Stretta as the initial antireflux procedure in children

Background

The Stretta procedure is an endoluminal antireflux procedure using radio frequency to induce collagen tissue contraction, remodeling, and modulation of lower esophageal sphincter physiology in an effort to treat gastroesophageal reflux disease (GERD). Although Stretta has been widely reported in the adult GERD literature as a viable initial surgical option, similar use in children has not been reported. The authors present the first report of Stretta as the initial antireflux procedure in children with GERD, evaluating indications, safety, and efficacy.

Method

The charts of 8 children (aged 11-16 years) who received Stretta between January 2003 and September 2003 were retrospectively reviewed under an Institutional Review Board protocol. All patients had documented GERD preoperatively. Three children required concomitant feeding tube placement (percutaneous gastrostomy tube, group A). Five children with isolated severe GERD refractory to aggressive medical therapy received Stretta only (group B).

Results

Stretta was successfully completed in all 8 children. In group A, 1 child developed a postoperative aspiration, which was successfully treated. All 3 children had resolution of their GERD symptoms (ie, feeding intolerance, emesis) and were able to tolerate full enteral nutrition post-Stretta. In group B, 3 of 5 children are currently off medications and asymptomatic on short-term follow-up (6-15 months). Of the remaining 2, 1 experienced symptomatic relief immediately postprocedure, but symptoms recurred off medications. Stretta was deemed unsuccessful in the remaining patient, and Nissen fundoplication was subsequently performed without difficulty.

Conclusions

Stretta can be safely and successfully used as the initial antireflux procedure for children with GERD. Concomitant Stretta with PEG is an attractive option in children with preexisting GERD who require long-term feeding access. Longer follow-up and a larger patient population are needed to better confirm the safety and efficacy of Stretta presented in this report.     

Watson fundoplication in children: a comparative study with Nissen fundoplication

Background

Nissen fundoplication is the gold standard antireflux procedure in children. In 1996, one pediatric surgeon adopted the anterior fundoplication described by Watson in 1991. This procedure is reported to achieve good reflux control while permitting burping, active vomiting, and reducing gas bloat. An audit project was undertaken to compare the clinical outcome of children undergoing Nissen and Watson fundoplication.

Methods

The case notes of 144 children undergoing open fundoplication between February 1995 and February 2002 were reviewed retrospectively.

Results

Results of 72 boys and 59 girls comprising 76 Nissen and 55 Watson fundoplications were assessed. In each group, one death occurred within 1 month of operation. Chest infections occurred in 6.6% (Nissen) and 1.8% (Watson), and wound infections in 2.6% and 1.8%, respectively. Dysphagia was recorded in 7.9% of Nissen and 1.8% of Watson fundoplications. Follow-up data were analyzed in 70 children with Nissen and 48 children with Watson fundoplication. When overall clinical outcome was assessed for those patients with a minimum follow-up of 1 year, 85.1% Nissen and 88.2% Watson were judged good/excellent; 14.9% Nissen and 11.8% Watson were judged poor/bad.

Conclusion

Watson fundoplication can safely be performed in children with comparable clinical outcome to Nissen fundoplication.     

Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I

Background/Purpose

Spinal muscular atrophy (SMA) in children leads to progressive muscle weakness, dysphagia, aspiration, and death. We hypothesized that early laparoscopic fundoplication and gastrostomy in infants with SMA type I could be performed safely perhaps leading to fewer aspiration events and improved nutritional status.

Methods

Children diagnosed with SMA type I from 2002 through 2005 were included (n = 12). All children underwent laparoscopic Nissen fundoplication with gastrostomy shortly after diagnosis. Postoperative respiratory management and discharge criteria were standardized.

Results

All patients were extubated immediately postoperatively. There were no significant complications. Average time to full feeding and inpatient length of stay were 42 ± 4.9 hours (range, 30-48 hours) and 78 ± 22.5 hours (range, 44-120 hours), respectively. Mean weight-for-length percentile was doubled at 1 year postoperatively (P = .03). The number of respiratory-related hospitalizations in the cohort decreased by almost 50% in the ensuing 12 months after surgery, although this did not reach statistical significance in this small cohort (P = .34).

Conclusions

Early laparoscopic fundoplication and gastrostomy is safe and is associated with improved nutritional status. A trend toward fewer significant long-term aspiration-related events was seen after fundoplication. To better assess the long-term benefits of performing an antireflux procedure in these high-risk patients, a larger prospective trial comparing current nutritional support practices is needed.     

Outcomes after laparoscopic surgery in neonates with hypoplastic heart left heart syndrome

Background/Purpose

Laparoscopy has advanced the care of children for a variety of pediatric surgical diseases. However, complication rates for laparoscopic interventions in neonates with hypoplastic left heart syndrome (HLHS) have not been well described. The purpose of this study is to present the largest reported series of laparoscopic surgery performed in patients with HLHS.

Methods

We conducted a single-institution, retrospective chart review for all neonates with HLHS who underwent a laparoscopic procedure from September 2002 to March 2005. Data regarding patient characteristics, intraoperative monitoring, previous cardiac surgery, perioperative complications, and postoperative mortality were assessed.

Results

Twelve patients with HLHS underwent a total of 13 operations during the study period (8 combined Nissen fundoplication and gastrostomy tubes, 3 isolated gastrostomy tubes, 1 Ladd procedure, and 1 combined Nissen fundoplication and gastrocutaneous fistula closure). All cases were completed laparoscopically. Patients had undergone palliative cardiac surgery but were not completely corrected; therefore, they were cyanotic. Perioperative complications were observed in 6 patients (3 gastrostomy tube site infections, 1 small bowel obstruction, 1 postoperative sepsis, and 1 urinary tract infection). There was no mortality in this series.

Conclusions

From this experience, it appears that laparoscopy can be performed safely and with satisfactory outcomes in patients with HLHS. However, a multidisciplinary approach, including the availability of a skilled and experienced cardiac anesthesia team, is believed to be critical to optimize outcomes in these critically ill children.     

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.     

The respiratory advantage of laparoscopic Nissen fundoplication

Background/purpose

Laparoscopic Nissen fundoplication is replacing the open approach in the treatment of children with gastroesophageal reflux. The postoperative respiratory advantages seem obvious but remain unproven. The authors hypothesized that laparoscopic Nissen fundoplication provides postoperative respiratory advantages in neurologically normal children as well as those with mental retardation or profound neurologic impairment.

Methods

The charts of all laparoscopic Nissen fundoplications over a 4-year period were reviewed. Sixty-one laparoscopic procedures were compared with the most recent 61 consecutive open Nissen fundoplications. The following variables were reviewed: age, weight, gender, preexisting comorbidities, operating time, postoperative pulmonary complications, and length of stay. Categorical data were compared for significance utilizing χ² cross tabulation. Variables representing numerical data were compared by t test.

Results

Although there appeared to be a trend toward sicker patients in the open group, the laparoscopic group showed significantly improved rates of extubation, shorter recovery room stays, shorter durations of chest physiotherapy, fewer intensive care unit admissions, more rapid resumption of baseline feedings, and overall decreased length of stay (P < 0.05). Pulmonary benefits also were noted in the neurologically impaired population when analyzed separately.

Conclusions

Laparoscopic Nissen fundoplication confers a definable benefit with a significant pulmonary advantage in both neurologically normal children and those with neurologic impairment.     

Laparoscopic Nissen Rossetti fundoplication in situs inversus totalis—A blessing in disguise

INTRODUCTION

Laparoscopic Nissen fundoplication and Nissen Rossetti fundoplication represent two different surgical approaches for treating hiatus hernia. We report a Laparoscopic Nissen Rossetti fundoplication (LNRF) for gastro esophageal reflux disease (GERD) in a patient with situs inversus totalis (SIT).

PRESENTATION OF CASE

: A 38-year-old man with SIT was diagnosed with sliding hiatus hernia. We performed Laparoscopic Nissen Rossetti procedure for this patient. The patient was discharged on first postoperative day after he tolerated oral liquids.

DISCUSSION

SIT is a rare anomaly presenting in 1–2 per 10,000 individuals. As this rare anomaly (SIT) led preoperative anticipation of respiratory and blood loss complications the above procedure was chosen. Less operating time, less calculated blood loss and improvement of symptoms with no associated gas bloating syndrome was noted especially with SIT.

CONCLUSION

We recommend relook into the Laparoscopic Nissen Rossetti fundoplication as an effective procedure in GERD especially with rare anomalies like SIT.     

Unilateral Versus Bilateral Wrap Crural Fixation in Laparoscopic Nissen Fundoplication for Children

Introduction:

Gastroesophageal reflux (GERD) is common in neurologically impaired (NI) children. Fundoplication and gastrostomy have previously been indicated in NI children with GERD who have not responded to medical treatment. The most common reason for fundoplication failure is intrathoracic migration of the wrap.

Objective:

The aim of the study is to measure the effect of wrap fixation on the final outcome of laparoscopic Nissen fundoplication in NI children.

Patients and Methods:

A retrospective file review was conducted for all NI children who underwent laparoscopic Nissen fundoplication in 2 tertiary pediatric surgery centers in the United Arab Emirates from February 15, 2006 to February 15, 2013. Redo fundoplication patients were excluded from the study. Patients were divided into 2 groups: group 1 in which the fundoplication wrap was fixed to the right crus only, and group 2 in which the wrap was fixed to the right and left crus simultaneously.

Results:

The study population included 68 patients; there were 47 male and 21 female children. Mean age at time of surgery was 8.2 years. Recurrent GERD at 1 year postoperatively was 26% versus 7% in group 1 and group 2, respectively, by upper contrast study. Redo surgery was required in 21% versus 3% in group 1 and group 2, respectively.

Conclusions:

Bilateral fixation of the wrap to diaphragmatic crura significantly reduced recurrent GERD, in laparoscopic Nissen fundoplication for neurologically impaired children, with no increased risk of morbidities. Future prospective studies should be conducted with larger patient populations and longer follow-up periods.     

Preoperative prediction of need for fundoplication before gastrostomy tube placement in children

Purpose

Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure performed for children with oral aspiration and failure to thrive. The concurrent presence of gastroesophageal reflux (GER) may be difficult to diagnose in these children and may dictate the need for an antireflux procedure. The purpose of this study was to review our preoperative evaluation of children undergoing PEG placement to better elucidate preoperative factors that may require eventual fundoplication.

Methods

A retrospective review at a tertiary care, children's hospital between May 2002 and August 2007 was performed of patients undergoing PEG placement. Patients were identified through database search by operative procedure codes. Patient groups were defined as those undergoing PEG alone (group 1) and those requiring fundoplication after prior PEG (group 2). Comparison of patient demographics and radiologic qualitative results of GER was analyzed using χ² analysis, with significance determined at P < .05.

Results

A total of 863 patients underwent PEG placement over this 64-month period. A sampled cohort of patients undergoing PEG over a year comprised group 1. Forty-four patients (5.1%) underwent Nissen fundoplication after prior PEG placement (group 2). Patient demographics were similar between the groups. Comparison of comorbid conditions and qualitative indicators of GER between the groups showed only cerebral palsy had a significantly higher associated risk of GER that required antireflux surgery. Preoperative clinical assessment had a 95% positive predictive value in identifying children who required only PEG.

Conclusions

Despite the high predictive value of individualized clinical assessment in the ultimate decision for gastrostomy without need of fundoplication, further studies are needed to determine whether children with conditions such as cerebral palsy may require a concurrent antireflux surgery at the time of gastrostomy.     

Use of esophagocrural sutures and minimal esophageal dissection reduces the incidence of postoperative transmigration of laparoscopic Nissen fundoplication wrap

Objectives

Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome.

Methods

A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II).

Results

Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29.

Conclusions

This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication.     

Inflammatory response in children after laparoscopic vs open Nissen fundoplication: randomized controlled trial

We performed a randomized controlled trial to compare the inflammatory and immune responses to Nissen fundoplication in infants and children undergoing either open or laparoscopic surgery.

Methods

Forty children undergoing Nissen fundoplication were randomized to laparoscopy or open surgery using minimization with respect to age, neurologic status, and operating surgeon. Intraoperative and postoperative analgesias were standardized. Inflammatory markers (plasma malondialdehyde, nitrate plus nitrite level, and cytokines) and monocyte class II major histocompatibility complex expression were measured preoperatively, at end of surgery, 4, 24, and 48 hours postoperatively. Postoperative changes were compared between open and laparoscopic groups.

Results

There were no significant changes in circulating malondialdehyde, nitrates plus/ nitrite, interleukin-10, or tumor necrosis factor α in the postoperative period in either group. Interleukin-1 receptor antagonist (IL-1rA) and IL-6 were significantly increased in both groups, with a tendency for greater elevation of IL-1rA in the open group. Monocyte major histocompatibility complex expression fell significantly in both groups; however, this fall appeared to be slightly more marked in the open group.

Conclusions

The postoperative cytokine response is similar in children undergoing open and laparoscopic Nissen fundoplication. This trial indicates that laparoscopy may partly reduce postoperative immune suppression.     

A reinforced suture line prevents recurrence after fundoplication in patients with familial dysautonomia

Background/Purpose

Long-term follow-up of fundoplication in patients with familial dysautonomia (FD) has revealed a high rate of recurrent gastroesophageal reflux. This may be because of the unique characteristics of patients with FD which include autonomic denervation accompanied by cyclic vomiting and retching. We reviewed our results with adaptations to the Nissen fundoplication to determine which would be most effective in preventing the need for reoperation.

Methods

We reviewed the records of 108 patient with FD who underwent fundoplication by a single pediatric surgeon from November 1978 to July 1, 2004. Patients were divided into 4 groups based on the operative technique: standard Nissen fundoplication, Nissen with a posterior gastropexy, Nissen with posterior gastropexy and a superior anchoring suture, and Nissen with a reinforced suture line in addition to the previous modifications. Demographic data and surgical outcomes were abstracted.

Results

Patients who underwent a Nissen fundoplication with a reinforced suture line were significantly less likely to require a reoperation for recurrent reflux than any other patients (P = .05, Fisher's Exact test) despite the fact that they were younger than patients who underwent a standard Nissen alone.

Conclusion

The addition of a reinforced suture line to the standard Nissen fundoplication decreases the failure rate for patients with gastroesophageal reflux and FD. A reinforced suture line may be an attractive modification for patients where the fundoplication may be under continued physical stress caused by autonomic perturbations, or other conditions such as uncontrolled seizures or progressive neurologic decline.     

Effectiveness of alimemazine in controlling retching after Nissen fundoplication

Background

Retching, an early component of the emetic reflex, is a common and distressing symptom in children after Nissen fundoplication. Alimemazine (trimeprazine, Vallergan; Castlemead, Herts, UK) is a phenothiazine derivative histamine₁ antagonist, which anecdotally relieves the retching symptoms.

Material and Methods

A prospective, double-blind, randomized, crossover, placebo-controlled study of 15 neurologically impaired children with retching after Nissen fundoplication over a period of 1 year (December 2002-December 2003). Patients were randomly allocated to receive 1 week each of alimemazine and placebo with crossover. A diary was maintained of retching episodes 1 week before, during, and 1 week after the trial. Dosage of alimemazine used was 0.25 mg/kg 3 times a day (maximum, 2.5 mg per dose). Statistical analysis was done using a paired Student's t test, where P value of less than .05 was considered significant. Results are presented as mean ± SD.

Results

Twelve parents completed the diaries (9 open, 3 laparoscopic Nissen fundoplication). Median age of the child was 36 months (8-180 months), median duration of retching was 4.5 months (1-52 months), and mean number of retching episodes per week was 60 ± 29.40. Mean number of retching episodes with alimemazine was 10.42 ± 9.48 vs 47.67 ± 27.79 with a placebo (P < .0001). No adverse effects were reported in those cases that completed the study.

Conclusion

At low dose, alimemazine (Vallergan) is a safe and effective drug in the management of retching after Nissen fundoplication.     

Outcomes of fundoplication in children with cystic fibrosis

Purpose

Children with cystic fibrosis (CF) have a high prevalence of gastroesophageal reflux disease (GERD). As GERD is associated with chronic respiratory symptoms and feeding problems, fundoplication is often performed in children with CF. Although the outcomes of fundoplication have been described across diverse pediatric groups, there is no published experience with CF.

Methods

The records of 25 children with CF who underwent fundoplication in our center were reviewed. Data on symptoms and diagnostic testing results as well as on complications related to fundoplication were collected. Nutritional parameters and pulmonary function were compared before and after fundoplication.

Results

There was no mortality associated with fundoplication, but 12% had complications that required a subsequent surgical procedure. Whereas 28% were able to discontinue their antireflux medications, 48% developed symptoms of recurrent GERD. Overall, there was no change in body mass index, body mass index percentile, or the slope of forced expiratory volume in 1 second (FEV₁) after fundoplication. Children who had an FEV₁ of less than 60% predicted at the time of fundoplication exhibited an improvement in FEV₁ slope compared to those with FEV₁ of 60% or more (+5.3% vs −8.6% per year, P = .004).

Conclusion

The complication rate of fundoplication is similar to what has been reported in large series in children without CF. There is a high rate of recurrent GERD and little apparent benefit for either nutritional or pulmonary outcomes. The observed difference on FEV₁ slope, in those with moderate-severe vs mild lung disease, highlights the need to thoroughly evaluate the role of fundoplication in children with CF.     

Gastrostomy revision: incidence and indications

Background/purpose

Although quite reliable, gastrostomy may require revision. However, there are no reports in the literature specifically delineating identifiable risk factors or circumstances that lead to gastrostomy revision in children with gastrostomy. The purpose of this report was to determine the rate of revision and correlate any factors that may lead to revision.

Methods

A retrospective chart review was performed on 1,042 children who underwent gastrostomy at The Children’s Hospital, Denver, Colorado, between 1992 and 2002. Charts of children who underwent gastrostomy were reviewed for pertinent clinical factors and compared with those who required gastrostomy revision.

Results

Of the 1,042 children, who had gastrostomies, 67 revisions were required in 61 children (6%). Of the many possible factors that could have had an influence on the revision rate, only fundoplication, percutaneous endoscopic gastrostomy (PEG), migration of the gastrostomy site, and time correlated with the need for gastrostomy revision.

Conclusions

Parents should be made aware that there is a 6% chance that their child’s gastrostomy may need revision and that the need for revision may increase with PEG, initial construction before 18 months of age, and the advancing age of the gastrostomy. Surgeons should avoid placing the gastrostomy near the costal margin, making a large gastrostomy exit tract through the abdominal wall and inserting a gastrostomy into the nutritionally depleted pulmonary stressed neurologically challenged child without first attempting to improve the child’s nutritional status.     

The use of fundoplication for prevention of apparent life-threatening events

Objective

Gastroesophageal reflux disease (GERD) is cited by many to be a common cause of apparent life-threatening events (ALTEs). However, there are few reports in the literature regarding the surgical treatment of GERD to prevent a recurrent ALTE.

Methods

A retrospective review of infants undergoing fundoplication between 2000 and 2005 for the prevention of another ALTE was undertaken. Preoperative, operative, and postoperative data as well as follow-up information were collected.

Results

During the study period, 81 patients underwent fundoplication after presenting with an ALTE. All but 3 patients (96.3%) had been treated with antireflux medication. Moreover, 71 infants (87.7%) were taking antireflux medication at the time of their ALTE. A significant number of infants (77.8%) were hospitalized with a second ALTE before referral for fundoplication. After fundoplication, only 3 patients (3.7%) experienced a recurrent ALTE during the follow-up period; 2 required a second fundoplication and 1 underwent pyloromyotomy. None of these 3 patients have experienced a recurrent ALTE after the second operation. The median follow-up has been 1738 days.

Conclusion

Our data suggest that among patients who had an ALTE and are found to have GERD, fundoplication appears to be an effective method for preventing recurrent ALTE.     

Can laparoscopic antireflux surgery improve the quality of life in children with neurologic and neuromuscular handicaps?

Purpose

Children with neurologic and neuromuscular handicaps frequently have various symptoms related to gastroesophageal reflux (GER) disease. The long-term efficacy of antireflux surgery remains controversial in such children with GER. The clinical results of such patients who underwent laparoscopic fundoplication were examined in the current study.

Methods

Between 1997 and 2003, laparoscopic fundoplication was performed in 56 handicapped children (mean age, 6 years), and gastrostomy was performed concurrently in 52. The main symptoms were emesis/hematemesis in 40 and respiratory symptoms, including repeated respiratory infection and distress, in 31.

Results

There were no severe postoperative complications or operative mortality. Emesis/hematemesis was controlled adequately in those without recurrence. Respiratory symptoms were controlled unsuccessfully in 16 patients (52%), 8 of whom required further respiratory care including nasal airway tube, tracheostomy, and laryngotracheal separation. Recurrence of GER disease occurred in 10 patients, 7 of whom underwent a second Nissen fundoplication successfully. Thirteen died within the median follow-up period of 14 months.

Conclusions

Laparoscopic fundoplication is effective in controlling emesis/hematemesis, but its efficacy is limited in terms of respiratory problems in handicapped children. Further refinements in diagnostic and treatment strategies are mandatory to improve the quality of life in such patients.     

Esophagogastric separation for failed fundoplication in neurologically impaired children

Purpose

Recurrent gastroesophageal reflux (GER) after a fundoplication in severely neurologically impaired children is a frustrating problem without an effective solution: redo fundoplications carry a significant recurrence rate and gastrojejunostomy (GJ) tube feedings are associated with frequent tube dislodgment. The authors report a series of esophagogastric separation (EGS) procedures aimed at the management of failed fundoplication in neurologically impaired children.

Methods

Medical records of 10 patients who underwent EGS for recurrent GER were reviewed retrospectively. Variables examined included diagnosis, preoperative problems, operative and perioperative data, and outcomes.

Results

None of the patients were feeding orally and all were dependent on tube feedings. A median of 1.5 (range, 1 to 3) fundoplications had been performed previously and failed. All had preoperative emesis and feeding intolerance. Eight had failure to thrive and 5 recurrent pneumonias. Median age at the time of the procedure was 7.5 years (range, 2 to 22). Median postoperative length of stay was 9 days (range, 5 to 17), and there were no leaks from the anastomosis. Salivary secretion intolerance was the most common postoperative problem (5 of 10 patients). Repeat exploration was required for perforation of the colon in one and paraesophageal hernia in another. Recurrent GER was not noted. All 9 currently surviving children are tolerating bolus gastrostomy feedings, which was an advantage to the parents.

Conclusions

EGS is an attractive alternative for failed fundoplication in severely neurologically impaired children.     

Delayed gastric emptying and typical scintigraphic gastric curves in children with gastroesophageal reflux disease: could pyloromyotomy improve this condition?

Background/Purposes

Delayed gastric emptying (DGE) is a cofactor in the etiopathogenesis of gastroesophageal reflux disease (GERD). Scintigraphy is the criterion standard to evaluate gastric emptying (GE). This study aims to define typical scintigraphic activity-time curves (ATCs) related to DGE and esophageal atresia (EA) and to demonstrate the effectiveness of pyloromyotomy (P) in improving GE.

Methods

Since 2002, 83 children underwent Nissen fundoplication. Patients were divided into 2 groups: group I, GORD-only patients; group II, patients with GORD owing to OA. Depending on preoperative scintigraphy, each group was subdivided into 2 subgroups. Before surgery and 1 year after, endoscopy and scintigraphy were performed. In the presence of DGE, P was associated with Nissen fundoplication. Gastric emptying differences at baseline and at follow-up were estimated by the Student t test. Pre- and post-ATCs were evaluated by the χ² test.

Results

During follow-up, GE completely normalized in subgroups with DGE. Scintigraphic ATC analysis documented an association between DGE and a typical rectilinear fitting, with a higher rate in OA patients. After P, the scintigraphic pattern changed in an exponential manner related to a faster GE.

Conclusions

Delayed gastric emptying is frequent in OA, and the scintigraphic ATCs are typical. Pyloromyotomy is a safe and effective technique to fully normalize GE.     

The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication

Objective

There are a number of reports in the literature describing the need for a redo fundoplication in patients who have previously undergone open fundoplication. However, these data are not well characterized in our current era of laparoscopic surgery. The purpose of this report is to document the management of patients requiring a redo fundoplication who originally underwent a laparoscopic Nissen fundoplication.

Methods

After internal review board approval, the senior surgeon performed a retrospective chart review on all patients undergoing laparoscopic fundoplication between January 2000 and April 2006. Data collected included the patient's age, sex, neurologic impairment, need for gastrostomy, time interval between the initial and redo fundoplication, operative approach for the redo fundoplication, use of a biologic patch for the redo procedure, and length of follow-up.

Results

Two hundred seventy-three patients underwent laparoscopic Nissen fundoplication by the senior author during this time interval. Twenty-one patients have required a redo fundoplication and repair of the enlarged hiatus after laparoscopic fundoplication. No patient has undergone a redo procedure without the development of transmigration of the fundoplication wrap. A redo operation was performed without mesh in 13 patients, of which there were 4 recurrences (31%). The other 8 cases were repaired with Surgisis (Cook, Inc, Bloomington, Ind), and none of these have recurred, with a minimum of 11 months' follow-up and a mean follow-up of 26 months. In the 4 patients requiring a second redo procedure, the enlarged esophageal hiatus was reinforced with Surgisis, and none of these cases have recurred, with a minimum of 3 years' follow-up.

Conclusions

Our data support the use of a biosynthetic mesh to reinforce the crural closure during the repair of iatrogenic hiatal hernias in children.