1. The IPEG Annual Congress joins with:
II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS)
VII Congress of the Federation of Pediatric Surgical
Associations of the South Cone of America (CIPESUR)

2. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital
Current Thoughts About Laparoscopic Fundoplication in Infants and Children
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, Missouri

3. GERD Barriers to Mucosal Injury
LES
Esophageal IAL
Angle of His
Esophageal motility

4. 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

5. 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

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

7. Treatment Options
Medical
Surgical
Endoluminal

8. Preoperative Evaluation
24 hr pH study
Upper GI contrast study
Endoscopy
Endoscopy with biopsy
Gastric emptying study ?
Esophageal motility study ?

9. Preoperative Evaluation Gastric Emptying Study ?

10. 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

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

12. ISSUES/QUESTIONS

13. Laparoscopic Fundoplication
When is it not a good option?
Significant hx of cardiac disease
Significant hx of lung disease
BPD
Significant O2 still needed
Chronic NICU baby
Previous upper abdominal operations?

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

15. 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

16. Laparoscopic Fundoplication
2. Can a loose, floppy, complete (Nissen) fundoplication be performed without ligation of the short gastric vessels?

17. Laparoscopic FundoplicationNo

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

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

20. Laparoscopic Fundoplication
Can stab (3mm) incisions be used rather than cannulas for laparoscopic operations and is there a financial advantage?

21. Laparoscopic Fundoplication

22. The Use of Stab Incisions
PAPS 2003
J Pediatr Surg 38: , 2003

23. Cost Savings from Stab Incisions
PAPS 2003
J Pediatr Surg 38: , 2003

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

25. 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

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

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

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

29. Laparoscopic Fundoplication Current Technique

30. Personal Series - CMH Jan 2000 – March 2002
130 Pts
No Esophagus – Crural Sutures
Extensive Esophageal Mobilization
Mean age/weight 21 mo/10 kg
Mean operative time 93 minutes
Transmigration wrap 15 (12%)
Postoperative dilation 0
APSA 2006
J Pediatr Surg 42:25-30, 2007

31. Personal Series - CMH April 2002 – December 2004
119 Pts
Esophagus – Crural Sutures
Minimal Esophageal Mobilization
Mean age/weight 27 mo/11 kg
Mean operative time 102 minutes
Transmigration wrap 6 (5%)
Postoperative dilation 1
APSA 2006
J Pediatr Surg 42:25-30, 2007

32. 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.

33. 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

34. 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

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. Prospective, Randomized Trial
2 Institutions: CMH, CH-Alabama
Power Analysis: 360 Patients
Primary endpoint-transmigration rate
(12% vs.5%-retrospective data)
2 Groups: minimal vs. extensive
esophageal dissection
Both groups receive esophago-crural
sutures

37. Re-Do Fundoplication Jan 00 – March 02 15/130 Pts – 12%
April 02 – December 06
7/184 Pts – 3.8%

38. Accepted, J Pediatr Surg
Re-Do Fundoplication
22 Pts
All but one had transmigration of wrap
Mean age initial operation – 12.6 (±5.8) mos
11 had gastrostomy
Mean time b/w initial operation & 1st redo – 14.1 (±1.7) mos
F/U – Minimum -19 mos
Mean mos
Accepted, J Pediatr Surg

39. Re-Do Fundoplication Operative Technique 21/249Pts
Laparoscopic Re-Do – 10
No SIS – 9
Open Redo with SIS - (1)
SIS 1

40. Re-Do Fundoplication Operative Technique 21/249 Pts
Open Re-Do - 11
SIS
No SIS
2 required open re-do with SIS

41. Re-Do Laparoscopic Fundoplication

42. SIS and Paraesophageal Hernia Repair
Multicenter, prospective randomized trial
108 patients
Recurrence: 7% vs 25% (1o repair)
No mesh related complications
Oelschlager BK, et al
ASA Meeting, April 2006

43. 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:

44. Laparoscopic Nissen Fundoplication Summary
The use of stab incisions for instrument access results in significant financial savings to the patient and institution.
The incidence of transmigration of the fundoplication wrap has been markedly reduced with the use of esophageal-crural sutures and minimal esophageal mobilization.
The long-term functional results should be equivalent to the open operation. The major advantages lie in reduced discomfort and hospitalization, faster return to routine activities and cosmesis.

45. ? ? ?