Laparoscopic fundoplication and gastrostomy

To Wrap or Not? Utility of Anti-reflux Procedure in Infants Needing Gastrostomy Tubes

PURPOSE

Gastrostomy tube (GT) insertion is commonly performed in children with failure to thrive. Pediatric patients' frequently have gastroesophageal reflux (GER) and discerning pathological GER can be challenging. Moreover, there is some evidence that GT insertion may lead to worsening GER and to avoid a subsequent anti-reflux procedure (ARP), though controversial some surgeons advocate considering an ARP concomitantly. The purpose of this report is to assess outcomes in infants who underwent a GT vs. GT with ARP.

METHODS

Retrospective review of all infants who had a GT placed at a single institution from 2009-2014. The patients were then divided into two cohorts based on the index operation i.e., GT vs GT with ARP and outcomes compared.

RESULTS

226 operations (104 GT, 122 GT with ARP) were performed. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion of neurologically impaired patients. Preoperative GER was significantly higher in the GT with ARP cohort (91 vs. 18%). No difference in the rate of immediate complications was noted between the two groups. Postoperative increase in anti-reflux medications was significantly higher in the GT cohort (p = 0.01). Post-op GER needing a secondary procedure (ARP or GJ tube) was noted in 21/104 (20%) patients. Those needing an additional procedure vs. those with GT alone were similar in the proportion of patients with pre-op GER, neurologic impairment, type of feeds, and age.

CONCLUSION

Identifying patients who would benefit from a concomitant ARP remains challenging. A fifth of GT patients needed a subsequent procedure despite most high-risk patients having already undergone an ARP. Since the overall rate of complications remained similar, initial GT approach can be considered reasonable.

Hiatal and paraesophageal hernia repair in pediatric patients

Hiatal and paraesophageal hernia (HH/PEH) can be congenital, resulting from embryologic abnormalities/genetic predisposition, or acquired, most commonly after gastroesophageal surgery such as fundoplication. Minimizing circumferential esophageal dissection at the time of Nissen fundoplication has been shown to decrease the risk of acquired HH/PEH from 36.5% to 12.2%. Gastrointestinal, respiratory, and constitutional symptoms, including anemia and failure to thrive, are common with high rates of associated gastroesophageal reflux. Chest x-ray is often abnormal and upper GI confirms the diagnosis. Treatment is surgical with the goal of reducing the hernia contents, excising the hernia sac, closing the crura, and performing an antireflux procedure. The laparoscopic approach is safe and effective.

Fever after redo Nissen fundoplication with hiatal hernia repair

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.

Fundoplication versus postoperative medication for gastro-oesophageal reflux in children with neurological impairment undergoing gastrostomy

BACKGROUND

Children with neurological impairments frequently experience feeding difficulties, which can lead to malnutrition and growth failure. Gastrostomy feeding is now the preferred method of providing nutritional support to children with neurological impairments who are unable to feed adequately by mouth. Complications may arise as a result of gastrostomy placement, and the development or worsening of gastro-oesophageal reflux (GOR) has been widely reported. This has led to the frequent use of surgical antireflux treatment in the form of a fundoplication, or other antireflux procedures. Fundoplication is associated with a high recurrence rate, surgical failure, and significant morbidity and mortality.Since proton pump inhibitors (PPIs) were introduced in the 1990s, they have come to play a larger part in the medical management of GOR in children with neurological impairments. Uncontrolled studies suggest that PPIs may be a safe, appropriate treatment for GOR. Other agents currently used include milk thickeners, acid suppression drugs, acid buffering agents, gut motility stimulants and sodium alginate preparations.There are risks and benefits associated with both surgical and medical interventions and further comparison is necessary to determine the optimal treatment choice.

OBJECTIVES

To compare the effectiveness of antireflux surgery and antireflux medications for children with neurological impairments and GOR who are undergoing placement of a gastrostomy feeding tube.

SEARCH METHODS

We searched the following databases on 23 March 2012: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, EMBASE, CINAHL, LILACS and ISI Web of Science. Previously, we searched the Child Health Library in June 2009. We also performed online searches of trial registries, medical journals, conference proceedings, dissertations and theses. We contacted specialists in the medical and industry setting for knowledge of completed or ongoing trials.

SELECTION CRITERIA

We sought to include randomised controlled trials that recruited children up to the age of 18 years with neurological impairments and GOR who were undergoing gastrostomy tube insertion.

DATA COLLECTION AND ANALYSIS

The review authors worked independently to select trials; none were identified.

MAIN RESULTS

We identified no trials that satisfied the criteria for this review.

AUTHORS' CONCLUSIONS

There remains considerable uncertainty regarding the optimal treatment when faced with the decision of fundoplication surgery versus antireflux medications for children with GOR and neurological impairment who are undergoing gastrostomy insertion. There is a need for robust scientific evidence in order to provide data on the comparable risks or benefits of the two interventions.

Nissen fundoplication in children with cerebral palsy: influence on rate of gastric emptying and postprandial symptoms in relation to protein source in caloric liquid meals

BACKGROUND & AIMS

The aim was to study the influence of Nissen fundoplication on rate of gastric emptying and postprandial symptoms in relation to protein source in liquid meals in children with cerebral palsy.

METHODS

Ten children with cerebral palsy and Nissen fundoplication and ten with cerebral palsy without Nissen fundoplication were studied. Patients had gastrostomy and received two meals, double-blinded, in random order, on separate days. Meals contained a standardised carbohydrate and fat base plus one of two protein modules (Meal A: 100% casein; Meal B: 40% casein/60% whey). The (13)C octanoic acid breath test was used to assess gastric emptying. Postprandial symptoms were recorded. Results are given as median.

RESULTS

For meal A and B, respectively, time until 50% of the meal had emptied (T1/2) was 110 in the Nissen fundoplication- and 181 min in the non-Nissen fundoplication group, (p = 0.35) and 50 and 85 min (p = 0.25). Seven in the Nissen fundoplication group reported postprandial symptoms to meal B, none in the non-Nissen fundoplication group (p < 0.01).

CONCLUSIONS

Compared with cerebral palsy-children without Nissen fundoplication, those with Nissen fundoplication have postprandial symptoms more frequently after receiving a rapid emptying meal. Gastric emptying alone, however, does not seem to explain the symptom occurrence. ClinicalTrials.gov: UUSKBK 28200706.

Does the placement of a FRECA gastrostomy at the time of laparoscopic fundoplication impact on outcome?

AIM

To assess the performance of a paediatric cohort having a FRECA PEG (FP) placed at the time of laparoscopic fundoplication.

METHODS

This is retrospective study of a single surgeon's experience of laparoscopic fundoplications over a decade. Patient details were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed.

RESULTS

Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery. Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg (12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication. Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days. Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old a year later from problems unrelated to surgery. FPs were changed to a button device under general anaesthetic 3-24 months following placement.

CONCLUSION

FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years of initial placement requires general anaesthetic.

Reiterative laparoscopic surgery for recurrent gastroesophageal reflux

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.

The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication

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.

Fundoplication versus post-operative medication for gastro-oesophageal reflux in children with neurological impairment undergoing gastrostomy

BACKGROUND

Children with neurological impairments (NI) frequently experience feeding difficulties which can lead to malnutrition and growth failure. Gastrostomy feeding is now the preferred method of providing nutritional support to children with NI who are unable to feed adequately by mouth. Complications may arise as a result of gastrostomy placement and the development or worsening of gastro-oesophageal reflux (GOR) has been widely reported. This has led to the frequent use of surgical anti-reflux treatment in the form of a fundoplication, or other Anti-Reflux Procedures. Fundoplication is associated with a high recurrence rate, surgical failure and significant morbidity and mortality. Since Proton Pump Inhibitors (PPIs) were introduced in the 1990s they have come to play a larger part in the medical management of GOR in children with NI. Uncontrolled studies suggest that PPIs may be a safe, appropriate treatment for GOR. Other agents currently used include milk thickeners, acid suppression drugs, acid buffering agents, gut motility stimulants and sodium alginate preparations. There are risks and benefits associated with both surgical and medical interventions and further comparison is necessary to determine the optimal treatment choice.

OBJECTIVES

To compare the effectiveness of anti-reflux surgery and anti-reflux medications for children with NI and GOR who are undergoing placement of a gastrostomy feeding tube.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) up to Issue 2, 2006, MEDLINE (1966 to June 2006), EMBASE (1980 to week 33, 2006), CINAHL (1982 -to May, week 4, 2006), LILACS (1982 to June 2006), ISI Web of Science (1970 to June 2006) and the Child Health Library (searched June 2006). We also performed online searches of trial registries, medical journals, conference proceedings, dissertations and theses. Specialists in the medical and industry setting were contacted for knowledge of completed or ongoing trials.

SELECTION CRITERIA

We sought to include only randomised controlled trials that recruited children up to the age of 18 years with NI and GOR who were undergoing gastrostomy tube insertion.

DATA COLLECTION AND ANALYSIS

Two reviewers worked independently on selected trials and performed data extraction and assessment of trial quality.

MAIN RESULTS

No trials were identified that satisfied the criteria for this review.

AUTHORS' CONCLUSIONS

There remains considerable uncertainty regarding the optimal treatment when faced with the decision of fundoplication surgery versus anti-reflux medications for gastro-oesophageal-reflux in the child with neurological impairment who is undergoing gastrostomy insertion. There is a need for robust scientific evidence in order to provide data on the comparable risks or benefits of the two interventions.

Use of esophagocrural sutures and minimal esophageal dissection reduces the incidence of postoperative transmigration of laparoscopic Nissen fundoplication wrap

OBJECTIVES

Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome.

METHODS

A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II).

RESULTS

Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29.

CONCLUSIONS

This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication.

Multimedia article. Laparoscopic fundoplication in an infant

BACKGROUND

Laparoscopic fundoplication in infants and children is rapidly becoming the procedure of choice for surgical correction of symptomatic gastroesophageal reflux because of the advantages of reduced discomfort and decreased hospitalization. In addition, there may be a hidden benefit of an earlier return to work by the parents.

METHODS

This video depicts the salient operative features for performing a laparoscopic fundoplication in an infant who presented with an acute life-threatening event, which was felt secondary to gastroesophageal reflux. In this operation, a 5 mm cannula was placed in the umbilicus through which insufflation was achieved and a 5 mm, 45 degrees angled telescope was inserted into the peritoneal cavity. The four instruments were placed directly through the abdominal wall using a stab incision technique rather than using cannulas. Moreover, the operation was performed using AESOP, the voice-activated telescopic holder, which provides a steady and consistent view.

RESULTS

The operative technique was straightforward in that the short gastric vessels were divided, the crura were closed, and the esophagus was secured to the crura to keep the esophagus in an intraabdominal position and to prevent transmigration of the fundoplication wrap in the postoperative period. The length of the fundoplication should be around 2.0 cm and was measured to ensure that the fundoplication approximates this length.

CONCLUSION

This patient made an eventful recovery and was discharged the following day. No complications have developed. [The full text of this article is a video computer file.]