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Surgical Management of Acute Life-Threatening Events affecting Esophageal Atresia and/or Tracheoesophageal Fistula Patients. J Pediatr Surg 2023; 58:803-809. [PMID: 36797107 DOI: 10.1016/j.jpedsurg.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Following surgical correction, many patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) present to the emergency department (ED) with acute airway complications. We sought to determine the incidence and risk factors for severe acute life-threatening events (ALTEs) in pediatric patients with repaired congenital EA/TEF and the outcomes of operative interventions. METHODS A retrospective cohort chart review was performed on patients with EA/TEF with surgical repair and follow-up at a single centre from 2000 to 2018. Primary outcomes included 5-year ED visits and/or hospitalizations for ALTEs. Demographic, operative, and outcome data were collected. Chi-square tests and univariate analyses were performed. RESULTS In total, 266 EA/TEF patients met inclusion criteria. Of these, 59 (22.2%) had experienced ALTEs. Patients with low birth weight, low gestational age, documented tracheomalacia, and clinically significant esophageal strictures were more likely to experience ALTEs (p < 0.05). ALTEs occurred prior to 1 year of age in 76.3% (45/59) of patients with a median age at presentation of 8 months (range 0-51 months). Recurrence of ALTEs after esophageal dilatation was 45.5% (10/22), mostly due to stricture recurrence. Patients experiencing ALTEs received anti-reflux procedures (8/59, 13.6%), airway pexy procedures (7/59, 11.9%), or both (5/59, 8.5%) within a median age of 6 months of life. The resolution and recurrence of ALTEs after operative interventions are described. CONCLUSION Significant respiratory morbidity is common among patients with EA/TEF. Understanding the multifactorial etiology and operative management of ALTEs have an important role in their resolution. TYPE OF STUDY Original Research, Clinical Research. LEVEL OF EVIDENCE Level III Retrospective Comparative Study.
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Impact of Esophageal Atresia on the Success of Fundoplication for Gastroesophageal Reflux. J Pediatr 2018; 198:60-66. [PMID: 29628411 DOI: 10.1016/j.jpeds.2018.02.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/13/2018] [Accepted: 02/27/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Fundoplication is commonly performed in patients with a history of esophageal atresia (EA), however, the success of this surgery is reduced, as reflected by an increased rate of redo fundoplication. We aimed to determine whether EA impacts the prevalence of fundoplication, its timing, and performance of a redo operation. STUDY DESIGN A single-center, retrospective review of all patients undergoing fundoplication over a 20-year period (1994-2013) was performed. Redo fundoplication was used as a surrogate for surgical failure. RESULTS A total of 767 patients (patients with EA 85, those who did not have EA 682) underwent fundoplication during the study period. Median age (months) at primary fundoplication was lower in patients with EA (7.2 vs those who did not have EA 23.3; P < .001). Redo fundoplication rates between groups were not significantly different (EA 11/85 vs 53/682; P = .14). Median time (months) between primary and redo fundoplication was greater in patients with EA (36.2 vs 11.7; P = .03). CONCLUSIONS Contrary to popular belief, the incidence of redo fundoplication was not significantly increased in patients with a history of EA. However, patients with EA underwent fundoplication at younger ages, which may be related to early life-threatening events in these patients. These results inform perioperative counseling, and highlight the importance of sustained surgical follow-up in patients with EA.
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Jancelewicz T, Lopez ME, Downard CD, Islam S, Baird R, Rangel SJ, Williams RF, Arnold MA, Lal D, Renaud E, Grabowski J, Dasgupta R, Austin M, Shelton J, Cameron D, Goldin AB. Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review. J Pediatr Surg 2017; 52:1228-1238. [PMID: 27823773 DOI: 10.1016/j.jpedsurg.2016.09.072] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the surgical treatment of pediatric gastroesophageal reflux disease (GERD). METHODS Five questions were addressed by searching the MEDLINE, Cochrane, Embase, Central, and National Guideline Clearinghouse databases using relevant search terms. Consensus recommendations were derived for each question based on the best available evidence. RESULTS There was insufficient evidence to formulate recommendations for all questions. Fundoplication does not affect the rate of hospitalization for aspiration pneumonia, apnea, or reflux-related symptoms. Fundoplication is effective in reducing all parameters of esophageal acid exposure without altering esophageal motility. Laparoscopic fundoplication may be comparable to open fundoplication with regard to short-term clinical outcomes. Partial fundoplication and complete fundoplication are comparable in effectiveness for subjective control of GERD. Fundoplication may benefit GERD patients with asthma, but may not improve outcomes in patients with neurologic impairment or esophageal atresia. Overall GERD recurrence rates are likely below 20%. CONCLUSIONS High-quality evidence is lacking regarding the surgical management of GERD in the pediatric population. Definitive conclusions regarding the effectiveness of fundoplication are limited by patient heterogeneity and lack of a standardized outcomes reporting framework. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly level 3-4).
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Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105.
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, Program Director, Pediatric Surgery Fellowship, University of Louisville, Louisville, KY
| | | | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC
| | - Shawn J Rangel
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105
| | - Meghan A Arnold
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Dave Lal
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth Renaud
- Department of Surgery, Division of Pediatric Surgery, Albany Medical Center, Albany, NY
| | - Julia Grabowski
- Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Mary Austin
- Department of Pediatric Surgery, The University of Texas Medical School at Houston and in Surgical Oncology and Pediatrics at the UT M.D., Anderson Cancer Center, Houston, TX
| | - Julia Shelton
- Division of Pediatric Surgery, University of Iowa Children's Hospital, Iowa City, IA
| | - Danielle Cameron
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
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Macchini F, Morandi A, Cognizzoli P, Farris G, Gentilino V, Zanini A, Leva E. Acid Gastroesophageal Reflux Disease and Apparent Life-Threatening Events: Simultaneous pH-metry and Cardiorespiratory Monitoring. Pediatr Neonatol 2017; 58:43-47. [PMID: 27262544 DOI: 10.1016/j.pedneo.2015.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 12/03/2015] [Indexed: 11/25/2022] Open
Abstract
AIM To investigate the prevalence and the characteristics of gastroesophageal reflux disease (GERD) in infants with apparent life threatening events (ALTE). MATERIALS AND METHODS Infants with at least one episode of ALTE in absence of predisposing factors were included. All infants underwent a cardiorespiratory recording with simultaneous 24-hour pH-monitoring. Patients were divided into 3 groups according to the severity of GERD: A. Reflux Index (RI) <3%, B. RI = 3-7%, C. RI >7%. Monthly evaluations were performed and the anti-reflux therapy was maintained till normalization of monitoring and clinic. RESULTS 41 infants were enrolled. GERD was found in 80% of patients (moderate in 54%, severe in 27%). A normalization of the cardiorespiratory tracks was recorded on average after 1 month for group A, 7 months for the group B and 9.5 months for group C. A significant difference was registered between group A and both group B and C (P < 0.0001), as well as between the group B and C (P < 0.05). CONCLUSION GERD influences significantly the time of normalization of the cardiorespiratory monitoring in infants with ALTE. GERD diagnosis and treatment are mandatory in these patients.
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Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Paola Cognizzoli
- Department of Pediatrics, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Zanini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Rintala RJ. Fundoplication in Patients with Esophageal Atresia: Patient Selection, Indications, and Outcomes. Front Pediatr 2017; 5:109. [PMID: 28555181 PMCID: PMC5430410 DOI: 10.3389/fped.2017.00109] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 04/25/2017] [Indexed: 11/16/2022] Open
Abstract
Patients with esophageal atresia (EA) suffer from abnormal and permanent esophageal intrinsic and extrinsic innervation that affects severely esophageal motility. The repair of EA also results in esophageal shortening that affects distal esophageal sphincter mechanism. Consequently, gastroesophageal reflux (GER) is common in these patients, overall approximately half of them suffer from symptomatic reflux. GER in EA patients often resists medical therapy and anti-reflux surgery in the form of fundoplication is required. In patients with pure and long gap EA, the barrier mechanisms against reflux are even more damaged, therefore, most of these patients undergo fundoplication during first year of life. Other indications for anti-reflux surgery include recalcitrant anastomotic stenoses and apparent life-threatening episodes. In short term, fundoplication alleviates symptoms in most patients but recurrences are common occurring in at least one third of the patients. Patients with fundoplication wrap failure often require redo surgery, which may be complicated and associated with significant morbidity. A safe option in a subset of patients with failed anti-reflux surgery appears to be long-term medical treatment with proton pump inhibitors.
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Affiliation(s)
- Risto J Rintala
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
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Concomitant Fundoplication With Gastrostomy: A Two-State Comparison Showing Continued Use of Reflux Medications. J Pediatr Gastroenterol Nutr 2016; 63:e163-e168. [PMID: 27070655 DOI: 10.1097/mpg.0000000000001211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to determine whether practice differences for fundoplication exist between 2 geographically distinct states, and to determine the reflux medication use pattern associated with concomitant fundoplication. METHODS A retrospective observational cohort study of children in Colorado (CO) and North Carolina (NC) insured by Medicaid from 2006 to 2008. Children who received a surgical gastrostomy during the study period were included, and our primary outcome measure was the performance of a concomitant gastric fundoplication. Thirty-day prescription fills for reflux medications were examined before and after gastrostomy procedure. RESULTS We examined 969 surgical gastrostomy admission in both states over the 3-year study period (CO, n = 341 and NC, n = 628). Patients in each state had similar age (median age, 6 months, P = 0.97). Use of pH probe (CO: 15%, NC: 11%) and diagnosis of reflux (CO: 84%, NC: 72%) differed in each state. Concomitant fundoplication was performed in 60% of patients in CO and 43% in NC (P < 0.01). Age less than 6 months was associated with an increased adjusted odds of fundoplication in CO (OR 9.77, CI, 3.91, 24.43), but less so in NC (OR 2.73, CI, 1.48, 5.04). Among patients undergoing gastrostomy, the proportion of patients on reflux medication 4 to 6 months post-discharge did not differ between those receiving fundoplication and those that did not in either state. CONCLUSIONS Rates of concomitant fundoplication varied in the 2 states despite patients having similar demographic and clinical characteristics. Antireflux surgery was not associated with a reduction in reflux medications in either state.
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Desai AA, Alemayehu H, Dalton BG, Gonzalez KW, Biggerstaff B, Holcomb GW, St. Peter SD. Review of the Experience with Re-Operation After Laparoscopic Nissen Fundoplication. J Laparoendosc Adv Surg Tech A 2016; 26:140-3. [DOI: 10.1089/lap.2015.0273] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amita A. Desai
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Hanna Alemayehu
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Brian G. Dalton
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | | | | | - George W. Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
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Sload RL, Brigger MT. Surgery for reflux induced airway disease: a systematic review. Int J Pediatr Otorhinolaryngol 2014; 78:1211-5. [PMID: 24865806 DOI: 10.1016/j.ijporl.2014.04.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 04/24/2014] [Accepted: 04/26/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES 1. Evaluate the current evidence regarding the efficacy and safety of anti-reflux surgery for the treatment of severe gastroesophageal reflux-related airway disease in children. 2. Provide evidence based recommendations regarding indications and outcomes of anti-reflux surgery for airway disease in children. METHODS An a priori protocol was defined to identify all articles addressing anti-reflux surgery for the treatment of reflux-related airway disease in children where details regarding the diagnosis, treatment, and outcomes were clearly presented. The search was inclusive of all references available through August 30, 2013 and included electronic databases to identify candidate articles as well as a comprehensive series of crosschecks. The two authors independently determined which references met inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled using a random effects model due to significant study heterogeneity. RESULTS Fourteen articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I(2)=82.7%; p<0.001). However, each article uniformly presented cases suggesting that anti-reflux surgery is efficacious and safe in treating children with severe reflux-related respiratory disease. The pooled success rate for complete or partial resolution of symptoms after anti-reflux surgery was 0.91 (95% CI: 0.88, 0.94). The pooled success rate for complete symptom resolution after surgery was 0.72 (95% CI: 0.62, 0.83). CONCLUSION The current literature suggests that anti-reflux surgery is an effective and safe treatment for severe reflux-related airway disease. However, the level of evidence lacks strength and further investigation is warranted.
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Affiliation(s)
- Ryan L Sload
- Naval Medical Center San Diego, Department of Otolaryngology - Head and Neck Surgery, San Diego, CA, 92134, United States
| | - Matthew T Brigger
- Naval Medical Center San Diego, Department of Otolaryngology - Head and Neck Surgery, San Diego, CA, 92134, United States.
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Fox D, Barnard J, Campagna EJ, Dickinson LM, Bruny J, Kempe A. Fundoplication and the pediatric surgeon: implications for shared decision-making and the medical home. Acad Pediatr 2012; 12:558-66. [PMID: 22981670 DOI: 10.1016/j.acap.2012.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 07/06/2012] [Accepted: 07/16/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Almost one-half of all pediatric gastrostomy tube insertions are accompanied by a fundoplication, yet little is understood about the surgical decision-making for these procedures. The objective of this study was to examine the decision-making process of surgeons about whether to perform a fundoplication in children already scheduled to have a gastrostomy tube placed. METHODS A written questionnaire of all pediatric surgeons at a major children's hospital was completed for each planned gastrostomy procedure over the course of 1 year; the questionnaire asked about various influences on the fundoplication decision: primary care and subspecialty physicians' opinions, patient characteristics, and parent opinions. Patient demographics and clinical characteristics from the medical record, as well as questionnaire responses, were summarized for each gastrostomy occurrence. We modeled the association of questionnaire responses and patient characteristics with the outcome of having a fundoplication. RESULTS We received questionnaires on 161 of 169 eligible patients (95%). A total of 52% of patients had fundoplication. Primary care physicians were involved in 44% of decisions, and when involved had "a lot" of influence on the fundoplication decision only 28% of time, compared with neonatologists (61%), hospitalists (44%), pediatric pulmonologists (42%), and pediatric gastroenterologists (40%). A total of 86% of patients had a subspecialist involved, and 28% had >1 subspecialist. A pH probe was performed in 7.5% of cases, and failed pharmacotherapy was noted by the surgeons in only 26.5% of the fundoplications performed. CONCLUSIONS The decision to do a fundoplication was rarely based on definitive testing or failed medical treatment. From the surgeon's perspective, subspecialists were more influential than primary care physicians, which is at odds with current concepts of the medical home.
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Affiliation(s)
- David Fox
- Department of Pediatrics, University of Colorado School of Medicine, Denver, USA.
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10
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Goessler A. Gastroesophageal reflux in children – news, trends and standards. Eur Surg 2012. [DOI: 10.1007/s10353-012-0104-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Abstract
This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.
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12
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Berkowitz CD. Sudden infant death syndrome, sudden unexpected infant death, and apparent life-threatening events. Adv Pediatr 2012; 59:183-208. [PMID: 22789579 DOI: 10.1016/j.yapd.2012.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Carol D Berkowitz
- Department of Pediatrics, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA 90509, USA.
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13
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Abstract
Gastroesophageal reflux is commonly encountered in the infant population. Most children will outgrow their reflux but some develop pervasive disease and require medical or surgical treatment. Many tools exist for use in the workup of pediatric gastroesophageal reflux disease; however, the most effective method of diagnosis is not clear. Delineating which patients will benefit from more definitive therapy is a remarkable challenge in this group, often borrowing tools and principles from the adult patient population. Therefore, we reviewed the available literature to critically evaluate the merits and limitations of the current diagnostic modalities available for the evaluation of infantile gastroesophageal reflux.
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St. Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW, Bartle D, Morgan T, Harmon CM, Georgeson KE, Holcomb GW. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg 2011; 46:163-8. [PMID: 21238659 PMCID: PMC3097032 DOI: 10.1016/j.jpedsurg.2010.09.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial. METHODS After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation. RESULTS One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006) CONCLUSIONS Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.
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Affiliation(s)
- Shawn D. St. Peter
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA,Corresponding author. Department of Surgery, Center for Prospective Clinical Trials, Children’s Mercy Hospital, Kansas City, MO 64108, USA. Tel.: +1 816 983 3575; fax: +1 816 983 6885. S.D. St. Peter
| | | | | | - KuoJen Tsao
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | | | - Susan W. Sharp
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Donna Bartle
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
| | - Tracey Morgan
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
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