Open Nissen Fundoplication Research Articles

Health-related Quality of Life of Children with Gastro-oesophageal Reflux Disease after Nissen Fundoplication and Gastrostomy Tube Insertion - A Retrospective Observational Study

Abstract Background: Severe gastro-oesophageal reflux disease (GERD) is associated with a poor health-related quality of life (HRQoL). Nissen fundoplication is the most common surgical procedure for patients with GERD. A feeding gastrostomy tube may be inserted at the same time in selected patients where there are unsafe swallowing and/or feeding difficulties. The goals of surgery are to eliminate symptoms, prevent reflux complications and ultimately improve the quality of life. The main objective of this study was to assess the HRQoL of children with GERD after Nissen fundoplication and gastrostomy tube insertion. Materials and Methods: This was an observational retrospective cohort study at two private, not-for-profit tertiary hospitals in Nairobi. The study population included children under 18 years of age with GERD who had Nissen fundoplication with or without gastrostomy tube insertion from January 2010 to December 2020. The quality of life was assessed from the caretakers using the Paediatric Quality of Life Inventory applied through a telephone call. Data analysis was done using SPSS version 26. The HRQoL was summarised using mean and standard deviation (SD) with a 95% confidence interval (CI) around the scores. Independent samples t-test was conducted to compare the means of HRQoL for gender, complications and comorbidities. Spearman’s correlation was done for HRQoL and age. Results: Eighty-two children were included in the study. Eighty-four per cent had comorbidities, with almost three-quarters of them having neurological impairment. Majority (91%) had open Nissen fundoplication, while 9% had laparoscopic Nissen fundoplication. One-third of these children reported complications post-procedure. Nissen fundoplication failure rate was 10%. Two-thirds had a concurrent gastrostomy tube insertion. The global mean HRQoL score was 75.8 (SD: 23.5, 95% CI: 70.4–81.2). Gastrostomy tube insertion had no impact on the quality of life. Children with neurological impairment had significantly lower quality of life than those without neurological impairment. Conclusion: The global score of the HRQoL following Nissen fundoplication in this cohort of children was 75.8. Further studies to reduce the proportion of children who experience complications postoperatively in this setting are required.

Outcome a decade after laparoscopic and open Nissen fundoplication in children: results from a randomized controlled trial

BackgroundRandomized controlled trials (RCT) comparing long-term outcome after laparoscopic (LF) and open fundoplication (OF) in children are lacking. Here we report recurrence rates and time to recurrence, frequency of re-interventions, use of antisecretory drugs, gastrointestinal symptoms, and patient/parental satisfaction a decade after children were randomized to LF or OF.MethodsCross-sectional long-term follow-up study of a two-center RCT that included patients during 2003–2009. Patients/parents were interviewed and medical charts reviewed for any events that might be related to the fundoplication. If suspicion of recurrence, further diagnostics were performed. Informed consent and ethical approval were obtained. Clinicaltrials.gov: NCT01551134.ResultsEighty-eight children, 56 (64%) boys, were randomized (LF 44, OF 44) at median 4.4 [interquartile range (IQR) 2.0–8.9] years. 46 (52%) had neurological impairment. Three were lost to follow-up before first scheduled control. Recurrence was significantly more frequent after LF (24/43, 56%) than after OF (13/42, 31%, p = 0.004). Median time to recurrence was 1.0 [IQR 0.3–2.2] and 5.1 [IQR 1.5–9.3] years after LF and OF, respectively. Eight (19%) underwent redo fundoplication after LF and three (7%) after OF (p = 0.094). Seventy patients/parents were interviewed median 11.9 [IQR 9.9–12.8] years postoperatively. Among these, use of anti-secretory drugs was significantly decreased from preoperatively after both LF (94% vs. 35%, p < 0.001) and OF (97% vs. 19%, p < 0.001). Regurgitation/vomiting were observed in 6% after LF and 3% after OF (p = 0.609), and heartburn in 14% after LF and 17% after OF (p = 1.000). Overall opinion of the surgical scars was good in both groups (LF: 95%, OF: 86%, p = 0.610). Patient/parental satisfaction with outcome was high, independent of surgical approach (LF: 81%, OF: 88%, p = 0.500).ConclusionsThe recurrence rate was higher and recurrence occurred earlier after LF than after OF. Patient/parental satisfaction with outcome after both LF and OF was equally high.Graphical abstract

The revised-Face, Leg, Activity, Cry, and Consolability scale: an Egyptian version

Background Children with cerebral palsy lack the luxury of self-reporting their pain postoperatively. The revised FLACC (Face, Leg, Activity, Cry, and Consolability) pain scale is a behavioral pain assessment tool that is universally accepted for use in children with cognitive dysfunction. Objective The aim of this study was to cross-culturally adapt and evaluate the validity and reliability of the Egyptian version of the revised FLACC (r-FLACC) scale for use in postoperative pain assessment in children with cerebral palsy. Patients and methods The study was carried out in Ain Shams University Pediatric Hospital on 30 children with cerebral palsy aged 3–12 years scheduled for open Nissen fundoplication. Pain was assessed at baseline, on arrival to postanesthesia care unit, and 30 min after administration of analgesia using the r-FLACC scale (by two independent caregivers) and the visual analog scale (by the child’s parent). Results The r-FLACC scores increased postoperatively and decreased after administration of analgesia (P Moderate to significant correlations between observers for total r-FLACC scores (P Conclusion The Egyptian version of the r-FLACC scale is a valid and reliable tool for postoperative pain assessment in Egyptian children with cerebral palsy.

Does Nissen Fundoplication Provide Lifelong Reflux Control? Symptomatic Outcome After 31–33 Years

A substantial number of people are suffering from gastroesophageal reflux disease (GERD). The indication for surgical treatment is the failure of medical treatment in patients with objectively verified GERD. The use of PPIs has been noted to increase with the length of follow-up after fundoplication, raising questions concerning the durability of surgical results. The aim of the study was to investigate the results of open Nissen fundoplication (ONF) over a follow-up of more than 31years. ONF was performed for 38 consecutive patients. Questionnaires concerning long-term outcome were sent on December 14, 2015, to the 24 patients still living. Long-term symptom evaluation was carried out using the Gastrointestinal Symptom Rating Scale (GSRS), Visick grading, a Visual Analog Scale (VAS), the DeMeester-Johnson reflux scale, and the 15D tool. Seventeen (70.8%) of the 24 patients still living participated in the study. The typical symptoms of GERD had resolved significantly. Dysphagia was graded as none or minimal by 13 (81.3%) patients. The mean 15D score of the patient group was clinically and statistically the same (0.896 vs. 0.899) as that of the age- and sex-standardized general population (p=0.912). Six (15.8%) patients had used antireflux medication after the operation and 4 of them (10.6%) continuously. Patients in the present study used PPIs less frequently than what has been reported in previous long-term follow-up studies. Our results indicate that successful surgery may provide lifelong relief of GERD symptoms and normalize the health-related quality of life in GERD patients.

Outcome Evaluation of Laparoscopic and Open Nissen Fundoplication in Children—A Systematic Review and Meta-Analysis

Our aim was to estimate the efficacy of laparoscopic and open Nissen fundoplication (ONF) in the treatment of gastroesophageal reflux disease (GERD) in children. An electronic systematic review of the published literature was conducted in Cochrane Library, MEDLINE (PubMed), and EmBase in October 2015 in English and without time restrictions. The participants, interventions, and comparisons in the clinical question translated directly into eligibility criteria for study inclusion and exclusion. Study information extraction and methodological quality assessments were accomplished by two reviewers independently. Methodological quality was assessed by using the "Criteria for judging risk of bias in the 'Risk of bias' assessment tool." Odds ratio (OR) with 95 per cent confidence interval was computed as summary statistics. Fixed-effects model was used and a pooled OR was calculated with the Mantel-Haenszel method initially. If the studies were heterogeneous, then the DerSimonian and Laird random effects model was used for meta-analysis. Outcome indices included mortality of patients, recurrence of GERD, reoperation of GERD, patients with complications, length of postoperative hospital stay, and surgery duration of laparoscopic Nissen fundoplication (LNF) and ONF. Statistical analyses were carried out by using Review Manager 5.2. The duration of follow-up varied between two days and four years. Children operated with LNF had a higher recurrence rate of GERD than those undergoing ONF. The pooled OR of LNF versus ONF was 2.98 (95% confidence interval = 1.29-6.87) while the heterogeneity was I2 = 47 per cent and P = 0.13. Statistical analysis showed that there was no significant difference for mortality, reoperation, and complication. The mean duration of surgery was significantly longer in the LNF than the ONF group while the results of length of postoperative hospital stay remained inconformity. In this meta-analysis, children operated with LNF had a higher recurrence rate of GERD than those undergoing ONF. Meanwhile, when considering the outcomes of mortality, reoperation, and complications, there was no significant difference. The mean duration of surgery was significantly longer in the LNF than the ONF group while no consistent conclusion of length of postoperative hospital stay was found.

Factors Associated with the Risk of Persistent Gastrostomy Site Infection Following Laparoscopic or Open Nissen Fundoplication.

Background:Gastrostomy for feeding disorders or swallowing dysfunctions can be complicated by persistent gastrostomy site infection (PGSI). PGSI causes nutrient leakage, with dilated PGSI requiring gastrostomy reconstruction. The purpose of this study was to evaluate the causes, patient characteristics, and perioperative management of PGSI after Nissen fundoplication and gastrostomy for patients with gastro-oesophageal reflux.Patients and Methods:The records of all patients who underwent Nissen fundoplication and gastrostomy for gastro-oesophageal reflux over the past 12 years were retrieved. Risk factors were analysed, including age at surgery, gender, operative procedure, use of postoperative ventilator management, gastrostomy tube migration towards the pylorus, bacterial culture results, and length of hospital stay. PGSI as a cause of inflammation was analysed statistically.Results:Forty patients were identified, ranging in age from 1 to 49 years (median, 11 years) surgically. Twenty each underwent laparoscopic and open surgery, with all undergoing gastrostomy using the Stamm technique. Four patients developed PGSI. Gastrostomy tubes had migrated postoperatively to the pyloric side in three of these four patients (P < 0.005), increasing intragastric pressure. Three of these four patients also required positive pressure ventilation during the perioperative period (P < 0.001).Conclusion:PGSI correlates with the perioperative management of positive pressure and with increased intragastric pressure resulting from pyloric obstruction, which is caused by aberrant distribution of the gastrostomy tube to the pyloric side.Statistical Analysis Used:Factors in the two groups were compared statistically by Mann–Whitney U-test to determine whether PGSI caused inflammation. Statistical significance was defined as P < 0.05.

Pyloric reconstruction for refractory dumping syndrome after Nissen fundoplication and pyloroplasty in an infant: A case report

Abstract Dumping syndrome (DS) is common after gastrectomy or gastric bypass surgery, but DS in children has been described almost exclusively as a complication of Nissen fundoplication. DS resolves spontaneously in most patients; however some patients require dietary modification or medications, and surgical treatment is reserved for medically intractable cases. We herein describe an unusual case of DS in a neurologically impaired infant that developed after Nissen fundoplication and pyloroplasty and was treated by reversal of the pyloroplasty. A 12-month-old male infant was referred for medically intractable DS. He suffered from cerebral palsy and gastroesophageal reflux and underwent open Nissen fundoplication, gastrostomy tube placement, truncal vagotomy, and pyloroplasty two months before referral. Gastric emptying scintigraphy confirmed rapid gastric emptying, which was consistent with early DS. On laparotomy, a pyloroplasty scar was identified and opened along the scar. The pyloric ring was identified, reapproximated, and the incision was closed longitudinally. Postoperative gastric emptying scan showed normalized gastric emptying, and the half-emptying time was measured as 110 min. Pyloric reconstruction is a technically easy and less destructive surgery and should be considered as a therapeutic option in medically refractory DS following fundoplication and pyloroplasty.

A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age

AimsThe surgery of gastroesophageal reflux disease (GERD) is common in modern pediatric surgical practice. Any differences in perioperative and long-term clinical outcomes following laparoscopic (LN) or open Nissen (ON) fundoplication have not been comprehensively described in young children. This randomized, prospective study examines outcomes following LN versus ON in children <2years of age. MethodsFour surgeons at a single institution enrolled patients under 2years of age that required surgical management of GERD, who were then randomized to LN or ON between 2005 and 2012. A universal surgical dressing was employed for blinding. Analgesia and enteral feeding pathways were standardized. The primary outcome was postoperative length of stay. Perioperative outcomes and long-term follow up were collected as secondary outcomes and used to compare groups. ResultsOf 39 enrolled patients, 21 were randomized to ON and 18 to LN. Length of postoperative hospital stay, time of advancement to full enteral feeds, and analgesic requirements were not significantly different between treatment cohorts. The LN group experienced longer median operating times (173 vs 91min, P<0.001) and higher surgical charges ($4450 vs $2722, P=0.002). The incidence of post-discharge complications did not differ significantly between the groups at last follow-up (median 42months). ConclusionsThis randomized trial comparing postoperative outcomes following LN vs ON did not detect statistically significant differences in short- or long-term clinical outcomes between these approaches. LN was associated with longer surgical time and higher operating room costs. The benefits, risks, and costs of laparoscopy should be carefully considered in clinical pediatric surgical practice.

Can Different Subsets of Ineffective Esophageal Motility Influence the Outcome of Nissen Fundoplication?

BackgroundIneffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF). MethodologyA retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N = 38), non-propulsive (NPC, N = 18), and simultaneous low-amplitude esophageal contractions (SC, N = 16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery. ResultsPreoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p = 0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p = 0.390). A longer duration of postoperative dysphagia was noted in the SC group (p < 0.05). Improvement of nadir values of contraction amplitudes in distal esophagus occurred postoperatively in all groups, significantly higher in LAC (p < 0.001). ConclusionThree years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.

Thirty-day outcome in children randomized to open and laparoscopic Nissen fundoplication

BackgroundLaparoscopic Nissen fundoplication (LNF) is considered by some to be superior to open Nissen fundoplication (ONF). To test this hypothesis, we compared early results after LNF and ONF in a randomized trial. MethodsAll children accepted for antireflux surgery for gastroesophageal reflux disease were offered enrollment. Ethical approval and parental consent were obtained. Anesthesia, surgical methods, and postoperative treatment were standardized. Patient demographics, length of hospital stay (LOS), and complications occurring the first 30 postoperative days were registered. ResultsEighty-eight children were randomized to LNF (n = 44) or ONF (n = 44). The groups were comparable with regard to age, weight, and comorbidity. Duration of surgery was 150 ± 34 minutes for LNF and 89 ± 25 minutes for ONF (P < .001). Median LOS was 7.0 days (range, 3-57 days) and 7.5 days (range, 2-20 days) after LNF and ONF, respectively (P = .74). Postoperative complications occurred in 48 patients, 24 in both groups. Twenty-four patients (LNF: n = 12, ONF: n = 11) were readmitted to hospital because of complications occurring after discharge. ConclusionsThis study failed to show that LNF is superior to ONF when surgery duration, LOS, and complications occurring during the first postoperative month were compared. Apart from surgery duration, the results were surprisingly similar.

Comparison between Laparoscopic and Open Nissen Fundoplication in Pediatric Patients

Comparison between Laparoscopic and Open Nissen Fundoplication in Pediatric Patients

Fifteen-Year Outcome of Laparoscopic and Open Nissen Fundoplication: A Randomized Clinical Trial

Laparoscopic Nissen fundoplication (LNF) has become the method of choice in the surgical treatment of gastroesophageal reflux disease (GERD), replacing its open counterpart without confirmation by the long-term results of controlled clinical studies. The goal of the present study was to compare the 15-year outcome of a randomized controlled comparison study of LNF versus open Nissen fundoplication (ONF). From 1992 to 1995, 110 consecutive patients were randomized to undergo LNF or ONF. The 15-year objective results were evaluated by endoscopy, and the subjective symptomatic outcome was assessed by interviews. A total of 86 patients (48 in the LNF [LAP] and 38 in the ONF [OPEN] group) participated in the study. The late long-term symptomatic outcome was similar in the two patient groups. In the LAP group, 91.7% of the patients gave a positive evaluation of their surgical result, as compared with 76.3% of the patients in the OPEN group (p=0.0484). A significantly greater number of disrupted plications (p=0.0115) and incisional hernias (p<0.001) occurred in the OPEN than in the LAP group. Both the subjective outcome and the objective endoscopic and clinical findings in the present study were in accord with our previously reported outcomes at 11-years after laparoscopic versus open fundoplication. The study found a trend toward (p=0.0851) an increasing need for the regular use of a proton pump inhibitor with the passage of time after Nissen fundoplication. The 15-year results obtained in the present study define laparoscopic Nissen fundoplication as the procedure of choice in the surgical management of GERD. The long-term symptomatic outcomes of open and laparoscopic Nissen fundoplication appear to remain unaltered after the first 10 postoperative years.

A meta-analysis of outcomes after open and laparoscopic Nissen's fundoplication in the treatment for gastro-oesophageal reflux disease

BACKGROUND: A meta-analysis of published literature comparing peri-operative, short-term and long-term outcomes after open Nissen's fundoplication (ONF) versus laparoscopic Nissen fundoplication (LNF) for gastro-oesophageal reflux disease. METHODS: Electronic databases were searched from January 1991 to October 2009. A systematic review was performed to obtain a summative outcome. RESULTS: Nine randomized controlled trials involving 657 patients were analysed. Three hundred and thirty-six patients were in the laparoscopic and 321 in the open groups. LNF took longer to perform compared with ONF [random effects model: SMD = -1.64, 95% CI (-2.21, -1.06), z = -5.57, df = 8, p < 0.0001]. Patients undergoing LNF stayed in hospital for less time [random effects model: SMD = 1.19, 95% CI (0.74, 1.65), z = -5.14, df = 8, p < 0.0001] and returned to work sooner [random effects model: SMD = 1.23, 95% CI (0.37, 2.09), z = 2.81, df = 5, p < 0.01]. No difference was seen for morbidity or mortality. Symptomatic outcomes after LNF were comparable to ONF in the short and long terms. LNF fared slightly worse than ONF at 6 months in relation to dysphagia; however, this difference disappeared at 12 months follow-up. CONCLUSIONS: Laparoscopic Nissen's fundoplication is safe, effective and has shorter hospital stays and is associated with an earlier return to work. LNF is comparable to ONF for symptoms and has a high patient satisfaction rate. This approach may be considered as a first line operative technique; however, further follow-up trials focusing on 6-month outcomes are required to strengthen the evidence.

Surgical management of hiatus hernia with chronic gastric volvulus: report of two cases

Totally intrathoracic gastric volvulus is an uncommon presentation of hiatus hernia. We report herein two patients of hiatus hernia repair with mesenteroaxial gastric volvulus who presented as so-called upside-down stomach, which resulted in excellent clinical outcomes. The two patients underwent an attempted laparoscopic floppy Nissen fundoplication. In patient 1, the duodenum severely adhered to the hernia sac and converted to an open Nissen fundoplication. The operating time for patient 1 and patient 2 was 224 and 232 min, respectively. No postoperative morbidities occurred. At a follow-up of 18 and 2 months, the two patients had not had a relapse or any of their prior symptoms. The repair of an esophageal hiatus hernia with chronic gastric volvulus can be accomplished successfully and safely with an open or laparoscopic approach. Because this condition occurs more frequently in the elderly, an attempt to perform laparoscopic surgery may contribute to minimal invasive treatment.

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population

Introduction The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population. Methods The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean ± SEM. Results Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 ± 0.4 vs 6.1 ± 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 ± 0.05 vs 0.55 ± 0.08 mg/kg, P = .007). Operation times (111 ± 5 [open] vs 113 ± 5 minutes, P = .76) and estimated blood loss (13 ± 2 [open] vs 11 ± 1 mL, P = .33) were comparable for both groups. Conclusion Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.

Clinical Outcome at 10 Years After Laparoscopic Versus Open Nissen Fundoplication

Laparoscopic surgery has become the elective approach for the surgical treatment of gastroesophageal reflux disease (GERD) in the last decade. Outcome data beyond 10 years are available for open fundoplication, but few studies report long-term follow-up after laparoscopic fundoplication and comparison between laparoscopic and open approaches. In this study, we performed a retrospective study of all the patients undergoing Nissen fundoplication (open and laparoscopic) for antireflux surgery between 1996 and 1998 at our institution. In total, 166 patients were included: 88 underwent open Nissen fundoplication and 78 the laparoscopic approach. Complication rate was 5% for both groups. Conversion rate for the laparoscopic approach was was 4%. Median postoperative hospital stay was 9.5 days for open surgery and 3 days for laparoscopic 1 (P < 0.001). During the follow-up, 3 patients required reoperation, 1 after laparoscopic Nissen and 2 after open surgery, all of them due to dysphagia, though complementary tests showed normal features. After 10 years, 24% of the patients of the open surgery group (OS) remain symptomatic, and in the laparoscopic group (LS) 11% (P < 0.05). Overall, 16% of OS take dialy proton-pump inhibitors and 7% of LS (P < 0.05). Three patients have undergone an open Nissen fundoplication and 2 a laparoscopic referring mild dysphagia (NS). The satisfaction rate of the patients was 96% for OS and 97% for LS (NS). Laparoscopic Nissen fundoplication appears to be at least as safe and long term in effectiveness for GERD as the open approach, with the associated postoperative advantages of a minimally invasive access.

HP25P SLEEVE GASTRECTOMY FOR LARGE PARAOESOPHAGEAL HIATUS HERNIAS

Purpose: The initial experience with laparoscopic partial sleeve gastrectomy to excise the herniated stomach to treat symptomatic, large para-oesophageal hernias is reported. Methodology: The laparoscopic repair consisted of 1 Reduction of the herniated stomach from the chest 2 Partial sleeve gastrectomy 3 Repair of hiatal defect with or without mesh 4 Gastropexy. Results: Since May 2006, 11 patients had surgery for large para-oesophageal hernias. All suffered with post prandial discomfort and vomiting preoperatively. One patient underwent open Nissen fundoplication instead of laparoscopic sleeve gastrectomy because of intraoperative haemorrhage. Ten patients had a partial sleeve gastrectomy. Hiatal repair included the use of mesh in 7 out of the 10 patients and 9 of the patients had an anterior gastropexy. The only patient not to have a gastropexy suffered a symptomatic recurrence 13 days after surgery. Five out of 10 patients had complete relief of symptoms after surgery. Four out of ten patients were symptomatic with reflux. One patient continues to have post prandial discomfort and vomiting intermittently, due to a “twist” of the gastric tube. Observations: In this series, laparoscopic partial sleeve gastrectomy for large para-oesophageal hernia repair was associated with a recurrence rate of 1 in 10. Anterior gastropexy may be important in preventing recurrence. Relief of preoperative symptoms was achieved in 9 out of 10 patients but 4 of these 9 report reflux symptoms.

Infections of pediatric cerebrospinal fluid shunts related to fundoplication and gastrostomy

There is conflicting information in the literature regarding the increased risk of ventriculoperitoneal (VP) shunt infection after abdominal surgical procedures such as gastrostomy tube (GT) placement and Nissen fundoplication (NF) in the young patient. To further elucidate this potential association, the authors reviewed their institutional experience with such cases. The authors retrospectively reviewed the records of all patients with shunted hydrocephalus who also underwent NF procedures and/or GT placements over a 9-year period. During this 9-year period, 3065 cerebrospinal fluid (CSF) shunts were placed and 1630 NF procedures/GT placements were performed. Ninety-six patients were identified who received both a CSF shunt and NF procedures/GT placements. Seventy-nine patients had a functioning VP shunt (without recent [< 6 months] CSF infection or shunt revision) at the time of their abdominal procedure (NF procedure or GT placement). Of this latter cohort, there were 38 males and 41 females with a mean age of 6.4 months; 12.7% of these patients developed a shunt infection and 60% of these infections were due to Staphylococcus species. Based on this study, an NF procedure/GT placement in a child with a VP shunt appears to carry approximately the same risk of shunt infection as a shunt placement operation. Moreover, the microbiology observed in these patients with infection did not differ significantly from the usual microorganisms responsible for VP shunt infections in infants/neonates. Finally, but not conclusively, an open NF procedure/GT placement may carry a higher infection risk than a laparoscopic-assisted NF procedure/GT placement.

Tratamiento quirúrgico de la displasia de alto grado en el esófago de Barrett

Barrett's esophagus undergoes malignant transformation in 0.5-1% of patients per year following the sequence of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. The aim of the present study was to present our experience in the surgical treatment of Barrett's esophagus with high-grade dysplasia. Of a group of 128 patients with a diagnosis of Barrett's esophagus, 8 (6.2%) developed high-grade dysplasia during a median follow-up of 7 years (2-25). A further 5 patients with high-grade dysplaing out side the study were referred for evaluation and surgical treatment. Eight patients were under medical treatment with omeprazole (40 mg daily) while the remaining 5 patients had undergone open Nissen fundoplication, with a diagnosis of high-grade dysplasia at a median of 5 years (1-16) after treatment initiation. After confirmation of the diagnosis by a second pathologist and tumoral staging, transthoracic esophagectomy with anastomosis at the apex of the thorax was performed in all patients. Postoperative mortality was nil. Morbidity was 36% (5 patients). Definitive histological analysis of the surgical specimen revealed high-grade dysplasia in 7 patients (54%) and adenocarcinoma in 6 (46%). All patients remain alive after a median follow-up of 4.7 years (1-14). In patients with Barrett's esophagus with high-grade dysplasia, the best therapeutic option is surgical resection, which can be performed with nil mortality in experienced centers. In almost half of surgical patients, the surgical specimen shows adenocarcinoma. Five-year survival is higher than 90%.

Comparison of Long-term Outcome of Laparoscopic and Conventional Nissen Fundoplication

The aim of this study was to compare the long-term objective and subjective outcomes of laparoscopic and open Nissen fundoplication in a randomized clinical trial with an 11-year follow-up. Laparoscopic Nissen fundoplication has become the method of choice in antireflux surgery, replacing its open counterpart despite the lack of long-term results from controlled clinical studies. Between April 1992 and June 1995, 110 consecutive patients were randomized to either laparoscopic (LAP) or conventional (open) Nissen fundoplication. The objective long-term follow-up consisted of an upper gastrointestinal endoscopy and a clinical assessment; the subjective long-term outcome was investigated by personal interviews using a structured questionnaire. Forty-nine patients in the LAP group and 37 patients in the open group were available for evaluation. Late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in both groups. With the benefit of hindsight, 73.7% of the patients in the open group and 81.8% in the LAP group would again choose surgical treatment (P = 0.3042). In the LAP group, there were 5 (13.2%) partially or totally disrupted plications compared with the 14 (40.0%) disrupted plications in the open group (P = 0.0152). There were 10 incisional hernias in the open group compared with none in the LAP group (P < 0.001). At long-term follow-up, the open and LAP approaches for the Nissen fundoplication have similar long-term subjective symptomatic outcome despite the significantly higher incidence of incisional hernias and defective fundic wraps at endoscopy in the open group defining laparoscopic Nissen fundoplication as the procedure of choice in surgical management of gastroesophageal reflux disease.