Steven S Rothenberg MD FACS FAAPThe Rocky Mountain Hospital For ChildrenDenver, Colorado
¨All laparoscopic Fundoplications 1992-2012¨Ages 5 days- 18yrs¨Weight 1.2- 120kg ¨2018 completed fundoplications¨< 6 months: 616¨6 – 12 months: 137¨1-6 years: 425¨> 6 years: 543¨282 redos
¨Refractory Reflux: 1456¨Failure to Thrive: 588¨Neurologic impairment/G-tube dependant: 210¨Severe esophagitis/ Stricture: 156¨Severe Steroid dependant asthma: 250 Work-up¨UGI: 1989¨24-hour pH probe: 1420¨EGD: 744¨Gastric Emptying: 118
¨4-5 ports¨Division upper short gastric vessels¨Exposure right crus and anterior esophagus¨Identification and preservation anterior and posterior Vagus nerves¨Establish adequate intra-abdominal esophagus¨Crural stitch all cases, Pledgets for redo¨Floppy / Loose wrap (3 stitch) above GE jct¨G-tube/ button only if needed for feeding difficulties or primary aspiration¨Feeds started 2 hours post-op. No NG tube, antiemetic x 24 hours
Average operative time 1st 30 cases- 109 minutes Last 30 cases – 35 minutesComplication rate Intra-op 0.13% (2 esophageal perforations: 1 gastric) Post-op 4.0% prolonged gastroparesis -3 debilitating dysphagia -12 5 readmitted for > 24 hours, 8 dilated. 3 converted to partial wrap
Average days to D/C – 1.4 days (1.1 for Nissen only, 2.1 Nissen/ G tube)Wrap Failure rate: 4.6% (93 patients)All repaired laparoscopically: 6 secondary breakdowns: 5 underwent 2nd repair and are intact 4 to 16 yrs later. 1 open repairHighest rate in < 6months of age – 5.2%85% of Pts with GERD and severe RAD had improved pulmonary function after laparoscopic Nissen
Avg Age : 6.8 years 85 open 196 laparoscopic 36: more then 1 previous fundoplicationAvg Operative time : 82 minutesAvg Hospital stay: 1.6 daysComplication rate ¨ Intra-op – 2.2%¨ Post-op – 4.2% (2 delayed perforations: 1 incarcerated para-esophageal hernia)¨Average hospital stay: 1.4 days¨Secondary Failure rate : 6.2%¨8 Collis-Nissen (7 in pts with EA) Pain/ Heartburn (78%)Dysphagia (10%)Pulmonary complications/worsening RAD (14%) INDICATIONS
¨Herniation: 46%¨Slipped or improperly placed wrap: 34%¨Wrap grossly intact: 6% but symptoms improved after redo
¨Laparoscopic Nissen fundoplication in infants and children is a safe and effective technique; and should be considered the gold standard for the treatment of reflux in children¨Patients with severe GERD and steroid dependant asthma show significant airway symptom improvement with fundoplication with minimal morbidity ¨The overall recurrence rate is low (<5%) but is highest in the under 6 months of age group; but the morbidity of a redo operation in these patients is minimal
¨Hiatal Hernia continues to be the highest post-operative complication; but failed wraps formed at the level of the GE are increasing in frequency¨A congenitally short esophagus may be better treated by an esophageal lenthening procedure to avoid recurrence of hiatal hernia¨Initial pledgeted repair of the crural defect maybe indicated