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The IPEG Annual Congress joins with:. II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) VII Congress of the Federation of Pediatric Surgical Associations of the South Cone of America (CIPESUR). - PowerPoint PPT PresentationTRANSCRIPT
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The IPEG Annual Congress joins with:• II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) • VII Congress of the Federation of Pediatric Surgical
• Associations of the South Cone of America (CIPESUR)
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Current Thoughts About Laparoscopic Fundoplication in
Infants and Children
George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital
Kansas City, Missouri
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GERDBarriers to Mucosal Injury
• LES
• Esophageal IAL
• Angle of His
• Esophageal motility
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Transient LES Relaxations
• LES relaxation not related to swallowing
• Thought to be the primary mechanism for GERD in children
Werlin SL, et al: J Peds 97:244-249, 1980Werlin SL, et al: J Peds 97:244-249, 1980
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Barriers to Injury2. IAL Esophagus
• Adults - > 3 cm, 100% LES competency
- 3 cm, 64%
- <1 cm, 20%
• Important to mobilize intraabdominal esophagus and secure it into abdomen
*DeMeester, et al: Am J Surg 137: 39-46, 1979*DeMeester, et al: Am J Surg 137: 39-46, 1979
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Barriers to Injury
• Normally, an acute angle
• When obtuse, more prone to GER
• Important consideration following gastrostomy
3. Angle of His
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Treatment Options
• Medical
• Surgical
• Endoluminal
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Preoperative Evaluation
• 24 hr pH study
• Upper GI contrast study
• Endoscopy
• Endoscopy with biopsy
• Gastric emptying study ?
• Esophageal motility study ?
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Preoperative EvaluationGastric Emptying Study ?
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GERDFundoplication
Indications for operation
Failure of medical therapy
ALTE/weight loss in infants
Refractory pulmonary symptoms
Neurologically impaired child who needs gastrostomy
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Options for Fundoplication
• Laparoscopic vs open
• Complete (Nissen) vs Partial (Thal,
Boix-Ochoa, Toupet)
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ISSUES/QUESTIONSISSUES/QUESTIONS
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Laparoscopic Fundoplication
• Significant hx of cardiac disease
• Significant hx of lung disease
BPD
Significant O2 still needed
• Chronic NICU baby
• Previous upper abdominal operations?
1. When is it not a good option?
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Pneumoperitoneum
• SVR
• PVR
• SV
• CI
• Venous Return (Head up)
• pCO2
• FRC
• pH
• pO2
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Proceed With Caution VSD with reactive pulmonary HTN
CAVC – ( PVR 2o to pCO2, pO2, pH) Neonates (in general) with reactive or persistent P-
HTN Palliated defects with passive pulmonary blood flow
(Glenn, Fontan procedures) – Risk is pulmonary flow, reversal of flow thru shunt and clotting of shunt
Any defect adversely affected by SVR• HLHS• CHF (unrepaired septal defects: VSD, CAVC)
• Risk is acute CHF 2o to afterload & shunting, unbalancing the defect
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Laparoscopic Fundoplication
2. Can a loose, floppy, complete (Nissen)
fundoplication be performed without
ligation of the short gastric vessels?
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Laparoscopic Fundoplication
No
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Laparoscopic Fundoplication
3. Is dysphagia a common problem
following laparoscopic Nissen
fundoplication in infants and
children?
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Intraoperative Bougie Sizes
PAPS 2002PAPS 2002
J Pediatr Surg 37:1664-1666, 2002J Pediatr Surg 37:1664-1666, 2002
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Laparoscopic Fundoplication
4. Can stab (3mm) incisions be used rather than cannulas for laparoscopic operations and is there a financial advantage?
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Laparoscopic Fundoplication
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The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4
Nissen (14) 2 3
Heller Myotomy (7) 2 3
Appendectomy (102) 2 1
Meckel’s Diverticulum (2) 2 1
Pyloromyotomy (77) 1 2
Cholecystectomy (31) 2 2
Pullthrough (20) 2 1
Splenectomy (21) 2 2
Adrenalectomy (6) 2 2
UDT (15) 1 2
Varicocele (5) 1 2
Ovarian (2) 1 2
Totals (511) 714 1337
PAPS 2003PAPS 2003J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
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Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) 5,880 / 2,604 3,864 / 1,722 Heller (7) 2,940 / 1,302 1,932 / 861 Appy (102) 14,280 / 6,324 9,384 / 4,182 Meckel’s (2) 280/ 124 184 / 82 Pyloric (77) 21,560 / 9,548 14,168 / 6,314 Chole (31) 8,680 / 3,844 5,704 / 2,542 Pullthrough (20) 2,800 / 1,240 1,840 / 820 Spleens (21) 5,880 / 2,604 3,864 / 1,722 Adrenal (6) 1,680 / 744 1,104 / 492 UDT (15) 4,200 / 1,860 2,760 / 1,230 Varicocele (5) 1,400 / 620 920 / 410 Ovarian (2) 560 / 248 368 / 164 Total = 511 $187,180/$82,894 $123,004/$54,817
PAPS 2003PAPS 2003J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
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Laparoscopic Fundoplication
5. Is there a financial advantage with the
laparoscopic approach when compared
to the open operation?
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Clinical and Financial Analysis of Pediatric Laparoscopic versus Open Fundoplication
100 Patients
Favoring LF P Value Favoring OF P Value
LOS (1.2 vs 2.9 days) <0.01 Op Time (77 vs 91 min) 0.03
Initial Feeds (7.3 vs 27.9 hrs)
Full Feeds (21.8 vs 42.9 hrs)
<0.01
<0.01
Hospital Room ($1290 vs $2847)
Pharmacy ($180 vs $461)
Equipment ($1006 vs $1609)
0.004
0.01
0.003
Anesthesia ($389 vs $475)
Operating Suite ($4058 vs $5142)
Central Supply/Sterilization ($1367 vs $2515)
0.01
0.04
<0.001
Total Charges Similar (LF - $11,449 OF - $11,632)IPEG 2006IPEG 2006
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Laparoscopic Fundoplication
6. Should the esophagus be extensively mobilized in laparoscopic fundoplication?
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Current Thoughts
1. Less mobilization of esophagus
2. Keep peritoneal barrier b/w esophagus & crura
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Current Thoughts
3. Secure esophagus to crura at 8, 11, 1 and 4 o’clock
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Laparoscopic FundoplicationCurrent Technique
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Personal Series - CMHJan 2000 – March 2002
130 PtsNo Esophagus – Crural Sutures
Extensive Esophageal Mobilization
Mean age/weight 21 mo/10 kg
Mean operative time 93 minutes
Transmigration wrap 15 (12%)
Postoperative dilation 0APSA 2006 APSA 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
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Personal Series - CMHApril 2002 – December 2004
119 PtsEsophagus – Crural Sutures
Minimal Esophageal Mobilization
Mean age/weight 27 mo/11 kg
Mean operative time 102 minutes
Transmigration wrap 6 (5%)
Postoperative dilation 1
APSA 2006 APSA 2006 J Pediatr Surg 42:25-30, 2007J Pediatr Surg 42:25-30, 2007
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The relative risk of wrap transmigration
in patients without esophago-crural
sutures and with extensive esophageal
mobilization was 2.29 times the risk if
these sutures were utilized and if minimal
esophageal dissection was performed.
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Patients Less Than 60 MonthsGroup I
Jan 00-March 02
117 Pts
Group II
April 02-Dec 04
102 Pts
P Value
Mean Age (mos) 10.26 10.95 0.650
Mean Wt (kg) 7.03 7.17 0.801
Gastrostomy 47% 46% 0.893
Neuro Impaired 71% 61% 0.118
Wrap Transmigration
14 (12%) 6 (6%) 0.159
The relative risk of transmigration of the wrap is 2.03 times greater for Group I than for Group II
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Patients Less Than 24 MonthsGroup I
Jan 00-March 02
104 Pts
Group IIApril 02-Dec 04
93 PtsP Value
Mean Age (mos) 6.99 8.15 0.175
Mean Wt (kg) 6.32 6.46 0.759
Gastrostomy 46% 46% 0.999
Neuro Impairment
73% 60% 0.069
Wrap Transmigration 13 (12%) 6 (6%) .226
The relative risk of transmigration of the wrap is 1.94 times greater for Group I than for Group II
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Group II119 Patients
Esophago-Crural Sutures
# Patients Transmigration %
2 silk sutures 20 5 25%(9, 3 o’clock)
3 silk sutures 43 1 2.3%(9, 12, 3 o’clock)
4 silk sutures 56 0 0%(8, 11, 1, 4 o’clock)
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Prospective, Randomized Trial
• 2 Institutions: CMH, CH-Alabama
• Power Analysis: 360 Patients
• Primary endpoint-transmigration rate
(12% vs.5%-retrospective data) • 2 Groups: minimal vs. extensive
esophageal dissection
• Both groups receive esophago-crural
sutures
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Re-Do Fundoplication
• Jan 00 – March 02
15/130 Pts – 12%
• April 02 – December 06
7/184 Pts – 3.8%
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Re-Do Fundoplication
22 Pts• All but one had transmigration of wrap
• Mean age initial operation – 12.6 (±5.8) mos
• 11 had gastrostomy
• Mean time b/w initial operation & 1st redo – 14.1 (±1.7) mos
• F/U – Minimum -19 mos
Mean - 34 mos
Accepted, J Pediatr SurgAccepted, J Pediatr Surg
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Re-Do FundoplicationOperative Technique
21/249Pts
Laparoscopic Re-Do – 10
• No SIS – 9
Open Redo with SIS - (1)
• SIS1
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Re-Do FundoplicationOperative Technique
21/249 Pts
Open Re-Do - 11
• SIS - 7
• No SIS - 4
2 required open re-do with SIS
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Re-Do Laparoscopic Fundoplication
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SIS and Paraesophageal Hernia Repair
• Multicenter, prospective randomized trial
• 108 patients
• Recurrence: 7% vs 25% (1o repair)
• No mesh related complications
Oelschlager BK, et alOelschlager BK, et alASA Meeting, April 2006ASA Meeting, April 2006
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Postoperative StudiesNissen Fundoplication
• number and magnitude TLESR 1, 2
• Disruption efferent vagal input to GE junction with TLESR3
1. Ireland, et al: Gastroenterology 106:1714-1720, 19942. Straathof, et al: Br J Surg 88: 1519-1524, 20013. Sarani, et al: Surg Endosc 17:1206-1211 2003
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Laparoscopic Nissen FundoplicationSummary
• The use of stab incisions for instrument access results in significant financial savings to the patient and institution.
• The incidence of transmigration of the fundoplication wrap has been markedly reduced with the use of esophageal-crural sutures and minimal esophageal mobilization.
• The long-term functional results should be equivalent to the open operation. The major advantages lie in reduced discomfort and hospitalization, faster return to routine activities and cosmesis.
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