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Laparoscopic Refundoplication in Childhood

Ciro Esposito¹, Francesca Alicchio¹, Francesco Corcione², Philippe Montupet ³, Alessandro Settimi ²

¹ Chair of Pediatric Surgery, Federico II University, Naples, Italy

² Department of Laparoscopic Surgery, Monaldi Hoispital, Naples, Italy

³ Clinique Chirurgical Boulogne Billancourt, Paris, France

 

Abstract

Background: The aim of this paper was to determine the feasibility of laparoscopic revision surgery in children following previous open and laparoscopic antireflux operations.

Methods: To give an objective overview about this topic we have preferred to analyze the outcome of 15 children (8 girls and 7 boys) who had undergone attempted laparoscopic revision between 4 months and 72 months (median 16 months) after a previous antireflux operation. Seven patients had previously had an open antireflux procedure ( 4 Nissen fundoplication, 3 Thal procedure) and 8 a laparoscopic procedure (5 Nissen; 3 Toupet’s procedure ). Two of these children were mentally handicapped. The indications for revision were: recurrent reflux, 5; valve migration, 5; valve dismount, 5. Eight procedures comprised construction of a new Nissen fundoplication, in 7 cases a Toupet’s procedure was performed.

Results: Revision was successfully completed laparoscopically in 10 cases; 7/8 patients following a previous laparoscopic procedure and in 3/7 following a previous open operation. Operating time ranged between 70 and 140 minutes (med 90 minutes). No perioperative complications occurred in either group.All patients were discharged within 3-4 days after the redo procedure. Follow-up time varied between 6 months- 7 yrs. Preoperative symptoms were relieved in all patients and all antireflux medication have been discontinued, except in two cases that still had rare symptoms .

Conclusions: Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with good results, in the hands of experienced endoscopic surgeons. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one. Concerning the type of procedure, is more difficult to perform a redo surgery after Nissen’s that after Toupet’s or Thal’s procedure.

Key words: GERD, Redo surgery, laparoscopy, children.

 

Correspondence:

Ciro Esposito

Via Bernini 58, 80129 Naples, Italy;

Tel: + 39.081. 746 33 77; Fax.+ 39.081.746 33 61;

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Introduction

Gastroesophageal fundoplication actually can be considered one of the most common major operations performed in infants and children by pediatric surgeons (5, 7). in about 3-7% of cases, laparoscopic technique can be adopted to treat patients in which antireflux surgery has failed (1, 6, 18). The reports concerning laparoscopic redo operations after failed antireflux procedure are rarely reported in children, of the contrary in the international literature there are a quite large experience concerning adults series (4, 16,17). The aim was to determine the feasibility of laparoscopic revision surgery following previous open and laparoscopic antireflux operations in children.

Methods

The authors, to avoid to write an excessively arid technical description of this topic, have preferred to analyze their experience of laparoscopic redo procedures in children after a failed antireflux procedure. The outcome was determined for 15 children children (8 girls and 7 boys) who had undergone attempted laparoscopic revision between 4 months and 72 months (median 16 months) after a previous antireflux operation. Seven patients had previously had an open antireflux procedure ( 4 Nissen fundoplication, 3 Thal procedure) and 8 a laparoscopic procedure (5 Nissen; 3 Toupet’s procedure ). Two of these children were mentally handicapped. The indications for revision were: recurrent reflux, 5; valve migration, 5; valve dismount, 5. We used a five trocars technique in 8 cases and a 4 trocars procedure in 7 cases. The first step of the operation consisted in the lysis of the adhesions particularly strong after open procedures (Fig. 1, 2). Than the old antireflux mechanism was dismounted, the anatomic structures were identified and than a new fundoplication was performed. The choice of type of the fundoplication dipended from the choice of the surgeon, on the basis of preoperative exams and of neurological status of the children. Eight procedures comprised construction of a new Nissen fundoplication, in 7 cases a Toupet’s procedure was performed. In all the patient a posterior closure of the crura were performed with one or two stitched of non resorbable suture. The valve wall always fixed at the end of procedure a the right crura with one or two stitches to stabilize the wrap. 

lap refundo 1 lap refundo 2
Figure 1. The first step of the redo procedure  consists into the lysis of the adhesions  between the stomach and the abdominal wall Figure 2.  After an open fundoplication there are several adhesions between the inferior face of the left liver lobe and the anterior part of the stomach

 Results

Revision was successfully completed laparoscopically in 10 cases (66.6%); 7/8 (87.5%) patients following a previous laparoscopic procedure and in 3/7 (42.8%) following a previous open operation. Operating time ranged between 70 and 150 minutes (median 95 minutes). No perioperative complications occurred in either group.

All patients were discharged within 3-4 days after the redo procedure. Follow-up time varied between 6 months- 7 yrs. Preoperative symptoms were relieved in all patients and all antireflux medication have been discontinued, except in two cases that still had rare symptoms . These two patients, have an intermittente medical therapy only when they have symptoms.

Discussion

The failure of an antireflux procedure, that can be caused by the recurrence of GERD or from the thorax migration of the valve, is reported in about 3- 7% of patients operated on using open or laparoscopic procedure (1, 6, 18). The laparoscopic approach may be used successfully to treat patients with failed antireflux operations (2,3). Good results were achieved in adults despite the technical difficulty of the procedure (10, 12, 13). Pediatric reports about this problem are extremely scanty (16,17,18). For this reason it’s extremely important analyzed our experience and a review of the literature to try to give an overview of the problems in pediatric patients.

First of all it’s important to underline that it’s completely different to approach a child operated previously using open surgery or in laparoscopy (8,11).

Infact the patients operated in open surgery the first time have a large number of adhesions betweeen the epiploon and the abdominal wall scar and moreover they presents adhesions between the internal face of the left liver lobe and the anterior part of stomach (9,14). For this reason in case of recurrence after open surgery, the first part of redo laproscopic procedure consists in the lysis of adhesions that can be easy at the beginning but it’s extremely difficult when you try to identify a correct dissection plane between liver and stomach (6,15).

Of the contrary in laparoscopy there aren’t particulary problems to approach the eg junction.

The second problem depends of the type of fundoplication performed the first time, infact in cas of Thal procedure or others anterior valve the posterior part of the esophagus is free from adhesions because it is don’t touched during the first procedure (7, 14,16). Of the contrary in case of Toupet or in case of Nissen can be difficult also the dissection of the two crura and of the posterior wall of the esophagus (11,13).

The third difficulty can depend from the cause of the recurrence. In case of the valve disruption, it’s no difficult to create a new valve and well fix it at the end of the procedure. Also in case of recurrent reflux it’s only necessary to have a longer endoabdominal esophageal part and eventually to change type of fundoplication, in the majority of case it’s necessary to perform a 360° fundoplications according to Nissen (9,17).

In case of thorax migration of the valve, the redo procedure can be difficult and sometime to reduce the possibility to create iathrogenic complications a conversion in open surgery can be indicated (1, 11). Concerning the migration of the valve, the majority of patients in which this event it happens, are neurologically impaired patients because these patients have a abnormal mouvements of the diaphragm and esopgaus, for this reason the fundoplications in this patients is sottoposta to a great working (16,17,18).

The intervention consist into reduce the migration, to approximate the crura and into redo the fundoplication preferably a Nissen. In children, contrarly to the adult, prothesis to close the crura aren’t adopted after the reduction of the valve migration (16). The key factors to gain success in a redo procedure is to well close posteriorly the crura, into create a solid valve and into fix it to the right crura at the end of the procedure. To reduce the incidence of complications and conversion is to performed a blunt and delicate dissection at the beginning of the redo procedure to identify exactly anatomic structures and a correct dissection plane.

In conclusion, laparoscopic reoperative antireflux surgery is feasible for skilled laparoscopic surgeons. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one.

 

 

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