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How I Do It Laparoscopic Fundoplication George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO
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Laparoscopic Fundoplication
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The Use of Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003
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Cost Savings from Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003
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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 time93 minutes Transmigration wrap15 (12%) Postoperative dilation0 APSA 2006 Accepted, J Pediatr Surg
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Current Thoughts 1.Less mobilization of esophagus 2.Keep peritoneal barrier b/w esophagus & crura
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Current Thoughts 3.Secure esophagus to crura at 8, 11, 1 and 4 o’clock
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Personal Series - CMH April 2002 – December 2004 119 Pts Esophagus – Crural Sutures Minimal Esophageal Mobilization Mean age/weight 27 mo/11 kg Mean operative time102 minutes Transmigration wrap6 (5%) Postoperative dilation1 APSA 2006 Accepted, J Pediatr Surg
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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.
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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)10.2610.950.650 Mean Wt (kg)7.03 7.170.801 Gastrostomy47%46%0.893 Neuro Impaired71%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
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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)6.998.150.175 Mean Wt (kg)6.326.460.759 Gastrostomy46% 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
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Group II 119 Patients Esophago-Crural Sutures # PatientsTransmigration% 2 silk sutures20525% (9, 3 o’clock) 3 silk sutures4312.3% (9, 12, 3 o’clock) 4 silk sutures5600% (8, 11, 1, 4 o’clock)
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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
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Intraoperative Bougie Sizes PAPS 2002 JPS 37:1664-1666, 2002
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Re-Do Fundoplication Operative Technique 21/273 Pts No mesh (13) 4 recurrences Surgisis (8) 0 recurrences J Pediatr Surg 42: 1298-1301, 2007
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