Laparoscopic Nissen fundoplication in children with a pre-existing gastrostomy: challenges and tips

Area of Science:

• Pediatric Surgery
• Gastroenterology
• Minimally Invasive Surgery

Background:

• Gastro-oesophageal reflux disease (GERD) in children often necessitates surgical intervention.
• In-situ gastrostomy tubes (G-tubes) are common in patients requiring laparoscopic fundoplication (LF).
• The decision to detach a G-tube during LF impacts operative complexity and outcomes.

Purpose of the Study:

• To evaluate the feasibility and outcomes of laparoscopic fundoplication (LF) in patients with an in-situ gastrostomy tube (G-tube).
• To identify factors influencing the need for G-tube detachment during LF.
• To assess the safety and efficacy of LF with a retained G-tube.

Main Methods:

• Retrospective analysis of 170 LF procedures performed between 2014 and 2024 by a single surgeon.
• Categorization of patients into two groups: those with (Group A) and without (Group B) G-tube detachment.
• Analysis of operative details, including operating time and port positioning, and postoperative outcomes.

Main Results:

• Of 170 LF procedures, 33 involved patients with an in-situ G-tube.
• G-tube detachment was avoided in 85% of cases (Group A), with a median operative time of 75 minutes.
• Five patients (15%, Group B) required G-tube detachment due to complex anatomy (e.g., giant hiatus hernia, severe scoliosis), with a median operative time of 100 minutes.
• No early postoperative complications occurred in Group A, though five fundoplications failed, requiring redo LF.
• One redo surgery was needed in Group B for milk peritonitis following gastrostomy dehiscence.

Conclusions:

• Laparoscopic fundoplication (LF) with an in-situ gastrostomy tube (G-tube) is a safe and feasible procedure.
• Detachment of the G-tube is infrequently required but associated with specific challenging anatomies.
• Tailored port placement is crucial in complex cases to avoid G-tube detachment and its associated risks.