Laparoscopic Nissen fundoplication in children under 2 years of age

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population

INTRODUCTION

The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population.

METHODS

The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean +/- SEM.

RESULTS

Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 +/- 0.4 vs 6.1 +/- 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 +/- 0.05 vs 0.55 +/- 0.08 mg/kg, P = .007). Operation times (111 +/- 5 [open] vs 113 +/- 5 minutes, P = .76) and estimated blood loss (13 +/- 2 [open] vs 11 +/- 1 mL, P = .33) were comparable for both groups.

CONCLUSION

Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.

Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center

Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.

Is there a changing trend in surgical management of gastroesophageal reflux disease in children?

Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD. However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD in children.

Hemodynamic and respiratory effects of robot-assisted laparoscopic fundoplication in children

Laparoscopic fundoplication is increasingly used for treating gastro-esophageal reflux disease in children. Mechanical and pharmacological effects may contribute to hemodynamic and respiratory changes during carbon dioxide pneumoperitoneum. The aim of the present study was to evaluate the hemodynamic and respiratory effects of pneumoperitoneum (PP) with an intra-abdominal pressure (IAP) of 12 mmHg in children undergoing robot-assisted laparoscopic fundoplication during total intravenous anesthesia. Ten children, aged 8-16 years, American Society of Anesthesiologists physical status II-III, scheduled for robot-assisted laparoscopic fundoplication in the reverse Trendelenburg position were investigated. Minute ventilation (MV), peak inspiratory pressure (PIP), IAP, heart rate (HR), mean arterial blood pressure (MAP) were recorded, together with pH, base excess, HCO3-, P(et)CO2, PaCO2, and PaO2 at six time points: before insufflation, 10, 30, 60, 90 minutes after creating PP and after desufflation. The IAP was maintained at 12 mmHg. During insufflation MAP increased significantly from 70.6 (+/-9.0) to 84.8 (+/-10.4) mmHg, MV was increased from 4.6 (+/-0.8) to 5.5 (+/-0.9) l min(-1), PIP increased, PaO2 and pH decreased. P(et)CO2 increased from 33.1 (+/-1.6) to 36.6 (+/-1.6) mmHg together with PaCO2. Hemodynamic and respiratory effects due to the intra-abdominal insufflation of CO2 with an IAP of 12 mmHg are well tolerated, and anesthesia with remifentanil, propofol and mivacurium facilitates extubation immediately at the end of surgery.

24-hour ambulatory blood pressure monitoring in children with familial dysautonomia

BACKGROUND

Familial dysautonomia (Riley Day syndrome) is a genetic disease. The present study of 24-hour ambulatory blood pressure monitoring in children with familial dysautonomia was carried out to investigate the pattern of blood pressure in this syndrome.

OBJECTIVE

To the best of our knowledge, this is the only description of patients with 24-hour blood pressure monitoring.

STUDY DESIGN

Vasomotor instability reflected in extreme hypertension and hypotension was recorded by 24-hour ambulatory blood pressure monitoring in three patients with familial dysautonomia: a 16-year old girl, a 14-year old boy and a 3-year old boy. Recordings were taken on a routine school day in the first two patients and during hospitalization in the third.

RESULTS

Patients 1 and 2 displayed circadian rhythm but with significantly higher than normal blood pressure and heart rate. Patient 3 exhibited these fluctuations to a lesser degree. Postural hypotension without compensatory tachycardia was frequently seen in all three patients. Unusual variability in blood pressure was recorded during routine activities in patients 1 and 2 and during an acute attack in patient 3.

CONCLUSIONS

Close monitoring of antihypertensive therapy should be considered in familial dysautonomia patients in whom blood pressure reaches excessive levels.

The surgical treatment of gastro-esophageal reflux in neonates and infants

Gastro-esophageal reflux (GER) is a physiological process characterized by the involuntary passage of gastric contents into the lower esophagus not induced by noxious stimuli. It represents a common condition in preterm infants and may occur in healthy neonates. The phenomenon is only considered as GER disease when it causes the patient to be symptomatic or results in pathological complications. Fundoplication is recommended in symptomatic neonates and infants with GER that does not respond to medical treatment. The presence of respiratory symptoms related to GER is the primary indication for fundoplication in this selected population. The Nissen fundoplication is the antireflux procedure of choice and the experience concerning other procedures, including laparoscopic techniques, is limited in this age group. The best results are achieved in newborn infants with isolated GER, as the recurrence rate of GER in infants with associated anomalies is high. Further studies are necessary to evaluate the benefit of laparoscopic fundoplication in this age group.

Postfundoplication Complications in Children

The optimal "treatment" of postfundoplication complications is preoperative prevention of them. Nonreflux causes of the symptom prompting surgery should be carefully eliminated preoperatively. Failure to respond to optimal powerful antireflux pharmacotherapy suggests that GERD was not the cause of symptoms. Neurologic or respiratory disease, delayed gastric emptying or retching, short esophagus, and esophageal dysmotility may predispose patients to complications, and may require careful tailoring of the fundoplication. The optimal antireflux surgery, with a wrap neither too loose nor too tight, may require a nadir lower esophageal sphincter pressure of more than 5 mm Hg to prevent reflux, but less than some value to prevent dysphagia. This latter value may be approximately 10 mm Hg, but depends on swallowing parameters such as peristaltic pressure, lower esophageal sphincter opening diameter, swallowed bolus diameter, and other considerations. Infants may require a gastrostomy tube for venting because of their lower gastric compliance to deal with swallowed air. Children with delayed gastric emptying may benefit from pyloroplasty, but this is debated. When complications occur, re-evaluate the diagnosis and the competence of the fundoplication with barium fluoroscopy, endoscopy with histology, pH probe, and other modalities as indicated. Initially try conservative management of the patient's complications, including dietary and feeding modifications. Give a trial of antireflux pharmacotherapy for recurrent reflux or pharmacotherapy directed at the specific side-effect of the fundoplication if one is present. Consider endoscopically dilating a persistently tight wrap or surgically revising the fundoplication if it is suggested by the evaluation.

Laparoscopic surgery for gastroesophageal reflux disease during the first year of life

BACKGROUND

Very few children need gastroesophageal antireflux surgery during their first year of life; hence, no series has been published so far. The authors report their experience in 3 centers.

METHODS

From January 1993 to December 1998, 36 infants between 23 days and 13 months of age, suffering from gastroesophageal reflux disease (GERD), underwent surgery by a laparoscopic approach. The patients' weights ranged from 2.4 to 8.5 kg. Preoperative diagnostic studies included esophagograms, manometries, endoscopies, and pH-metries. Fifteen babies (41.6%) had associated anomalies, and 10 (27.7%) were neurologically impaired. Thirty-six laparoscopic fundoplications were performed according to either Toupet's procedure (17 of 36), Rossetti's (10 of 36), Nissen's (8 of 36) or Lortat-Jacob's (1 of 36). Four infants previously had undergone a gastrostomy, whereas 6 needed one during the antireflux procedure.

RESULTS

There was no mortality in our series. Three infants (8.3%) had an intraoperative complication: 1 lesion of a diaphragmatic vessel, 1 pneumothorax, and 1 case of severe hiatal hernia requiring conversion to open surgery. During the median follow-up of 22 months, 4 redo procedures were performed (11.1%).

CONCLUSIONS

This experience shows the feasibility of laparoscopic fundoplication even in children below 1 year of age. An accurate preoperative diagnostic study is mandatory, because 50% of these patients presented associated anomalies. A long and accurate follow-up is necessary to evaluate long-term results and detect possible complications, which can occur as late as 1 year after surgery. In addition, we believe that redo antireflux surgery is possible by the laparoscopic approach without major difficulties, based on our larger experience with older children.

Technical aspects of feeding the disabled child

Children with neurological impairment frequently have difficulties in consuming sufficient energy and other nutrients to maintain adequate nutritional status. Under-nutrition is a significant contributory factor to growth failure. Eating may be distressing and time-consuming for the child and carer. Aspiration of feeds is common and may predispose to chronic chest infections. Gastro-oesophageal reflux is also common and may contribute to significant morbidity. This paper discusses some of the issues involved in the nutritional management of neurologically impaired children.