Laparoscopic Paraesophageal Hiatal Hernia Repair and Fundoplication
Current Thoughts About Laparoscopic Fundoplication in Infants and Children George W. Holcomb, III,...
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Transcript of Current Thoughts About Laparoscopic Fundoplication in Infants and Children George W. Holcomb, III,...
Current Thoughts About Laparoscopic Fundoplication in
Infants and Children
George W. Holcomb, III, M.D., MBA
Surgeon-in-ChiefChildren’s Mercy Hospital
Kansas City, Missouri
Gastroesophageal Reflux
GER – presence of gastroesophageal reflux
GERD – symptomatic gastroesophageal reflux
• Wt loss/FTT
• ALTE
• Pulmonary Sxs., RAD
• Esophagitis: pain, stricture, Barrett’s
GERDBarriers to Mucosal Injury
• Lower esophageal sphincter (LES)
• Esophageal IAL
• Angle of His
• Esophageal motility
Preoperative Evaluation• 24 hr pH study – gold standard in many centers
Only measures acid reflux
• Impedance – acid & alkaline reflux
• Upper GI contrast study -reflux seen in only 30%
• Endoscopy - visualization only not sensitive
• Endoscopy with biopsy – probably most sensitive
• Gastric emptying study ? – not performed at initial operation
• Esophageal motility study - not needed in children?
Children’s Mercy Hospital(Jan 2000 – June 2007)
843 fundoplications( 3.6% op. vol.)
UGI – 656 pts
pH study – 379 pts
Sensitivity UGI – 30.8%AAP, 2009AAP, 2009
J Pediatr Surg 45:1169-1172, 2010J Pediatr Surg 45:1169-1172, 2010
Children’s Mercy HospitalUGI – 656 pts
Abnormality (other than GER) – 30 pts (4.5%)
Suspected malrotation – 26 pts (4.0%)
Confirmed (16 pts) No malrotation (6 pts) Prev. Ladd (4 pts)
AAP, 2009AAP, 2009
J Pediatr Surg 45:1169-1172, 2010J Pediatr Surg 45:1169-1172, 2010
Children’s Mercy Hospital
Preoperative UGI – 656 pts
Influences management - 4%
Malrotation is the most common finding
AAP, 2009AAP, 2009
J Pediatr Surg 45:1169-1172,J Pediatr Surg 45:1169-1172, 20102010
GERDFundoplication
Indications for operation (U.S.)
Failure of medical therapy
ALTE/weight loss in infants
Refractory pulmonary symptoms
Neurologically impaired child who needs gastrostomy
Options for Fundoplication
• Laparoscopic vs open
• Complete (Nissen) vs Partial (Thal,
Boix-Ochoa, Toupet)
1) Effects of Pneumoperitoneum
• SVR
• PVR
• SV
• CI
• Venous Return (Head up)
• pCO2
• FRC
• pH
• pO2
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
Laparoscopic Fundoplication
2) Is dysphagia a common problem
following laparoscopic Nissen
fundoplication in infants and
children?
Intraoperative Bougie Sizes
PAPS, 2002PAPS, 2002
J Pediatr Surg 37:1664-1666, 2002J Pediatr Surg 37:1664-1666, 2002
Laparoscopic Fundoplication
3) Can stab (3mm) incisions be used
rather than cannulas for
laparoscopic operations?
The Use of Stab Incisions2000-2002
Procedure (n) Used/case Saved/case Nissen (209) 1 4
Nissen (14) 2 3
Heller Myotomy (7) 2 3
Appendectomy (102) 2 1
Meckel’s Diverticulum (2) 2 1
Pyloromyotomy (77) 1 2
Cholecystectomy (31) 2 2
Pullthrough (20) 2 1
Splenectomy (21) 2 2
Adrenalectomy (6) 2 2
UDT (15) 1 2
Varicocele (5) 1 2
Ovarian (2) 1 2
Totals (511) 714 1337 PAPS, 2003PAPS, 2003
JPS 38:1837-1840, 2003JPS 38:1837-1840, 2003
Laparoscopic Fundoplication
4) Is there a financial advantage with the
laparoscopic approach when compared
to the open operation?
Clinical and Financial Analysis of Pediatric Laparoscopic versus Open Fundoplication
100 Patients
Favoring LF P Value Favoring OF P Value
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)
<0.01
<0.01
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)
0.01
0.04
<0.001
Total Charges Similar (LF - $11,449 OF - $11,632)
IPEG 2006IPEG 2006J Lap Endosc Surg Tech 17:493-496,2007J Lap Endosc Surg Tech 17:493-496,2007
Laparoscopic Fundoplication5) Should the esophagus be extensively mobilized?
Technique 2000 - 2002Please use this link if you experience problems viewing the video above.
Current ThoughtsTechnique 2003 - 2010
1. Less mobilization of esophagus
2. Keep peritoneal barrier b/w esophagus & crura
Laparoscopic FundoplicationCurrent Technique - 2010
Please use this link if you experience problems viewing the video above.
Personal Series - CMHJan 2000 – March 2002
Group I - 130 PtsNo 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 APSA, 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
Personal Series - CMHApril 2002 – December 2004
Group II - 119 PtsEsophagus – 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 APSA, 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
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.
Summary
Group II119 Patients
Esophago-Crural Sutures
# Patients Transmigration %
2 silk sutures 20 5 25%(9, 3 o’clock)
3 silk sutures 43 1 2.3%(9, 12, 3 o’clock)
4 silk sutures 56 0 0%(8, 11, 1, 4 o’clock)
Patients Less Than 60 MonthsGroup 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
APSA, 2006 APSA, 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
Patients Less Than 24 MonthsGroup I
Jan 00-March 02
104 Pts
Group IIApril 02-Dec 04
93 PtsP Value
Mean Age (mos) 6.99 8.15 0.175
Mean Wt (kg) 6.32 6.46 0.759
Gastrostomy 46% 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
APSA, 2006 APSA, 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
Prospective, Randomized Trial• 2 Institutions: CMH, CH-Alabama
• Power analysis using retrospective data (12% vs 5%) : 360 patients
• Primary endpoint -- transmigration rate
• 2 groups: minimal vs. extensive esophageal dissection
• Both groups received esophago-crural sutures
• Stratified for neurological status
• UGI contrast study one year post-op
• APSA, 2010
Minimal vs Extensive Esophageal Mobilization During Laparoscopic
Fundoplication
Extensive Esophageal Mobilization (N=87)
Minimal Esophageal Mobilization (N=90)
P-Value
Age (yrs) 1.9 +/- 3.3 2.5 +/- 3.5 0.30
Weight (kg) 10.7 +- 11.9 12.6 +/- 18.2 0.44
Neurologically Impaired (%)
51.7 54.4 0.76
Operating Time (Minutes)
100 +/- 34 95 +/- 37 0.37
APSA, 2010APSA, 2010J Pediatr Surg 43:163-169, J Pediatr Surg 43:163-169,
20112011
Preoperative Demographics177 Patients
Minimal vs Extensive Esophageal Mobilization During Laparoscopic
Fundoplication
Extensive Esophageal Mobilization (N=87)
Minimal Esophageal Mobilization (N=90)
P-Value
Postoperative Wrap Transmigration (%) 30.0% 7.8% 0.002
Need for Re-do Fundoplication (%) 18.4% 3.3% 0.006
APSA, 2010APSA, 2010J Pediatr Surg 43:163-169, 2011J Pediatr Surg 43:163-169, 2011
Results177 Patients
Current Study
• Analysis (80% power,α- 0.05) – 110 patients
• Minimal esophageal dissection in all patients
• 4 esophago-crural sutures vs. no sutures
No Esophago-crural Sutures
Please use this link if you experience problems viewing the video above.
Study # Pts % Re-op Herniation Wrap Dehiscence
Other
Wheatley (Michigan) 1974-1989
242 12%
(29)
3 14 3
Caniano (Ohio State) 1976 - 1988
358 6%
(21)
16 2 3
Dedinsky (Indiana) 1975-1985
429 6.7%
(29)
29
Fonkalsrud (UCLA)
1976-1996
7467 7.1%
Operative ResultsOpen Operations
Re-Do Fundoplication (Personal Series)
• Jan 00 – March 02
15/130 Pts – 12%
• April 02 – December 06
7/184 Pts – 3.8%
J Pediatr Surg 42:1298-1301, 2007J Pediatr Surg 42:1298-1301, 2007
Re-Do Fundoplication (Personal Series)
22 Pts (2000 – 2006)
• 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 - 34 mos
J Pediatr Surg 42:1298-1301, 2007J Pediatr Surg 42:1298-1301, 2007
SIS and Paraesophageal Hernia Repair
• Multicenter, prospective randomized trial
• 108 patients
• Recurrence: 7% vs 25% (1o repair)
• No mesh related complications
Oelschlager BK, et alOelschlager BK, et alAnn Surg 244:481-490, 2006 Ann Surg 244:481-490, 2006
ASA Meeting, 2006ASA Meeting, 2006
QUESTIONS
www.cmhmis.com
www.cmhclinicaltrials.com