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Results of laparoscopic antireflux procedures in neurologically impaired children
1Department of Paediatric Surgery, The Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
Insights
Laparoscopic fundoplication is a safe and effective treatment for severe gastroesophageal reflux in neurologically impaired children, showing lower mortality and morbidity compared to open surgery.
Area of Science:
- Pediatric Surgery
- Gastroenterology
Background:
- Laparoscopic fundoplication is common in children, but long-term outcomes in neurologically impaired (NI) populations are not well-established.
- Severe gastroesophageal reflux (GER) significantly impacts the health and well-being of NI children.
Purpose of the Study:
- To evaluate the safety and efficacy of laparoscopic Nissen fundoplication in neurologically impaired children with severe GER.
- To compare the outcomes of laparoscopic fundoplication with historical data for open surgical techniques in this population.
Main Methods:
- A single surgeon's experience with 54 consecutive NI children undergoing laparoscopic Nissen fundoplication over 8.5 years.
- Data collection included surgical indications, operative details, complications, and long-term follow-up.
- Comparison with historical data for open fundoplication was performed.
Main Results:
- Laparoscopic fundoplication was successful in the majority of NI children, with a low rate of conversion to open surgery (3/54).
- Postoperative complications included gas bloat, diarrhea, dumping, and one major gastrostomy infection.
- Long-term follow-up (median 5.2 years) showed persistent/recurrent problems in 16% of patients, with low rates of re-operation for recurrent hernia or reflux.
- Mortality was primarily due to underlying conditions, not the surgical procedure.
Conclusions:
- Laparoscopic fundoplication is a safe and successful surgical option for managing severe GER in neurologically impaired children.
- This minimally invasive approach offers lower mortality and morbidity compared to historical open techniques, with similar intermediate and long-term results.
Abstract:
Although laparoscopic fundoplication is now performed commonly in children, its long-term results in neurologically impaired (NI) children is unknown. We present a single surgeon's experience. During an 8.5 year period, 54 consecutive NI children (age 5 months to 16 years; weight 2.7 to 42 kg) who had failed medical treatment for severe gastroesophageal reflux (GER) underwent laparoscopic Nissen fundoplication without (7) or with (47) gastrostomy. Indications for surgery included failure to thrive and feeding difficulties in all, major vomiting in 42, recurrent chest infections in 44, and inability to take oral medication in 14. Hiatus hernia was present in 14 and delayed gastric emptying in 6 patients. Eight (15%) had undergone previous abdominal surgery. Access was modified according to individual anatomy and 4 or 5 cannulae were used in each patient. Postoperative epidural/morphine analgesia was used in the first 12 to 24 hours, and fluid intake and feeding were started on day 1 and 2, respectively. The average operating time for fundoplication was 2.2 hours (range 1.05 to 3) and for fundoplication and gastrostomy 2.3 hours (range 1.22 to 4.10). Three patients had conversion to open surgery (1 perforated esophagus, 1 hypercarbia and hepatomegaly, 1 camera failure). There were no other operative complications or mortality. One child with Down syndrome developed a food bolus obstruction 3 days postoperatively. The vast majority of patients were discharged home 3 to 4 days following fundoplication and 5 to 7 days following fundoplication and gastrostomy. Postoperative gas bloat was common, diarrhea developed in 4, dumping in 3, and major gastrostomy infection in 1 case. During follow-up (median 5.2, range 3 months to 8.6 years), 9 (16%) children showed signs of persistent/recurrent problems. Investigations showed a recurrent hiatus hernia in 1 (requiring re-operation) and minor reflux in 3 patients. To date 6 (11%) children have died of their background conditions. In NI children, laparoscopic fundoplication is safe and successful. Awareness of the differences in access and risks for NI and normal children is important. Compared with historical data for open technique, laparoscopic fundoplication produces lower mortality and morbidity and similar intermediate and long-term results.
