Hugh W. Grant

Long-term outcome of laparoscopic nissen fundoplication compared with laparoscopic thal fundoplication in children: a prospective, randomized study.

Background:Laparoscopic fundoplication is increasingly performed in pediatric surgery. Many types of fundoplication are performed, each has advantages and disadvantages. To date there has been no prospective randomized study to determine the optimal laparoscopic technique in children. The aim of the study was to compare the long-term outcomes and control of symptoms after laparoscopic Nissen fundoplication with laparoscopic Thal fundoplication in children. Methods:Between July 1998 and April 2007, 175 patients were recruited to this prospective, randomized study. Patients were assessed before the operation and after defined intervals starting at 3 months after surgery. The “absolute” outcome measure for fundoplication failure was recurrence of symptoms that merited a redofundoplication or insertion of a transgastric jejunostomy. “Relative” outcome measures were recurrence of symptoms necessitating reintroduction of antireflux medication (ie, “intention to treat”) and postoperative complications (eg, postoperative dysphagia). The median follow-up time was 30 months (range, 1–109). This study has been registered with clinicaltrials.gov (NCT01027975). Results:Long-term results were available in 167 patients of which 85 underwent a Nissen and 82 a Thal fundoplication. Four patients in the Nissen group (4.7%) and 12 in the Thal group (14.6%) required a redofundoplication. One child in each group developed recurrence of symptoms and had a transgastric jejunostomy performed. The “absolute” failure rate was significant lower in the Nissen group (n = 5; 5.9%) compared with the Thal group (n = 13; 15.9%) (P = 0.038). The vast majority of these patients (17 of 18) had underlying neurological disorders. The “relative” failure rate (ie, “intention to treat”) was similar in both groups. Nearly one-quarter of patients developed postoperative dysphagia similarly distributed between both groups. However, severe dysphagia requiring endoscopy +/− dilatation was significantly higher in the Nissen group (n = 10, 11.8%) compared with the Thal group (n = 2; 2.4%) (P = 0.020). One of 31 deaths (0.6%) in this series occurred after surgery, but was not directly related to the fundoplication technique. Conclusions:In the long-term a laparoscopic Nissen fundoplication had a significantly lower recurrence rate than a Thal fundoplication, particularly in patients with underlying neurological disorders. There was no significant difference between the 2 types of fundoplication in normal children. There was no significant difference between the need for restarting antireflux medication between both groups because of recurrence of moderate symptoms. The incidence of postoperative dysphagia was similar in the 2 groups, however, significantly more patients in the Nissen group required intervention for severe dysphagia. Overall the perioperative death rate was low even in high-risk patients.

Adhesions after abdominal surgery in children.

PURPOSE The objective of this study is to quantify the overall burden (operative and nonoperative) of small bowel obstruction caused by adhesions after laparotomy in children. METHODS Data from the Scottish National Health Service Medical Record Linkage database were used to assess risk of an adhesion-related readmission in the 5 years after open abdominal surgery in children and adolescents younger than 16 years from April 1996 to March 1997. RESULTS A total of 1581 children underwent abdominal surgery (ie, from duodenum downward). Patients undergoing surgery on the ileum had the highest risk of readmission because of adhesions in the subsequent 5 years after surgery (9.2%)--formation/closure of ileostomy had the greatest risk (25%); 6.5% of children were readmitted after general laparotomy, 4.7% after duodenal surgery, and 2.1% after colonic surgery. The incidence of readmissions was 0.3% after appendicectomy. The overall readmission rate was 5.3% (if appendicectomy was excluded) and 1.1% (if appendicectomy was included). CONCLUSION This population-based study has demonstrated that children have a high incidence of readmissions owing to adhesions after lower abdominal surgery. The risks are related to the site and the type of the original surgery. The risk of further readmissions was highest in the first year but continued with time. The data enable surgeons to target antiadhesion strategies at procedures that lead to a high risk of adhesions.

The value of anal endosonography compared with magnetic resonance imaging following the repair of anorectal malformations.

Abstract Background. Surgery for anorectal malformations (ARMs) attempts to position the neo-anus anatomically within the anal sphincter complex. Currently, MRI is the imaging modality of choice in determining the position of the neo-anus after reconstructive surgery. Objective. The aim of this study was to compare the accuracy of anal endosonography (AES) with conventional MRI in demonstrating the anatomy of the neo-anus following repair of ARMs. Materials and methods. Fourteen children (ten girls, four boys), born with ARMs (four low, ten high) underwent both AES and pelvic MRI following anorectoplasty. The results of both investigations were compared with muscle stimulation and were reported blindly by a clinician and a radiologist. Results. AES findings were comparable with MRI in 9 of the 14 cases. In four cases, MRI and AES findings differed, with nerve stimulation supporting AES but not MRI. Conclusions. AES is an accurate alternative to MRI in the assessment of anorectoplasty. It provides more detailed information and can be performed under anaesthesia in combination with a surgical procedure.

Laparoscopic Nissen Fundoplication Versus Thal Fundoplication in Children: Comparison of Short-Term Outcomes

BACKGROUND The aim of this study was to compare short-term outcomes, including intra- and perioperative complications following laparoscopic Nissen versus Thal fundoplication. PATIENTS AND METHODS From July 1998 until April 2007, 175 patients were recruited. Patients were prospectively randomized to either a Nissen wrap or a Thal wrap. Observation period was 6 weeks after surgery. RESULTS 89 Nissen and 86 Thal were performed. The mean age at the time of operation (OP) was 5.2 years. Demographics were similar, although weight at OP was significantly less in the Nissen group. Intraoperative complications during a Nissen included bleeding from a liver laceration in 2 patients (1 required conversion) and small bowel perforation during open port insertion in 1 patient. There were two conversions in the Thal group, due to bleeding from the omentum in 1 patient and equipment failure in the other. In a third patient the colon was perforated during insertion of percutaneous endoscopic gastrostomy (PEG) and repaired laparoscopically. Post-OP dysphagia was similarly distributed among both groups, but was significantly more severe after a Nissen (P = 0.018). There were two early deaths: in the Nissen group, 1 child died from peritonitis after the gastrostomy tube fell out, whereas one death in the Thal group was caused by respiratory failure associated with the patients underlying condition. CONCLUSIONS There was no statistical difference in the short-term outcomes between laparoscopic Nissen and Thal fundoplication, apart from a higher rate of esophagoscopy for severe dysphagia in the Nissen group. The higher number of postoperative complications in the Nissen group was largely due to gastrostomy-related problems.

Epidemiology of adhesions in infants and children following open surgery

Adhesions following intra-abdominal surgery are a major cause of small bowel obstruction. The nature of surgical interventions in children (especially neonates) increases the risk of adhesion-related complications. Following laparotomy in neonates, the collective literature reveals an aggregate mean incidence of adhesive small bowel obstruction (ASBO) of 6.2%; malrotation, 14.2%; gastroschisis, 12.6%; necrotising enterocolitis, 10.4%; exomphalos, 8.6%; Hirschsprungs disease, 8.1%; congenital diaphragmatic hernia, 6.3% and intestinal atresia, 5.7%. In children beyond the neonatal period, the aggregate mean incidence was 4.7%; colorectal surgery, 14%; open fundoplication, 8.2%; small bowel surgery, 5.7%; cancer surgery, 5.5%; choledochal cyst, 3.1%; appendicectomy, 1.4% and pyloromyotomy, 0.1%.

Trilogy of gastrointestinal atresias: a case report and review of the literature.

This is a case report of a child with a rare combination of pyloric and colonic atresias, imperforate anus, hypoganglionosis of the rectum and sigmoid colon, unilateral multicystic dysplastic kidney, bilateral sensorineural deafness, spondyloepimetaphyseal dysplasia, subglottic stenosis, growth failure, and limb anomalies.

Laparoscopic Thal Fundoplication

The Thal fundoplication is a 180–270° anterior wrap. The basic dissection is similar to that of any other fundoplication, except that it does not require a posterior window or posterior mobilisation of the oesophagus and requires less dissection of the crus. It achieves the same surgical objectives as other types of fundoplication, i.e., ensuring an intra-abdominal oesophagus, creating an acute angle at the gastro-oesophageal junction, and creating a high-pressure zone around the lower oesophagus [1]. Thal fundoplication has an equivalent success rate in neurologically normal children but has a higher failure rate in neurologically impaired children when compared with the Nissen fundoplication. It also results in less postoperative dysphagia [2].

Equipment and Ergonomics

Minimal access surgery (MAS) differs from traditional open surgery in that it accesses and visualizes the operative field via small skin incisions. The small access points minimize the morbidity and unsightly scars caused by larger open wounds. The endoscopic visualization can also offer additional views by reaching deeper within the body cavity. The procedure can still be invasive and traumatic, and therefore it is more appropriate to describe the approach as “minimal access” instead of “minimally invasive.”

Laparoscopic fundoplication in children with ventriculo-peritoneal shunts.

BACKGROUND Children with ventriculo-peritoneal (V-P) shunts have a significant risk of morbidity and mortality from infections. Many of these patients have other co-morbidities and may require subsequent abdominal surgery, including fundoplication with or without gastrostomy placement. The aim of our study was to assess the outcomes of laparoscopic fundoplication in children with a V-P shunt in situ. SUBJECTS AND METHODS A retrospective review of a prospectively maintained database on children who underwent laparoscopic fundoplication with a V-P shunt in situ at the time of surgery between July 1998 and March 2011 was conducted. Primary outcomes included intra- and postoperative complications as well as shunt-related problems within a 6-month period after surgery. The subset of children with V-P shunts was compared with those who underwent fundoplication without shunts. Variables were compared using the two-tailed Students t test, chi-squared test, or Fishers exact test. Significance was defined as P≤.05. RESULTS Out of a total of 343 children who underwent fundoplication, 11 (6 girls, 5 boys) had a V-P shunt in situ at the time of surgery (3.2%). The median age at laparoscopy was 2.2 years (range, 0.7-13.8 years). Weight at surgery ranged from 5.8 to 39.0 kg (median, 12.0 kg). The operating time (without gastrostomy placement) was 105 minutes (range, 80-140 minutes). In 6 patients (55%) moderate to severe adhesions were documented, but only 1 child required conversion to open surgery because of bleeding from the omentum. In a second patient the colon was perforated during insertion of the percutaneous endoscopic gastrostomy (PEG) and repaired laparoscopically. There was no postoperative shunt dysfunction or infection related to the laparoscopic procedure. There was no significant difference between V-P shunt patients and the main cohort regarding operating time, conversion to open surgery, need for admission to a high-care unit, opiate requirements, time to full feeds, and length of hospital stay. CONCLUSIONS These data suggest that laparoscopic fundoplication is feasible in children with previous V-P shunt placement. Although there were considerable adhesions in approximately half of these patients, the rate for conversion to open surgery was low. Complications associated with simultaneous PEG insertion occur and should be anticipated by placing the gastrostomy under laparoscopic guidance.