparoscopic pelvic surgery in small infants is a safe procedure with advantage of magnification, access, and cosmesis.