Long-term results after laparoscopic Thal procedure in children

Comparison of long-term outcomes between open and laparoscopic Thal fundoplication in children

OBJECTIVES

In recent years laparoscopic fundoplication is increasingly performed in pediatric surgery. The aim of this study was to compare the long-term outcomes between open and laparoscopic Thal fundoplication in children.

METHODS

This retrospective study includes children who underwent a Thal fundoplication between 3/1997 and 7/2009. The minimum follow-up time to enter the study was 2 years; the overall median follow-up was 77 months (range, 29-176 months).

RESULTS

A total of 101 patients were included, of which 47 underwent an open and 54 a laparoscopic Thal. Intraoperative problems, early postoperative complications, time to establish enteral feeds and length of stay did not differ among both groups. The mean duration of surgery was significantly less in the open group (OPG) (108.0 (± 7.72) versus 144.1 (± 6.36) minutes; p=0.001) and this was mainly attributed to patients with neurological problems. Severe dysphagia requiring endoscopy was observed in 10 patients, but this did not differ significantly between groups (n=2 in the OPG vs. n=8 in the laparoscopic group (LAPG); p=0.10). Overall 12 patients (11.9%) (6 in each group) required a redo-fundoplication after a median of 18.7 months (range, 6-36 months). In the whole study group, 80 patients (79.2%) were classified as having surgical results being excellent, good or satisfactory and this did not differ significantly between groups.

CONCLUSIONS

In the long-term open and laparoscopic Thal fundoplication have similarly good outcomes. The laparoscopic approach can be considered as an alternative, however there is not a clear superiority compared with the open counterpart.

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.

Fast-track surgery in infants and children

BACKGROUND/PURPOSE

Fast-track surgery is not well established for infants and children. The aim of our prospective study was to investigate the feasibility of fast-track concepts for pediatric surgical procedures including laparoscopic techniques.

METHODS

Fast-track concepts, including immediate postoperative feeding, immediate mobilization, and morphine sparing pain treatment, were established for pyeloplasty, appendectomy, bowel anastomosis, fundoplication, hypospadia repair, and full/partial nephrectomy. All consecutive patients undergoing these procedures were prospectively investigated from June 2004 to June 2005. Patients with additional relevant diseases, reoperation, and perforated appendicitis were excluded from fast-track treatment. The length of hospital stay was compared with data derived from the German reimbursement system with German diagnosis-related groups for patients with a similar case mix index and hospitals with a similar structure.

RESULTS

Of a total of 159 patients (mean age, 5.8 +/- 5.3 years), 113 (71%) were finally treated according to the fast-track protocols. There were no complications associated with fast-track surgery. The intensity of pain during the immediate postoperative period was higher than 5 on a 10-point scale in children older than 4 years. Analgesia was excellent at all other time points. The mean hospital stay of fast-track patients was 2.3 +/- 1 days and was significantly shorter (P < .01) compared with German diagnosis-related group data for all procedures (pyeloplasty, 1.9 +/- 0.9 vs 12.2 +/- 0.2; nephrectomy, 1.9 +/- 1.0 vs 14.4 +/- 2.8; bowel anastomosis, 3.2 +/- 0.6 vs 12.9 +/- 2.4; fundoplication, 3.2 +/- 0.8 vs 15.2 +/- 4.2; appendectomy, 3.7 +/- 2.4 vs 6.3 +/- 1.8; hypospadia repair, 2.1 +/- 1 vs 8.4 +/- 1.4). Two readmissions were recorded. Ninety-six percent of patients and parents scored the fast-track concepts as excellent.

CONCLUSION

The feasibility of fast-track concepts in children is excellent, with short duration of hospitalization and high comfort.

Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children

PURPOSE

Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication.

METHODS

The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed.

RESULTS

Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 +/- 1.0 and 2.6 +/- 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth.

CONCLUSION

Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.

Laparoscopic modified Thal fundoplication for gastroesophageal reflux in a patient with severe scoliosis and sliding esophageal hiatal hernia

A 14-year-old girl with severe scoliosis and sliding esophageal hiatal hernia underwent laparoscopic fundoplication for gastroesophageal reflux. Of various fundoplication procedures, anterior partial fundoplication (Thal fundoplication) was performed because it is effective, with less postoperative gas bloat syndrome. Laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach. In our "modified anterior partial fundoplication," the sutures between the crura and the esophagus and the sutures on the left of esophageal wall with the fundus of the stomach could be exactly performed by laparoscopic surgical technique. The wrapping of the esophagus in fundoplication was done over the ventral 180 degrees to 270 degrees. Six months postoperatively, the patient did not develop gas bloat syndrome, distal esophageal obstruction from fundoplication, and delayed gastric emptying. Modified anterior partial fundoplication achieves effective control of reflux symptoms.

Long-term results of boerema anterior gastropexy in children

OBJECTIVES

To analyze the long-term results of Boerema anterior gastropexy using the Visick grading system in a university teaching hospital.

METHODS

Retrospective review of 247 children with severe or complicated gastroesophageal reflux disease (GERD). Patients who underwent primary gastropexy between 1990 and 2001 were divided in 3 groups: (A) neurologic impaired patients (n = 83); (B) esophageal atresia patients (n = 36); and (C) patients without underlying disease (n = 128). The median length of follow-up after gastropexy was 7 years and 8 months (range, 1.5-13 years). Follow-up was carried out using a standardized questionnaire and was obtained by telephone. Postoperative recurrence of symptoms during follow-up was considered as failure of the operation.

RESULTS

Postoperative complications occurred in 20 patients (24%) in group A, in 13 patients (36%) in group B and in 23 patients (18%) in group C. Thirty-three patients died during the follow-up period, 5 of whom during the postoperative period. Six children could not be traced; thus, 208 were available for long-term follow-up. Postoperative failures occurred in 12 patients (23%) in group A, in 11 patients (31%) in group B and in 17 patients in group C (14%). Reoperation for recurrence of symptoms due to GERD was performed in 6 patients in group A, in 7 patients in group B and in 2 patients in group C. The final outcome at the time of interview was successful in 81% of group A, in 88% of group B and in 91% of group C.

CONCLUSIONS

In the long term, Boerema anterior gastropexy is an effective operation for complicated GERD in children without underlying disease as well as in neurologically impaired children and patients with esophageal atresia.

Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease

BACKGROUND

Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures.

METHODS

This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created.

RESULTS

The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann-Whitney U test are not statistically significant.

CONCLUSIONS

For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon's experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.