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Laparoscopic Nissen Fundoplication in Children An Initial Experience

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					                                                           Annals of Pediatric Surgery, Vol 1, No 1, October 2005: PP 10-16

  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        edical treatment of gastroesophageal reflux
         disease (GERD), especially after introduction
of the proton pump inhibitors (PPI), is generally very
                                                               patients need, however, some may not get enough
                                                               benefit and surgical intervention is warranted.2
                                                               Laparoscopy has revolutionized the surgical
effective.1 In most cases, this is usually all what the        management of the disease and has become the

Correspondence to: Correspondence to: Ashraf A. Kabesh M.D, 10 Salah Galal St, Heliopolis, 11351 Cairo, Egypt.
                                                                                                        Kabesh et al.

preferred approach by most surgeons. This is mainly          another on the left. Patients were operated upon in 45-
as it combined both the high success rate with the           degree anti-Trendelenberg position. Five trocars were
well-known benefits of laparoscopy, including the            placed: one epigastric, one umbilical (the camera
shorter     hospitalization,   fewer     post    surgical    port), a right and a left subcostal, and one left iliac
complications and less pain compared to the open             fossa trocar. Trocar sizes and insufflation pressure
approach.3 Laparoscopic fundoplication in children,          depended on the size, weight and age of the child.
in contrast to its popular use in the adult form of          Trocar sizes were usually 3-5mm and insufflation
disease, is slowly taking its role as the norm.4-7 In this   pressure ranged from 5 to 9 mm Hg. The procedure
work, we report our initial experience with                  began with exposure of the esophageal hiatus by
laparoscopic Nissen fundoplication in children.              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
          MATERIAL AND METHODS                               expose the right crus. The dissection was then carried
                                                             cephalad and along the gastrophrenic membrane until
During a period of 3 years time (October 2002 –
                                                             the left crus was identified. A large posterior
October 2005), 13 patients (nine boys and four girls)
                                                             ‘window’ was then created with careful blunt
underwent laparoscopic fundoplication in the
                                                             dissection anterior and lateral to the left crus. The
pediatric surgery department, Ain Shams University
                                                             crura were dissected free for a distance of 2 to 3
Hospitals.    The    preoperative,     operative    and
                                                             centimeters before narrowing of the hiatus with
postoperative data of these patients were reviewed
                                                             intracoporeal knots (Fig 2).       A large posterior
retrospectively. Age at operation ranged from 6
                                                             window was essential to provide enough room for the
months to 10 years (mean 27 months). Ten patients
                                                             subsequent fundoplication. The fundus was then
were neurologically normal (NN) and 3 were
                                                             pulled to the right side from behind the esophagus
neurologically impaired (NI). All patients had their
                                                             (Fig 3). The short gastric vessels were only divided if
gastroesophageal reflux documented preoperatively.
                                                             tethering the fundus (Fig 4). A bougie was then
Upper gastrointestinal contrast study was performed
                                                             inserted transorally to calibrate the wrap. The size of
for all patients. Endoscopy and 24-hour pH
                                                             the dilator was determined by size of the patient's
monitoring were performed when the diagnosis was
                                                             esophagus. The stomach wrap included adequate
in doubt (n = 4). Indications for surgery included
                                                             portion of the fundus to ensure a "floppy" wrap was
reflux refractory to medical therapy for more than 3
                                                             created. Both the right and left sides of the fundus
months in all patients. This was also associated with,
                                                             were secured with intracorporeal sutures, completing
vomiting in 8 patients, failure to thrive in 4 patients,
                                                             a 360 wrap around the lower esophagus (Fig 5). After
esophagitis in 3 patients and anemia in 3 patients.
                                                             withdrawal of the bougie, the wrap was secured to
Three patients were operated upon due to refractory
                                                             the patch with intracorporeal suture along the
reflux with repeated severe upper respiratory
                                                             superior edge. When a gastrostomy was indicated (in
infection and distress (Table 1). The mean period of
                                                             all the NI patients), it was performed laparoscopically
postoperative follow-up was 18 (6-35) months.
                                                             at the end of the procedure.
                                                                 Follow-up included clinical evaluation at 3, 6 and
Surgical technique:                                          12 months postoperatively. Upper gastrointestinal
                                                             contrast study was performed routinely to all patients
     Total (360 degree) fundoplication was performed
                                                             at 3 months. Endoscopy and pH monitoring were
in all patients with inclusion of both vagi in the wrap.
                                                             only used in patients with functional complications
Short gastric vessels division (SGVD) was performed          (heartburn, regurgitation or dysphagia), or when the
in four patients.                                            contrast study showed an abnormality
    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

Vol 1, No 1, October 2005                                                                                      11
                                                                                                     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

                                                      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
Fig 3. The fundus of the stomach brought behind the   gastrostomy was concurrently performed in all NI
esophagus.                                            patients. Mean operative time was 188 (135-240)
                                                      minutes in the first 10 cases and 126 (120-135) minutes

12                                                                                     Annals of Pediatric Surgery
                                                                                                       Kabesh et al.

in the last 3 cases (p<0.05). Oral intake began on the                         DISCUSSION
2nd postoperative day on average and resumption of
                                                           Following the advent of proton pump inhibitors (PPI),
normal feeding began on the third postoperative day
                                                           controversy arose as to where surgery should be
(mean). The mean date of discharge was
                                                           placed, if ever, in the general management plan of
postoperative day 4.
                                                           GERD.8,9 The high frequency of postoperative
     Two patients developed transient postoperative        complications, as well as poor outcomes, have been
dysphagia. They were managed conservatively, and           cited as indications for a rather extensive and lengthy
both were asymptomatic by the first postoperative          use of the medical therapy, despite the fact that
follow up. Recurrence of symptoms was observed in          volume reflux, and consequently pulmonary
two patients, the second and the eighth in the series.     aspiration, cannot be corrected by simply reducing
In the first case, heartburn recurred 3 months             gastric acid production.10 Furthermore, certain
postoperatively. An upper gastrointestinal contrast        medications (eg, omeprazole) are difficult to
study, endoscopy and pH monitoring confirmed               administer to infants, have side effects when given for
reflux recurrence. This patient underwent a redo open      prolonged periods, and are expensive.11 This is above
Nissen fundoplication successfully. In the second          all against the numerous published reports, from
patient, recurrent upper respiratory infection was         various centers, that document the satisfactory results
observed one year postoperatively, an upper                and the relatively few major complications of
gastrointestinal contrast study, endoscopy and pH          antireflux surgery in children, especially in the
monitoring excluded recurrent or residual reflux as        laparoscopy era.12
the cause. This patient responded well to medical
                                                               Individual and institutional bias has resulted in
treatment. The intra and postoperative complications
                                                           variation in the selection criteria for antireflux surgery
are shown in (Table 2).
                                                           in children. 6 However, all agree that patients should
Table 1. Preoperative symptoms (n = 13)                    complete at least a three-month period of medical
                                                           treatment before the disease is considered refractory
Refractory reflux (RF)                     13
                                                           and before surgical referral. In our study, failure of
Vomiting                                   8               medical therapy has been associated with failure-to-
                                                           thrive, feeding disorders, respiratory symptoms and
Failure to thrive                          4
                                                           esophagitis. Most series would consider these as
Esophagitis                                3               indications for surgical intervention5
Anaemia                                    3                    The practice of fundoplication in the NI children
Respiratory symptoms                       3               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
Table 2. Intra-operative & Post-operative                  total number of cases in some studies. On the other
Complications.                                             hand, as the morbidity in such a high-risk group of
                                                           patients is likely to increase four folds, compared to
Intra-operative complications and course                   the NN patients, some consider this inappropriately
Intraoperative               Conversion to open            high and unless severe GERD is demonstrated, a
bleeding                     technique                     percutaneous endoscopic gastrostomy (PEG) would
                                                           be all what they offer.13 As a new technique in our
Inadequate                   Conversion to open
                                                           department, the NI patients subjected to the
                                                           laparoscopic Nissen fundoplication (23% of the cases)
Postoperative complications and course                     were carefully selected (minimal cardiopulmonary
Dysphagia                2   Medical treatment
                                                               The need for antireflux surgery in the premature
                             Slipped wrap requiring open
Heartburn                1                                 infants has recently been recognized. Investigators
                             redo Nissen fundoplication
                                                           have reported a close association between chronic
Recurrent respiratory                                      respiratory distress and GERD in premature
                         1   Medical treatment
infection                                                  newborns. Similarly, many infants with complex

Vol 1, No 1, October 2005                                                                                     13
                                                                                                         Kabesh et al

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

14                                                                                        Annals of Pediatric Surgery
                                                                                                              Kabesh et al.

posturing.     Postoperatively, two of our patients            4. Ostlie DJ, Miller KA and Holcomb GW (3rd): Effective
developed postoperative temporary dysphagia and                Nissen fundoplication length and bougie diameter size in
responded to medical treatment. Recurrence of                  young     children    undergoing      laparoscopic Nissen
                                                               fundoplication. J Pediatr Surg 37 :1664-6, 2002
symptoms occurred in 2 patients, the second and
eighth cases in the study, the first presented after 3         5. Ackroyd R, Watson DI, Majeed AW, et al.: Randomized
months with heartburn, and was confirmed by an                 clinical trial of laparoscopic versus open fundoplication for
upper gastrointestinal contrast study and pH                   gastro-oesophageal reflux disease. Br J Surg 91:975-82, 2004
monitoring, and underwent an open Nissen                       6. O'Riordan JM, Byrne PJ, Ravi N, et al.: Long-term clinical
fundoplication successfully, and the second showed             and pathologic response of Barrett's esophagus after
recurrence of the pulmonary symptoms after one year            antireflux surgery. Am J Surg 188:27-33, 2004
follow up, an upper gastrointestinal contrast study            7. Powers CJ, Levitt MA, Tantoco J, et al.: The respiratory
and pH monitoring were performed and showed no                 advantage of laparoscopic Nissen fundoplication. J Pediatr
reflux, the patient responded to medical treatments.           Surg 38:886-91, 2003
     Looking to our data, laparoscopic Nissen                  8. Patti MG, Robinson T, Galvani C, et al.: Total
fundoplication was safe and effective in controlling           fundoplication is superior to partial fundoplication even
the reflux symptoms. With minimal intra and post               when esophageal peristalsis is weak. J Am Coll Surg
operative complication rates. In the literature,               198(6):863-9, 2004
Laparoscopic surgery also provided advantages in the           9. Gold BD: Gastroesophageal reflux disease: could
immediate postoperative period, was safe in terms of           intervention in childhood reduce the risk of later
short- and long-term complications and led to a                complications? Am J Med 117 Suppl 5A:23S-9S, 2004
shorter hospital stay, less need for analgesics and            10.Allal H, Captier G, Lopez M, et al:. Evaluation of 142
better     respiratory   function.     Intra-operative         consecutive laparoscopic fundoplications in children: effects
complications as bleeding and visceral perforation, or         of the learning curve and technical choice. J Pediatr Surg
long-term complications such as wrap disruption and            36:921-6, 2001
slipping, though recorded in many lapaoscopic series,
                                                               11.Hatch KF, Daily MF, Christensen BJ, et al.: Failed
do not constitute laparoscope-specific complication,           fundoplications. Am J Surg 188:786-91, 2004
as they were recorded in most open series as well.26-30
                                                               12.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 187:599-603, 2004
                                                               13. Jesch NK, Schmidt AI, Strassburg A, et al.: Laparoscopic
In our hands, laparoscopic Nissen fundoplication was           fundoplication in neurologically impaired children with
a safe and effective treatment for children with GERD.         percutaneous endoscopic gastrostomy. Eur J Pediatr Surg
Time to resume regular feeding, and hospital stay              14: 89-92, 2004
were comparable to other series. The low morbidity
                                                               14. Thompson LD, McElhinney DB, Jue KL, et al.:
and absence of peri-operative mortality would                  Gastroesophageal reflux after repair of atrioventricular
encourage us to perform the technique in the younger           septal defect in infants with trisomy 21: a comparison of
age groups (less than 3 months of age).                        medical and surgical therapy. J Pediatr Surg 34:1359-63,
                                                               15.Fonkalsrud EW, Bustorff-Silva J, Perez CA, et al.:
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16                                                                                              Annals of Pediatric Surgery