The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children

Comparative study of laparoscopic Nissen fundoplication versus Hill-Snow procedure for the treatment of gastroesophageal reflux disease in children: a single-blinded randomized controlled trial

Background

Gastroesophageal reflux disease (GERD) is a common condition in children. Complete fundoplication provides better reflux control but it results in more dysphagia and gas-bloat symptoms. Antireflux surgery without wrap has fewer adverse effects but a higher failure rate in controlling reflux. Until now, there is little evidence as to whether complete or partial fundoplication is the optimal procedure in this age group.

Objective

This study aimed to compare the safety and efficacy of laparoscopic Nissen fundoplication versus Hill-Snow procedure among children with GERD.

Methods

We conducted a randomized, single-blinded, comparative trial that included 40 children with a diagnosis of GERD, who were scheduled to undergo surgery. Children were randomly allocated to undergo laparoscopic Nissen fundoplication or Hill-Snow procedure.

Results

While the incidence of postoperative dysphagia was similar between both groups, the duration of dysphagia was significantly shorter in the Hill-Snow group. Likewise, the incidence of bloating was significantly lower in the Hill-Snow group than the Nissen group (0% versus 55%, respectively). We found three recurrent Hill-Snow cases versus two recurrent Nissen cases. The operative time was significantly longer in the Hill-Snow procedure (150 ± 52 min) than in the Nissen group (120 ± 48 min).

Conclusions

The Hill-Snow procedure is an effective alternative to Nissen fundoplication with no bloating and much less dysphagia, leading to faster recovery of ordinary eating patterns.

Laparoscopic Revision of Nissen to Partial Fundoplication 20 Years After Initial Surgery as an Infant

We report a case of a 21-year-old male who presented with adult-onset dysphagia after previous Nissen fundoplication initially created at age 10.5 months. The patient first presented one year ago to a different hospital, where he underwent extensive workup for his symptomatology. Physiologic tests performed were esophagogastroduodenoscopy (EGD), abdominal ultrasound, hepatobiliary iminodiacetic acid scan, esophageal manometry, and lactulose breath test. The EGD identified stricture at the level of the gastroesophageal junction. The other studies did not reveal other physiologic causes for his symptoms. The patient then presented to our institution, at which time a repeat EGD showed evidence of tight Nissen fundoplication. The patient subsequently underwent laparoscopic exploration, which revealed that the fundoplication had was partially disrupted, herniated, and twisted causing a long-segment distal stricture. To alleviate the patient’s presenting symptom of dysphagia as well as prevent possible future reflux, it was decided to convert repair the hernia and revise the Nissen into a partial fundoplication. This was successfully accomplished laparoscopically with subsequent resolution of the patient’s symptoms.

Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review

BACKGROUND

Antireflux surgery is commonly performed in children, yet evidence for its efficacy is limited. The aim of this review was to determine the effect of antireflux surgery with regard to objective measures of quality of life (QoL) and value of upper gastrointestinal investigations in neurologically normal (NN) and neurologically impaired (NI) children.

METHODS

A systematic review was conducted of articles reporting children undergoing antireflux surgery in whom preoperative and postoperative objective testing was performed. Primarily, Embase, CINAHL, MEDLINE and PubMed were searched from inception to April 2019. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess article quality.

RESULTS

Of 789 articles, 14 met the eligibility criteria, 12 prospective observational and 2 retrospective studies. The median MINORS score was 59·4 (i.q.r. 39 to 62·5) per cent. Seven studies reported assessment of validated QoL measures before and after antireflux surgery in 148 children. Follow-up ranged from 1 to 180 months. All studies confirmed significant improvements in QoL measures among NN and NI children at all follow-up points. Eleven studies reported on preoperative and postoperative investigations in between 416 and 440 children children. Follow-up ranged from 0·5 to 180 months. Nine studies confirmed improvements in gastro-oesophageal reflux using 24-h oesophageal pH monitoring with or without manometry, but conflicting results were identified for four studies reporting gastric emptying. No studies reported fluoroscopy or endoscopy adequately.

CONCLUSION

Based on the results of studies of low-to-moderate quality, antireflux surgery improved QoL and reduced oesophageal acid exposure in NN and NI children in the short and medium term. Although antireflux surgery is a common elective operation, the lack of rigorous preoperative and postoperative evaluation(s) in the majority of patient-reported studies is striking.

Laparoscopic antireflux surgery increases health-related quality of life in children with GERD

INTRODUCTION

Improving health-related quality of life (HRQoL) is increasingly recognized as an essential part of patient care outcome. Little is known about the effect of laparoscopic antireflux surgery (LARS) on the HRQoL in the pediatric patients. The aims of this study were to evaluate the effect of LARS on HRQoL in children with gastroesophageal reflux disease (GERD) and to identify predictors that influence HRQoL outcome after LARS.

METHODS

Between 2011 and 2013, 25 patients with therapy-resistant GERD [median age 6 (2-18) years] were included prospectively. Caregivers and children with normal neurodevelopment (>4 years) were asked to fill out the validated PedsQL 4.0 Generic Core Scales before and 3-4 months after LARS.

RESULTS

The PedsQL was completed by all caregivers (n = 25) and 12 children. HRQoL total score improved significantly after LARS, both from a parental (p = 0.009) and child's perspective (p = 0.018). The psychosocial health summary and physical health summary scores also improved significantly after LARS. HRQoL before and after LARS was significantly lower in children with impaired neurodevelopment (p < 0.001). However, neurodevelopment did not influence the effect of LARS on HRQoL. The only significant predictor for improvement in HRQoL after LARS was age at the time of operation (p = 0.001).

CONCLUSIONS

HRQoL significantly improves after LARS. Although children with impaired neurodevelopment had lower overall HRQoL, neurodevelopment by itself does not predict inferior improvement in HRQoL after LARS. Older children have a more favorable HRQoL outcome after LARS compared to younger children. This may suggest caution when considering LARS in younger GERD patients.

Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study

INTRODUCTION

Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS.

METHODS

Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a ¹³C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS.

RESULTS

After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001).

CONCLUSIONS

In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.

Management of gastroesophageal reflux disease in pediatric patients: a literature review

Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.

Physiological analysis of the effects of rikkunshito on acid and non-acid gastroesophageal reflux using pH-multichannel intraluminal impedance monitoring

PURPOSE

To clarify the effects of rikkunshito on acid reflux, non-acid reflux, and esophageal clearance in patients with gastroesophageal reflux disease (GERD).

METHODS

We enrolled seven patients with vomiting and/or stridor (median 6 years; 1 month-17 years), with a percent total time of esophageal pH <4.0 (reflux index) over 4.0%. Rikkunshito (TJ-43; Tsumura Co, Tokyo, Japan) was given in three divided doses before meals. We retrospectively investigated its efficacy using pH-multichannel intraluminal impedance before and 7 (6-10) days after starting treatment. Statistical analyses were conducted using Wilcoxon signed-rank test.

RESULTS

In the pH analyses alone, the median number of acid reflux episodes >5 min (14 versus 10, p = 0.046) and median acid-clearance time (184 versus 134 s, p = 0.03) decreased significantly, although median decrease in reflux index did not reach significance (16.0 versus 17.9%, p = 0.06). In the combined impedance and pH analyses, the median number (36 versus 36, p = 0.03) and median duration (1.9 versus 1.1%, p = 0.046) of acid reflux decreased significantly; non-acid reflux and bolus clearance time did not change.

CONCLUSION

Rikkunshito effectively reduced acid reflux, but not esophageal clearance, in patients with GERD.

Outcomes of pediatric laparoscopic fundoplication: a critical review of the literature

BACKGROUND/OBJECTIVE

Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure.

METHODS

Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality.

RESULTS

A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%.

CONCLUSION

The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.

Surgical management of pediatric gastroesophageal reflux disease

Gastroesophageal reflux (GER) is common in the pediatric population. Most cases represent physiologic GER and as the lower esophageal sphincter (LES) matures and a solid diet is introduced, many of these patients (>65%) experience spontaneous resolution of symptoms by two years of age. Those who continue to have symptoms and develop complications such as failure to thrive, secondary respiratory disease, and others are classified as having gastroesophageal reflux disease (GERD). Goals of GERD treatment include the resolution of symptoms and prevention of complications. Treatment options to achieve these goals include dietary or behavioral modifications, pharmacologic intervention, and surgical therapy. This paper will review the clinical presentation of GERD and discuss options for surgical management and outcomes in these patients.

[Video-assisted surgery in children: current progress and future perspectives]

This review presents the evidence of video-assisted surgery in the pediatric population and discusses future progress in this field. Videosurgery minimizes the cosmetic impact and the pain induced by open procedures and has been in constant development in adults and children. Earlier training of surgeons and residents combined with advances in anesthetics and technology have expanded the use of videosurgery for more complex interventions. Although most feasible surgical procedures have been performed by laparoscopy, the literature has not yet defined it as the gold standard for most interventions, especially because of the lack of evidence for many of them. However, laparoscopy for cholecystectomy is now the preferred approach with excellent postoperative outcomes and few complications. Although no evidence has been demonstrated in children, laparoscopy has been shown to be superior in adults for gastroesophageal reflux disease and splenectomy. Laparoscopic appendectomy remains controversial. Nevertheless, meta-analyses have concluded in moderate but significant advantages in terms of pain, cosmetic considerations, and recovery for the laparoscopic approach. Laparoscopy is now adopted for undescended testes and allows both localization and surgical treatment if necessary. For benign conditions, videosurgery can be an excellent tool for nephrectomy and adrenalectomy. However, laparoscopy remains controversial in pediatric surgical oncology.

Antireflux surgery after congenital diaphragmatic hernia repair: a plea for a tailored approach

OBJECTIVES

Preventive antireflux surgery (ARS) at the moment of congenital diaphragmatic hernia (CDH) repair has been suggested by some authors, particularly in subgroups with a liver herniated in the chest or patch requirement. We evaluated the incidence and associated factors of gastro-oesophageal reflux disease (GERD) and the need for subsequent ARS in our CDH patients.

METHODS

We retrospectively reviewed our CDH database. Demographics, prenatal assessment of severity, prenatal treatment, type of repair, intraoperative findings and incidences of gastro-oesophageal reflux and ARS were recorded.

RESULTS

CDH repair was performed in 77 infants between July 1993 and November 2009. Eight died after repair. Seven were lost to follow-up. The median follow-up was 4.0 (0.16-14.88) years. Fourteen of these 62 patients were prenatally treated with fetoscopic endoluminal tracheal occlusion (FETO) because of severe pulmonary hypoplasia. After CDH repair, GERD was diagnosed in 31 patients. In all of them, medical antireflux treatment was started. Thirteen (42%) patients needed ARS at a median age of 64 (37-264) days. One year after starting medical treatment, 14 (45%) patients were completely off antireflux medication. In CDH subgroups with patch repair, liver herniated in the chest or previous FETO, the incidences of gastro-oesophageal reflux and ARS were 61 and 32%, 73 and 38% and 71 and 43%, respectively. Univariable analysis of associated potentially predisposing factors shows that patch repair, liver herniated in the chest, pulmonary hypertension, high-frequency oscillatory ventilation and FETO are associated with subsequent ARS. On multivariable analysis, liver herniated in the chest was the only independent predictor for both gastro-oesophageal reflux and ARS.

CONCLUSIONS

Of all CDH patients, 50% developed gastro-oesophageal reflux and 21% required ARS. For both, liver in the chest was the only independent predictor. Routine ARS in certain subgroups at the time of CDH repair seems not to be justified. Foetal endoluminal tracheal occlusion creates a new cohort of survivors with an increased risk for undergoing ARS. The surgical group, in particular, reflects a more complex gastro-oesophageal reflux physiopathology.

Splenic size after division of the short gastric vessels in Nissen fundoplication in children

PURPOSE

Nissen fundoplication is an effective treatment for gastro-esophageal reflux disease (GERD). Mobilization of the gastric fundus during fundoplication requires division of short gastric vessels of the spleen, which may cause splenic ischemia. The aim of this study was to determine if Nissen fundoplication results in hypotrophy of the spleen.

METHODS

We performed pre-operative and post-operative ultrasound measurements of the spleen in children undergoing Nissen fundoplication. During operation, the surgeon estimated the compromised blood flow by assessment of the percentage of discoloration of the spleen.

RESULTS

Twenty-four consecutive children were analyzed. Discoloration of the upper pole of the spleen was observed in 11 patients (48%) of a median estimated splenic surface of 20% (range 5-50%). The median ratio for pre-operative and post-operative length, width, and area of the spleen was 0.97, 1.03, and 0.96, respectively. The percentage of the estimated perfusion defect during surgery was not correlated with the ratios. In three patients, the area ratio was smaller than 0.8 (0.67-0.75), meaning that the area decreased with at least 20% after surgery. In none of these patients a discoloration was observed.

CONCLUSION

Discoloration of the spleen after Nissen fundoplication is not associated with post-operative splenic atrophy.

A meta-analysis of outcomes after open and laparoscopic Nissen's fundoplication for gastro-oesophageal reflux disease in children

The objective of this study is to meta-analyse the published literature comparing outcomes after open (ONF) versus laparoscopic Nissen fundoplication (LNF) for gastro-oesophageal reflux disease in children. Electronic databases were searched from January 1993 to October 2009. A systematic review was performed to obtain a summative outcome. Six comparative studies were analysed. There were 466 patients in the laparoscopic group and 255 in the open group. There was no significant difference in operative time between LNF compared with ONF (p = 0.35). Children stayed in hospital for less time after undergoing LNF compared with ONF [random effects model: SMD = 0.93, 95% CI (0.41, 1.44), z = 3.53, p < 0.01]. Children feed earlier after LNF [random effects model: SMD = 4.13, 95% CI (1.00, 7.27), z = 2.58, p < 0.001] and had less morbidity [fixed effects model: RR = 3.22, 95% CI (1.98, 5.25), z = 4.71, p < 0.01; random effects model: RR = 2.90, 95% CI (1.49, 5.66), z = 3.12, p < 0.01]. No difference in recurrence at 12 months was highlighted (p = 0.29). In conclusion, the laparoscopic Nissen's fundoplication in children may be considered a safe and effective alternative to open surgery; however, careful case selection is required.

Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

BACKGROUND/PURPOSE

Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux.

METHODS

A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patient's profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ(2) tests and t tests.

RESULTS

Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open.

CONCLUSION

Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.

Physiological and clinical characteristics of gastroesophageal reflux after congenital diaphragmatic hernia repair

BACKGROUND/PURPOSE

Gastroesophageal reflux (GER) is an important sequela of congenital diaphragmatic hernia (CDH) repair. This study investigated the physiological and clinical characteristics of GER in CDH survivors.

METHODS

A total of 52 CDH survivors were investigated retrospectively. Esophageal acid exposure was evaluated with 24-h esophageal pH monitoring in all patients, and esophageal anatomical and motor functional abnormalities were examined with videomanometry in 16 patients.

RESULTS

Fundoplication was necessary in 1 patient. Medical treatment with acid suppression or rikkunshito, a traditional Japanese medicine, was successful in nine patients, and the reflux symptoms were ameliorated at the age of 3 years. The percentage of total time the esophageal pH was below 4.0 (reflux index: RI) ranged from 0.1 to 44.3%. No patient with an RI < 10% had reflux symptoms requiring treatment. The basal lower esophageal sphincter (LES) tone ranged from 15 to 35 mmHg (median 25 mmHg). Esophageal peristalsis was preserved in all of the patients examined, except one who had failed peristalsis and poor clearance in the dilated esophagus.

CONCLUSION

The motor function of the esophageal body and LES is usually preserved in CDH survivors despite the wide range of esophageal acid exposure in early infancy. Those with symptomatic GER outgrow it, unless associated with advanced respiratory distress or neurological impairment.

Should fundoplication be added at the time of gastrostomy placement in patients who are neurologically impaired?

BACKGROUND/PURPOSE

Patients who have advanced neurologic impairment (NI) and require gastrostomy placement (GP) frequently have symptomatic gastroesophageal reflux. We investigated the outcomes of GP without fundoplication in patients who had NI.

METHODS

This was a retrospective review of 54 patients with NI (median, 7 years; range, 1-18 years) undergoing GP alone. The operative criteria included medically controllable or no reflux symptoms. The patients were divided into 2 groups based on the percentage of total esophageal time with a pH less than 4.0 (reflux index, or RI): group I (GI, n = 33), RI less than 5.0% (median age, 6 years; range, 2-15 years); group II (GII, n = 21), RI 5.0% or greater (median age, 10 years; range, 1-18 years). Data are expressed as medians and ranges.

RESULTS

Nutritional management was successfully conducted after GP with or without the administration of lansoprazole, famotidine, or rikkunshito in all but 2 patients. One GI patient with alpha-thalassemia required fundoplication, and one GII patient with Cockayne syndrome required gastrojejunal tube feeding. The RI increased significantly in GI patients (2.1% [0%-4.8%] vs 4.5% [0.2%-11.4%], P = .004), whereas it decreased significantly in GII patients (11.2% [5.9%-41.6%] vs 9.8% [1.05-26.6%], P = .04).

CONCLUSION

Gastroesophageal reflux and related symptoms rarely deteriorate to require additional treatment after GP in patients with NI. Gastrostomy placement is a less invasive and effective procedure for improving the quality of life in those patients.

Does laparoscopy lower the threshold for the surgical treatment of gastroesophageal reflux disease in children?

OBJECTIVE

To assess whether laparoscopic surgery lowers the threshold for surgical intervention, we examined whether the introduction of the laparoscopic technique at our institution in 1997 has resulted in an increase in antireflux surgery in children at our clinic.

PATIENTS AND METHODS

The number of annual fundoplications between 1997 and 2008 at a single institution was assessed in children younger than 18 years. The number of fundoplications was compared with the number of pyloromyotomies and appendicectomies per year in the same period of time to prove or exclude a general increase in the referral of children.

RESULTS

Since 1997, the proportion of laparoscopic fundoplications increased from 60% in 1997 to 100% in 2008. During this period, 109 laparoscopic fundoplications were performed: 31 in the period from 1997 to 2002 and 78 from 2003 to 2008. Regression analysis shows a significant increase in the number of performed fundoplications (slope: 1.03 ± 0.28, P = 0.0043), whereas both the number of pyloromyotomies and appendicectomies remained stable (slopes: -0.14 ± 0.40, P = 0.73, and -0.75 ± 0.47, P = 0.14, respectively).

CONCLUSIONS

Since the introduction of minimally invasive surgery at our tertiary referral center in 1997, the number of patients referred for an antireflux operation has increased. This cannot be explained by an increase of referrals from outside the region or a change in the indication for surgery. We conclude that laparoscopy lowers the threshold for the surgical treatment of gastroesophageal reflux disease in children.

Laparoscopic Collis-Nissen for recurrent severe reflux in pediatric patients with esophageal atresia and recurrent hiatal hernia

PURPOSE

Patients following esophageal atresia repair may often have a congenitally short esophagus, leading to severe reflux and failed fundoplications. This report evaluates the efficacy of a laparoscopic Collis-Nissen fundoplication in this group of patients who have failed a previous fundoplication.

METHODS

From January 2005 to February 2010, 6 patients born with esophageal atresia presented with recurrent gastroesophageal reflux disease (GERD) and hiatal hernia (H/H). Patient's ages ranged from 5 to 12 years and weights from 17 to 32 kg. All patients had undergone at least three previous fundoplications and hiatal hernia repair. Four of 5 patients had at least one open laparotomy for their previous repair. Patient 6 had had a previous open Collis gastroplasty. The procedure was performed through five ports and consisted of a takedown of the previous fundoplication, elongation of the esophagus using an endoscopic stapler, closure of the hiatus using Teflon pledgets to buttress the repair, and formation of the fundoplication.

RESULTS

All procedures were completed successfully laparoscopically. Procedure times ranged from 180 to 300 minutes. A nasogastric (NG) tube was left for an average of 3 days in 5 patients. Patient 6 had a delayed perforation on day 3 and required reexploration and an NG tube that was left for 10 days. Five of 6 patients were started on feeds on day 4 and were discharged on day 5. Patient 6 with the perforation was discharged on day 14. At an average follow-up of 42 months, all patients have intact wraps and no recurrence of their hiatal hernia.

CONCLUSIONS

A laparoscopic Collis-Nissen in a child with previous failed fundoplication is a complex, but efficacious, procedure. Elongating the esophagus in patients with esophageal atresia may decrease the high recurrence rate of hiatal hernia in these patients and should be considered if the patient fails their primary repair.

Pledgeted mattress sutures reduce recurrent reflux after laparoscopic Nissen fundoplication

INTRODUCTION

In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction.

METHODS

We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with chi(2), logistic regression, and Kaplan-Meier analysis.

RESULTS

A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures (P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods.

CONCLUSIONS

The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.

Workflow analysis of laparoscopic Nissen fundoplication in infant pigs- a model for surgical feedback and training

BACKGROUND

Many fields use workflow analysis to assess and improve performance of complex tasks. In pediatric endosurgery, workflow analysis may help optimize operative planning and motor skills by breaking down the procedure into particular phases, evaluating these steps individually, and supplying feedback to the surgeon.

OBJECTIVE

To develop a module of computer-based surgical workflow analysis for laparoscopic Nissen fundoplication(LNF) and to evaluate its applicability in an infant pig model.

METHODS

LNF was performed in 12 pigs (weight, 7-10 kg) by a single surgeon. Based on synchronized intra and extracorporal movie recordings, the surgical workflow was segmented into temporal operative phases(preparation, dissection, reconstruction and conclusion). During each stage, all actions were recorded in a virtual timeline using a customized workflow editor. Specific tasks, such as knot-tying, were evaluated in detail.Time necessary to perform these actions was compared throughout the study.

RESULTS

While time required for the preparation decreased by more than 70% from 4577 to 1379 seconds,and the dissection phase decreased from 2359 to 399 seconds (pig 1 and 12, respectively), the other two phases remained relatively stable. Mean time to perform the entire suture and a 5-throw knot remained constant as well.

CONCLUSION

Our workflow analysis model allows the quantitative evaluation of dynamic actions related to LNF.This data can be used to define average benchmark criteria for the procedures that comprise this operation. It thereby permits task-oriented refinement of surgical technique as well as monitoring the efficacy of training.Although preoperative preparation time decreased substantially, and dissection became faster, time required for the reconstruction and conclusion phases remained relatively constant for a surgeon with moderate experience.Likewise, knot-tying did not accelerate in this setting.S-117

Impact of laparoscopic anterior 270 degrees fundoplication on the quality of life and symptoms profile of neurodevelopmentally delayed versus neurologically unimpaired children and their parents

BACKGROUND

This prospective study investigated the therapy-induced changes in the quality of life (QoL) experienced by neurologically healthy and neurodevelopmentally delayed children and their parents after laparoscopic anterior 270 degrees fundoplication (LAF).

METHODS

In this study, 40 patients (21 impaired) with a mean age of 7.8 years underwent LAF for gastroesophageal reflux disease (GERD) and were evaluated before surgery and then 3 and 6 months afterward using the Gastrointestinal Quality-of-Life Index (GIQLI) supplemented by conventional symptom markers.

RESULTS

Growth, proton pump inhibitor use, and frequency of supraesophageal/respiratory symptoms improved significantly (p < 0.001) as did feeding parameters (p < 0.05). The global GIQLI score improved by 49 +/- 21% (p < 0.001). The greatest improvement occurred in the symptoms domain (p < 0.001). However, positive alterations also were found in the dimensions of emotions (58%), social functions (37%) and physical functions (27%) (p < 0.001). Comparison of the overall benefit did not show any differences between the subgroups of neurologically fit and impaired children. However, for the child-centered symptoms domain, the benefit increased stepwise with the degree of impairment. This was counterbalanced by an inverse relationship for the parent-centered emotions domain (p < 0.05).

CONCLUSIONS

Besides the known improvement in symptoms, LAF achieves a significant improvement in QoL for children and their parents. There is no overall difference in the benefit experienced by neurologically impaired and healthy children.

Impact of rikkunshito, an herbal medicine, on delayed gastric emptying in profoundly handicapped patients

PURPOSE

Rikkunshito is used to treat functional dyspepsia in adults. This study investigated the effects of rikkunshito on delayed gastric emptying in handicapped patients.

METHODS

A retrospective review was performed in nine profoundly handicapped patients (aged 1-19 years). All were diagnosed with delayed gastric emptying based on their half gastric emptying time (T(1/2)) over 90 min. Gastric emptying was evaluated after the ingestion of liquid meals using the (13)C-acetate breath test and the BreathID system. Participants were given rikkunshito [0.3 g/(kg day)] with the aim of accelerating gastric emptying. Parameters related to gastric emptying before and during rikkunshito administration were compared using the Wilcoxon signed-rank test. Data were expressed as the median (range).

RESULTS

Emesis and hematemesis were relieved with rikkunshito administration in four symptomatic patients. The T(1/2) and T(lag) decreased significantly during rikkunshito administration from 115 min (94-167 min) to 107 min (64-66 min; p = 0.02), and from 60 min (42-90 min) to 47 min (29-59 min; p = 0.03), respectively. The gastric emptying coefficient did not show a significant change [3.1 (2.8-3.8) vs. 3.2 (2.6-4.0), p = 0.15)] with rikkunshito treatment.

CONCLUSION

The administration of rikkunshito resulted in symptomatic relief and improved gastric emptying in profoundly handicapped patients with delayed gastric emptying.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association

The use of the laparoscopic approach to perform antireflux procedures has increased dramatically since its introduction in 1991. To date, no prospective randomized studies comparing open surgery to the minimal invasive approach in children have been reported. Many retrospective reviews and case series have demonstrated that laparoscopic antireflux procedures are safe and effective once the learning curve is achieved. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize the available evidence to identify the risks and benefits of laparoscopic antireflux procedures.

Feasibility of complex minimally invasive surgery in neonates

The aim of this study was to assess the feasibility of complex minimally invasive surgery in neonates (and infants <5 kg). A systematic search of databases was performed. Inguinal herniotomy and pyloromyotomy were specifically excluded. Various operations were assessed for operative times, conversion rates, complications and centres performing the procedures. From 479 abstracts, 50 papers were identified describing 1,215 patients. Common operations performed were fundoplication (n = 473), operations for ovarian pathology (n = 151) and oesophageal atresia repair (n = 123). Other not-so-common operations included Kasai procedure (n = 61), Ladd's procedure (n = 55), bowel atresia surgery (n = 45) and congenital diaphragmatic hernia repair (n = 41). Mean operation times varied from 43 min for fundoplication to 209 min for Kasai procedure, with other operation times falling in between the two extremes. Likewise, conversion rates varied from 0.2% for fundoplication to 15% for congenital diaphragmatic hernia, with other conversion rates falling in between. Complications ranged from 0 to 67%. About 70-94% of the cases were performed in six pioneering centres. Fundoplication and operations for ovarian pathology have low complication and conversion rates and appear to be well suited to the average-trained paediatric laparoscopic surgeon. More complex procedures are feasible and safe, but technically demanding and need further expertise.

Workflow analysis of laparoscopic Nissen fundoplication in infant pigs- a model for surgical feedback and training

BACKGROUND

Many fields use workflow analysis to assess and improve performance of complex tasks. In pediatric endosurgery, workflow analysis may help optimize operative planning and motor skills by breaking down the procedure into particular phases, evaluating these steps individually, and supplying feedback to the surgeon.

OBJECTIVE

To develop a module of computer-based surgical workflow analysis for laparoscopic Nissen fundoplication(LNF) and to evaluate its applicability in an infant pig model.

METHODS

LNF was performed in 12 pigs (weight, 7-10 kg) by a single surgeon. Based on synchronized intra and extracorporal movie recordings, the surgical workflow was segmented into temporal operative phases(preparation, dissection, reconstruction and conclusion). During each stage, all actions were recorded in a virtual timeline using a customized workflow editor. Specific tasks, such as knot-tying, were evaluated in detail.Time necessary to perform these actions was compared throughout the study.

RESULTS

While time required for the preparation decreased by more than 70% from 4577 to 1379 seconds,and the dissection phase decreased from 2359 to 399 seconds (pig 1 and 12, respectively), the other two phases remained relatively stable. Mean time to perform the entire suture and a 5-throw knot remained constant as well.

CONCLUSION

Our workflow analysis model allows the quantitative evaluation of dynamic actions related to LNF.This data can be used to define average benchmark criteria for the procedures that comprise this operation. It thereby permits task-oriented refinement of surgical technique as well as monitoring the efficacy of training.Although preoperative preparation time decreased substantially, and dissection became faster, time required for the reconstruction and conclusion phases remained relatively constant for a surgeon with moderate experience.Likewise, knot-tying did not accelerate in this setting.S-117

Effects of rikkunshito on the clinical symptoms and esophageal acid exposure in children with symptomatic gastroesophageal reflux

Rikkunshito (TJ-43), a herbal medicine consisting of eight herbs, is used to treat chronic dyspepsia. Studies have shown that TJ-43 improves human gastric emptying. This study investigated the effects of TJ-43 on the clinical symptoms and esophageal acid exposure in children with symptomatic gastroesophageal reflux (GER). Eight children, aged from 2 months to 15 years (median age 4 years), were studied. Six of them had neurological impairment. TJ-43 (0.3 g/kg/day) was given orally or via nasogastric tubes in three divided doses before meals for 7 days. Their symptoms were frequent emesis in four, nausea in two, and hematemesis and stridor in one each. Twenty-four-hour esophageal pH monitoring was conducted using multichannel pH electrodes located at the distal esophagus (P1) and 10 cm proximal to P1 (P2). The clinical symptoms and esophageal pH were compared before and after TJ-43 therapy for 1 week. The frequency of emesis decreased in three patients. Other symptoms, including nausea, hematemesis, and stridor, were relieved in the remaining patients. Measured at the distal pH electrode, the percentage time of esophageal pH < 4.0 and the mean duration of reflux decreased significantly (P < 0.05). However, the number of acid reflux per hour did not change significantly, and no pH parameters measured at the proximal electrode differed significantly. The short-term administration of TJ-43 relieved symptoms and reduced the distal esophageal acid exposure through improved esophageal acid clearance.

Treatment options in pediatric GERD

Gastroesophageal reflux (GER) is a common physiologic phenomenon in infants and children. GER that results in symptoms or complications--hence the evolution to GER disease (GERD)--warrants targeted evaluation and appropriate treatment. Judicious use of acid-suppression therapy remains the mainstay of pharmacologic treatment of GERD. However, recognition of treatment goals and potentials risks of acid suppression must be considered prior to initiation of therapy. The role of surgical intervention for GERD remains limited.