Laparoscopic Nissen Fundoplication in Children: An Initial Experience

Transcription

1 Annals of Pediatric Surgery, Vol 1, No 1, October 2005: PP Original Article Laparoscopic Nissen Fundoplication in Children: An Initial Experience Ashraf A. Kabesh *, Fatma Al-Zahraa Abd Al-Bassit **, Dalia Mamdouh Dalam *** Departments of *Pediatric Surgery, **Pediatrics, and ***Radiology, Ain Shams University, Egypt Background/Purpose: In adults, laparoscopic Nissen fundoplication is a very popular antireflux technique. Its advantage over the traditional open approach is manifold. The use of this technique in children is growing slowly but surely. The aim of this work is to report our initial experience with laparoscopic Nissen fundoplication in children. Materials and Methods: A total of 13 (including 3 neurologically impaired) patients underwent laparoscopic Nissen fundoplication in the period between 2002 and 2005 in the pediatric surgery department of Ain Shams University Hospitals. These patients data were reviewed retrospectively. Their age ranged between 6 months and 10 years. The mean period of follow-up was 1.5 years. All patients had documented gastroesophageal reflux disease. Indications for surgery included medically refractory reflux for more than 3 months. Results: Eleven patients were completed laparoscopically and two were converted into an open approach. There were no cases of visceral perforation, splenic injury or blood loss requiring blood transfusion. A laparoscopic gastrostomy was concomitantly performed in the neurologically impaired patients. Mean operative time was 188 minutes early in the course and 126 minutes in the last 3 cases. Resumption of regular feedings began on postoperative day 3.5 (mean). Mean date of discharge was postoperative day 4. Complications included conversion to open technique in two cases. Two patients developed postoperative temporary dysphagia and responded to medical treatment. Recurrence of symptoms occurred in 2 patients, one underwent an open Nissen fundoplication and the other responded to medical treatment. Conclusion: In our hands, laparoscopic Nissen fundoplication was a safe and effective treatment for children with GERD. Time to resume regular feeding, and hospital stay were comparable to other series. The low morbidity and absence of perioperative mortality would encourage us to perform the technique in the younger age groups (less than 3 months of age). Index Word: Laparoscopy, children-gastroesophageal reflux, Nissen fundoplication M INTRODUCTION edical treatment of gastroesophageal reflux disease (GERD), especially after introduction of the proton pump inhibitors (PPI), is generally very effective. 1 In most cases, this is usually all what the patients need, however, some may not get enough benefit and surgical intervention is warranted. 2 Laparoscopy has revolutionized the surgical management of the disease and has become the Correspondence to: Correspondence to: Ashraf A. Kabesh M.D, 10 Salah Galal St, Heliopolis, Cairo, Egypt. akabesh@idsc.net.eg

2 Kabesh et al. preferred approach by most surgeons. This is mainly as it combined both the high success rate with the well-known benefits of laparoscopy, including the shorter hospitalization, fewer post surgical complications and less pain compared to the open approach. 3 Laparoscopic fundoplication in children, in contrast to its popular use in the adult form of disease, is slowly taking its role as the norm. 4-7 In this work, we report our initial experience with laparoscopic Nissen fundoplication in children. MATERIAL AND METHODS During a period of 3 years time (October 2002 October 2005), 13 patients (nine boys and four girls) underwent laparoscopic fundoplication in the pediatric surgery department, Ain Shams University Hospitals. The preoperative, operative and postoperative data of these patients were reviewed retrospectively. Age at operation ranged from 6 months to 10 years (mean 27 months). Ten patients were neurologically normal (NN) and 3 were neurologically impaired (NI). All patients had their gastroesophageal reflux documented preoperatively. Upper gastrointestinal contrast study was performed for all patients. Endoscopy and 24-hour ph monitoring were performed when the diagnosis was in doubt (n = 4). Indications for surgery included reflux refractory to medical therapy for more than 3 months in all patients. This was also associated with, vomiting in 8 patients, failure to thrive in 4 patients, esophagitis in 3 patients and anemia in 3 patients. Three patients were operated upon due to refractory reflux with repeated severe upper respiratory infection and distress (Table 1). The mean period of postoperative follow-up was 18 (6-35) months. Surgical technique: Total (360 degree) fundoplication was performed in all patients with inclusion of both vagi in the wrap. Short gastric vessels division (SGVD) was performed in four patients. A video monitor was placed on the left side of the patient s head. The surgeon operated in between the child s legs with two assistants, one on the right and another on the left. Patients were operated upon in 45- degree anti-trendelenberg position. Five trocars were placed: one epigastric, one umbilical (the camera port), a right and a left subcostal, and one left iliac fossa trocar. Trocar sizes and insufflation pressure depended on the size, weight and age of the child. Trocar sizes were usually 3-5mm and insufflation pressure ranged from 5 to 9 mm Hg. The procedure began with exposure of the esophageal hiatus by retraction of the left lateral segment of the liver using a fan retractor (Fig 1). Next, the exposed gastrohepatic ligament is incised with cautery to expose the right crus. The dissection was then carried cephalad and along the gastrophrenic membrane until the left crus was identified. A large posterior window was then created with careful blunt dissection anterior and lateral to the left crus. The crura were dissected free for a distance of 2 to 3 centimeters before narrowing of the hiatus with intracoporeal knots (Fig 2). A large posterior window was essential to provide enough room for the subsequent fundoplication. The fundus was then pulled to the right side from behind the esophagus (Fig 3). The short gastric vessels were only divided if tethering the fundus (Fig 4). A bougie was then inserted transorally to calibrate the wrap. The size of the dilator was determined by size of the patient's esophagus. The stomach wrap included adequate portion of the fundus to ensure a "floppy" wrap was created. Both the right and left sides of the fundus were secured with intracorporeal sutures, completing a 360 wrap around the lower esophagus (Fig 5). After withdrawal of the bougie, the wrap was secured to the patch with intracorporeal suture along the superior edge. When a gastrostomy was indicated (in all the NI patients), it was performed laparoscopically at the end of the procedure. Follow-up included clinical evaluation at 3, 6 and 12 months postoperatively. Upper gastrointestinal contrast study was performed routinely to all patients at 3 months. Endoscopy and ph monitoring were only used in patients with functional complications (heartburn, regurgitation or dysphagia), or when the contrast study showed an abnormality Vol 1, No 1, October

3 Kabesh et al Fig 1. Exposure of the esophageal hiatus. Fig 4. Securing the short gastric vessels Fig 2. Closure of the hiatus. Fig 5. The stomach wrap is created by encircling the esophagus and being sutured Fig 3. The fundus of the stomach brought behind the esophagus. RESULTS Eleven fundoplications were completed laparoscopically. In two patients, the second and fifth cases in the study, the technique was completed in an open fashion. The first conversion resulted from a mechanical problem (insufflator s failure), resulting in an inability to visualize the field. In the other case, uncontrollable bleeding from a short gastric vessel had to be secured through a laparotomy, however, no blood transfusion was needed in this case. No cases of visceral perforation or splenic injury occurred and no perioperative mortality was met. A laparoscopic gastrostomy was concurrently performed in all NI patients. Mean operative time was 188 ( ) minutes in the first 10 cases and 126 ( ) minutes 12 Annals of Pediatric Surgery

4 Kabesh et al. in the last 3 cases (p<0.05). Oral intake began on the 2 nd postoperative day on average and resumption of normal feeding began on the third postoperative day (mean). The mean date of discharge was postoperative day 4. Two patients developed transient postoperative dysphagia. They were managed conservatively, and both were asymptomatic by the first postoperative follow up. Recurrence of symptoms was observed in two patients, the second and the eighth in the series. In the first case, heartburn recurred 3 months postoperatively. An upper gastrointestinal contrast study, endoscopy and ph monitoring confirmed reflux recurrence. This patient underwent a redo open Nissen fundoplication successfully. In the second patient, recurrent upper respiratory infection was observed one year postoperatively, an upper gastrointestinal contrast study, endoscopy and ph monitoring excluded recurrent or residual reflux as the cause. This patient responded well to medical treatment. The intra and postoperative complications are shown in (Table 2). Table 1. Preoperative symptoms (n = 13) Refractory reflux (RF) 13 Vomiting 8 Failure to thrive 4 Esophagitis 3 Anaemia 3 Respiratory symptoms 3 Table 2. Intra-operative & Post-operative Complications. Intra-operative complications and course Intraoperative bleeding Inadequate visualization 1 1 Conversion to open technique Conversion to open technique Postoperative complications and course Dysphagia 2 Medical treatment Heartburn 1 Recurrent respiratory infection Slipped wrap requiring open redo Nissen fundoplication 1 Medical treatment DISCUSSION Following the advent of proton pump inhibitors (PPI), controversy arose as to where surgery should be placed, if ever, in the general management plan of GERD. 8,9 The high frequency of postoperative complications, as well as poor outcomes, have been cited as indications for a rather extensive and lengthy use of the medical therapy, despite the fact that volume reflux, and consequently pulmonary aspiration, cannot be corrected by simply reducing gastric acid production. 10 Furthermore, certain medications (eg, omeprazole) are difficult to administer to infants, have side effects when given for prolonged periods, and are expensive. 11 This is above all against the numerous published reports, from various centers, that document the satisfactory results and the relatively few major complications of antireflux surgery in children, especially in the laparoscopy era. 12 Individual and institutional bias has resulted in variation in the selection criteria for antireflux surgery in children. 6 However, all agree that patients should complete at least a three-month period of medical treatment before the disease is considered refractory and before surgical referral. In our study, failure of medical therapy has been associated with failure-tothrive, feeding disorders, respiratory symptoms and esophagitis. Most series would consider these as indications for surgical intervention 5 The practice of fundoplication in the NI children is increasing in most large centers. This is especially true for those who require a concomitant feeding gastrostomy, therefore accounting for up to 44% of the total number of cases in some studies. On the other hand, as the morbidity in such a high-risk group of patients is likely to increase four folds, compared to the NN patients, some consider this inappropriately high and unless severe GERD is demonstrated, a percutaneous endoscopic gastrostomy (PEG) would be all what they offer. 13 As a new technique in our department, the NI patients subjected to the laparoscopic Nissen fundoplication (23% of the cases) were carefully selected (minimal cardiopulmonary risk). The need for antireflux surgery in the premature infants has recently been recognized. Investigators have reported a close association between chronic respiratory distress and GERD in premature newborns. Similarly, many infants with complex Vol 1, No 1, October

5 Kabesh et al congenital heart disease have been found to experience periodic GERD. The recognition that GERD can be a life-threatening condition in infants has prompted a more aggressive search and, when necessary, early operative correction of reflux. GERD also has been recognized as a frequent sequel after surgical repair of esophageal atresia and congenital diaphragmatic hernias (CDH). Therefore, the number of small infants who may benefit from surgical correction of GERD is substantial, many of whom have other complex disorders. 14 Nowadays, many centers are performing the majority of their antireflux operations during the first 3 months of life. 15 In this initial experience, Although we acknowledge such benefits, we operated on somewhat older patients, starting at 6 months of age. The outcome of this study will certainly influence the shift to a smaller age group in the future. The preoperative work up varies in the literature. Although the use of endoscopy, ph monitoring or gastric emptying studies has been practiced by many centers, other centers performing large number of fundoplications doubt their use, and are more likely to rely on the clinical findings and the esophagogram to establish the diagnosis of reflux. 16 This seems, we think, more logical especially in the NI children who require a concomitant feeding gastrostomy. In this study, all patients had a preoperative esophagogram, which helped defining the local anatomy at the gastroesophageal junction. Endoscopy and esophageal ph monitoring studies were only performed when the esophagogram was doubtful. No isotope gastric emptying studies were used in this study. The applicability and results of such studies vary remarkably in the literature, particularly in the NN children. 17,18 In our study, all patients (NN and NI) had Nissen (360 ) fundoplication. This was influenced mainly by our familiarity with the open technique. In the literature, the antireflux technique performed varies greatly among centers. The use of Nissen and Thal techniques ranged between 2 and 98% [18] The Thal procedure was used in almost all hospitals for children who had previously undergone repair of esophageal atresia (EA) with subsequent symptomatic GERD. 19 The Toupet, Dor, Boix-Ochoa, or other antireflux procedures were reported in less 2% of the studies. 20, 21 Technique selection seems to have been based on the previous operative experience by the surgeons. 22 Several reviews have evaluated the advantages of different fundoplication techniques in the NI children. Unfortunately, no clear recommendations exist, although some authors have reported a higher recurrence rate in the NI children after the Thal repair. 13,23 It has been demonstrated in many studies that dexterity (translated into the operating time) improves significantly with experience. Champault et al studied the effect of the learning curve on the outcome of different laparoscopic fundoplications. They showed that the learning curve reached a plateau after the first 50 patients. 24 Paluzzi, in a series of 103 fundoplications, reported a significant reduction in the mean operating time, from an initial 202 minutes (in the first 50 cases) to 164 minutes (in his last 49 cases). 25 In our initial experience, the operating time was reduced significantly even after 10 cases (p<0.05). Currently, the time does not exceed 120 minutes. To avoid complications, regardless of the technique used, fundoplication should be performed with meticulous attention to details, including careful dissection, suture approximation of the crura and construction of a loose wrap around the esophagus. In our study, following such rules, no major intraoperative complications or peri-operative mortality were met. In the case with short gastric bleeding, the decision to convert to an open approach was taken early to assure safety, putting in mind our limited experience in managing such problem lapaoscopically. No cases of visceral perforation or splenic injury. Patients were carefully selected (none had previous upper abdominal surgery) to minimize the potential of organ injury in a field of dense adhesions. In the literature, following these rules, the incidence of major complications, as well as the need for re-operation, was low and remarkably similar between different center using different techniques Postoperatively, particular attention should be directed to correcting or preventing factors that favor breakdown of the fundoplication, including poor nutrition, gastric distention, delayed gastric emptying, mechanical small bowel obstruction, chronic lung disease, and seizures with retching. In our study, sedation and anti-seizure medications during the postoperative period were helpful in reducing seizure activity and the commonly observed retching and 14 Annals of Pediatric Surgery

6 Kabesh et al. posturing. Postoperatively, two of our patients developed postoperative temporary dysphagia and responded to medical treatment. Recurrence of symptoms occurred in 2 patients, the second and eighth cases in the study, the first presented after 3 months with heartburn, and was confirmed by an upper gastrointestinal contrast study and ph monitoring, and underwent an open Nissen fundoplication successfully, and the second showed recurrence of the pulmonary symptoms after one year follow up, an upper gastrointestinal contrast study and ph monitoring were performed and showed no reflux, the patient responded to medical treatments. Looking to our data, laparoscopic Nissen fundoplication was safe and effective in controlling the reflux symptoms. With minimal intra and post operative complication rates. In the literature, Laparoscopic surgery also provided advantages in the immediate postoperative period, was safe in terms of short- and long-term complications and led to a shorter hospital stay, less need for analgesics and better respiratory function. Intra-operative complications as bleeding and visceral perforation, or long-term complications such as wrap disruption and slipping, though recorded in many lapaoscopic series, do not constitute laparoscope-specific complication, as they were recorded in most open series as well CONCLUSIONS In our hands, laparoscopic Nissen fundoplication was a safe and effective treatment for children with GERD. Time to resume regular feeding, and hospital stay were comparable to other series. The low morbidity and absence of peri-operative mortality would encourage us to perform the technique in the younger age groups (less than 3 months of age). REFERENCES 1. Sharma P: Barrett esophagus: will effective treatment prevent the risk of progression to esophageal adenocarcinoma? Am J Med 117 Suppl 5A:79S-85S, Takeyama S, Numata A, Nenohi M, et al: Laparoscopic Nissen fundoplication for gastroesophageal reflux disease in Japan. Surg Today , Katada N: Review article: surgical and endoscopic therapy of gastro-oesophageal reflux disease in Japan. Aliment Pharmacol Ther 20 Suppl 8:28-31, Ostlie DJ, Miller KA and Holcomb GW (3 rd ): Effective Nissen fundoplication length and bougie diameter size in young children undergoing laparoscopic Nissen fundoplication. J Pediatr Surg 37 :1664-6, Ackroyd R, Watson DI, Majeed AW, et al.: Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease. Br J Surg 91:975-82, O'Riordan JM, Byrne PJ, Ravi N, et al.: Long-term clinical and pathologic response of Barrett's esophagus after antireflux surgery. Am J Surg 188:27-33, Powers CJ, Levitt MA, Tantoco J, et al.: The respiratory advantage of laparoscopic Nissen fundoplication. J Pediatr Surg 38:886-91, Patti MG, Robinson T, Galvani C, et al.: Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 198(6):863-9, Gold BD: Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications? Am J Med 117 Suppl 5A:23S-9S, Allal H, Captier G, Lopez M, et al:. Evaluation of 142 consecutive laparoscopic fundoplications in children: effects of the learning curve and technical choice. J Pediatr Surg 36:921-6, Hatch KF, Daily MF, Christensen BJ, et al.: Failed fundoplications. Am J Surg 188:786-91, Khajanchee YS, Hong D, Hansen PD, et al.: Outcomes of antireflux surgery in patients with normal preoperative 24- hour ph test results. Am J Surg 187: , Jesch NK, Schmidt AI, Strassburg A, et al.: Laparoscopic fundoplication in neurologically impaired children with percutaneous endoscopic gastrostomy. Eur J Pediatr Surg 14: 89-92, Thompson LD, McElhinney DB, Jue KL, et al.: Gastroesophageal reflux after repair of atrioventricular septal defect in infants with trisomy 21: a comparison of medical and surgical therapy. J Pediatr Surg 34: , Fonkalsrud EW, Bustorff-Silva J, Perez CA, et al.: Antireflux surgery in children under 3 months of age. J Pediatr Surg 34:527-31, Lukish JR, Eichelberger MR, Henry L, et al.: Gastroesophageal intussusception: a new cause of acute esophageal obstruction in children. J Pediatr Surg 39:1125-7, Bustorff-Silva J, Perez CA, Fonkalsrud EW, et al.: Gastric emptying after fundoplication is dependent on changes in gastric volume and compliance. J Pediatr Surg 34:1232-5, 1999 Vol 1, No 1, October

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