10 Year Follow-Up of Randomized Trial of Laparoscopic Nissen Versus Thal Fundoplication in Children.

Introduction: The aim of this study was to compare the long-term outcomes of laparoscopic complete (Nissen) fundoplication (LNF) with laparoscopic partial (Thal) fundoplication (LTF) in children. This is the only prospective, randomized study to follow patients up for more than 10 years. Interim results published in 2011 at median 2.5 year follow-up showed that LNF had a significantly lower failure rate compared with LTF. Materials and Methods: A randomized, controlled trial of LNF versus LTF in children (<16 years) was performed. The primary outcome measure was "absolute" failure of the fundoplication-recurrence of symptoms that merited either reoperation or insertion of transgastric jejunostomy (GJ). Secondary outcomes were "relative" failure (need for postop antireflux medication), complications (e.g., dysphagia), and death. Results: One hundred seventy-five patients were recruited; 89 underwent LNF, and 86 underwent LTF. Eight patients had no follow-up recorded. At long-term follow-up, 59 patients had died (35%); LNF 37/85 (43.5%) and LTF 22/82 (26.8%), P = .02. Median length of follow-up in survivors was 132 months. There was no statistically significant difference in "absolute" failure rate between LNF 8/85(9.4%) and LTF 15/82 (18%), P = .14. There was no difference in "relative" failure between LNF 7/85 (8.2%) and LTF 12/82 (14%), P = .23. Long-term dysphagia affected 5 out of 108 (4.6%) patients; 3/48 (6.2%) of LNF and 2/60 (3.3%) of LTF (P = .65). Conclusions: There was no statistically significant difference in 'absolute' failure between LNF and LTF at long-term follow-up. Neurologically impaired children have a high mortality rate following fundoplication due to comorbidities. This trial commenced in 1998 and was approved by the Oxfordshire Research Ethics Committee (No. 04.OXA.18-1998).

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%; Hirschsprung's 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%.

Long-term catch-up weight gain following fundoplication in children.

BACKGROUND: Laparoscopic fundoplication for severe gastroesophageal reflux (GOR) is well established in children. However, there are only a few reports on the long-term nutritional outcome following fundoplication. The aim of this study was to assess weight gain following fundoplication in children. METHODS: In this study, 127 children who underwent laparoscopic fundoplication ± gastrostomy between July 1998 and April 2007 were followed up for a median of 29.6 months postsurgery. Data (demography, weight) at fundoplication were collected prospectively, with ethical approval. Weights were converted to Z-scores for age (Z-score of 0 is equivalent to 50th percentile, -1 to 16th centile, and -2.0 is equivalent to 2nd centile). Severe failure to thrive (FTT) was defined as a Z-score of less than or equal to -2. Data were compared using the two-tailed Student t test, and multilevel regression modeling was applied. RESULTS: At the time of operation, patients had a low weight-for-age Z-score (-1.87 ± 0.19) and 61 children (48%) had FTT. Children who received a simultaneous gastrostomy had a significantly lower Z-score at operation (-2.80 ± 0.22) than those who did not (-0.68 ± 0.25, p < 0.001). Overall, patients exhibited significant catch-up weight gain following surgery (+0.88 ± 0.14, p < 0.001). The greatest increase in weight was mostly marked in patients who had a gastrostomy inserted (+1.22 ± 0.20, p < 0.001), but it was also significant in patients who did not receive a gastrostomy (+0.44 ± 0.17, p = 0.013). Catch-up weight gain occurred in neurologically impaired (NI) patients with (+1.31 ± 0.22, p < 0.001) or without (+0.81 ± 0.29, p = 0.012) gastrostomy. Weight of neurologically normal (NN) patients was within normal range but slightly lower than average before surgery (-0.45 ± 0.24) and this did not significantly change following surgery. There was no significant catch-up weight gain in patients (n = 9) with "esophageal pathologies" (Z-score of -1.35 ± 0.61 at operation compared with -0.35 ± 0.34 at follow-up; p = 0.14). CONCLUSIONS: Laparoscopic fundoplication (with or without gastrostomy placement) resulted in significant weight gain in children with GOR. Insertion of a gastrostomy at the same time resulted in greater weight gain. Pronounced weight gain occurred in NI children, whereas NN children and those with esophageal pathologies did not demonstrate any significant benefit in terms of weight gain following fundoplication.

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 Student's t test, chi-squared test, or Fisher's 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.

Surgical correction of tracheo-oesophageal fistula and oesophageal atresia in infants with VACTERL association: a retrospective case-control study.

INTRODUCTION: VACTERL is a rare, non-random association comprising at least three major component features defined by the acronym, and including Vertebral anomalies, Anorectal malformations, Cardiac defects, Tracheo-oEsophageal fistula with or without oesophageal atresia (TOF/OA), Renal abnormalities and Limb anomalies. The aim of this study was to compare the post-operative outcomes following surgical correction of TOF/OA in infants with VACTERL and isolated TOF/OA. METHODS: A retrospective case-control study comparing infants with VACTERL (case group) versus infants with isolated TOF/OA (control group) that underwent surgical correction of TOF/OA at our centre between January 2006 and December 2011. Patient demographics, types of anomalies, operative techniques and post-operative outcomes were collected using inpatient and outpatient records. RESULTS: We identified 30 consecutive infants with TOF/OA. Five infants had VACTERL (17 %) and 15 infants had isolated TOF/OA (50 %). There was no significant difference in the gestational age (P = 0.79), birth weight (P = 0.69) or operative repair (P = 0.14) between groups. Overall, surgical correction of TOF/OA led to satisfactory morbidity. Infants with VACTERL were not at higher risk of post-operative complications, such as oesophageal stricture (P = 0.17) or gastro-oesophageal reflux (P = 1.0), compared to infants with isolated TOF/OA. CONCLUSIONS: VACTERL association does not increase the risk of post-operative complications following TOF/OA repair.

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.

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.

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 patient's 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.

Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy.

BACKGROUND: When laparoscopic cholecystectomy (LC) is performed successfully, recovery is faster than after open cholecystectomy. However, LC results in higher incidences of biliary, bowel and vascular injury. METHODS: We performed a retrospective review of LC-related claims reported to the National Health Service Litigation Authority (NHSLA) during 2000-2005. The data were analysed from a medicolegal perspective to assess the effects of type of injury and delay in recognition on litigation costs. RESULTS: A total of 208 claims following laparoscopic procedures in general surgery were reported to NHSLA during 2000-2005, of which 133 (64%) were related to LC. Bile duct injury (BDI) accounted for the majority of claims (72%); bowel injury and 'others' accounted for 9% and 19%, respectively. Only 20% of BDIs were recognized during surgery; the majority were missed and diagnosed later. Claims related to LC resulted in payments totalling 6 m pound sterling, of which 4.3 m pound sterling was paid out for BDIs. The average cost was higher for patients who suffered a delay in diagnosis, as was the chance of a successful claim. CONCLUSIONS: Bile duct injury incurred during LC remains a serious hazard for patients. The resulting complications have led to litigation that has caused a huge financial drain on the health care system. Delayed recognition appears to correlate with more costly litigation.

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.

Population-based analysis of the risk of adhesion-related readmissions after abdominal surgery in children.

PURPOSE: The aim of this study was to quantify the risk of adhesion-related readmissions after abdominal surgery in children. METHODS: This was a population-based study. One thousand five hundred eighty-one children younger than 16 years underwent laparotomy in 1996. Patients were identified from the Scottish Morbidity Records database and followed up for 4 years. RESULTS: In children younger than 5 years, 4.2% had a readmission "directly" owing to adhesions. In children younger than 16 years, 1.1% had a readmission directly owing to adhesions. The highest risk of readmission followed surgery on the small intestine (9.3%), followed by abdominal wall surgery (5.8%), duodenal surgery (2.6%), colonic surgery (2.1%), and appendicectomy (0.3%). 55% of all readmissions occurred in the first year. CONCLUSION: There was no difference in readmission rates between younger and older children when comparing the organ on which surgery was initially performed. The highest readmission rate followed small intestinal surgery and the lowest followed appendicectomy. The risk of readmission was highest in the first year.

Small bowel obstruction due to adhesions following neonatal laparotomy.

The aim of this study was to assess the incidence of small bowel obstruction (SBO) due to adhesions following laparotomy in the neonatal period. This was a retrospective study of babies born between January 1998 and November 2003 who had a trans-abdominal procedure in the neonatal period in the John Radcliffe Hospital, Oxford, UK. Four hundred and fourteen patients had a trans-abdominal procedure during this period. The follow-up period ranged from 2 months to 6 years (median 39 months). Overall, twenty-three patients (6%) underwent subsequent laparotomy for SBO due to adhesions. Four patients (17%) who developed SBO due to adhesions had another adhesive obstruction requiring a further laparotomy. The majority of adhesions occurred within a year of the original procedure (87%). A single band caused the obstruction in eight patients (35%), multiple adhesions in six (26%), and dense adhesions in nine patients (39%). The incidence of SBO was highest following surgery for meconium ileus, followed by necrotizing enterocolitis (NEC), and malrotation. There were no deaths due to small bowel obstruction in this study.

Gastrostomy tube feeding in children with cerebral palsy: a prospective, longitudinal study.

We report a longitudinal, prospective, multicentre cohort study designed to measure the outcomes of gastrostomy tube feeding in children with cerebral palsy (CP). Fifty-seven children with CP (28 females, 29 males; median age 4y 4mo, range 5mo to 17y 3mo) were assessed before gastrostomy placement, and at 6 and 12 months afterwards. Three-quarters of the children enrolled (43 of 57) had spastic quadriplegia; other diagnoses included mixed CP (6 of 57), hemiplegia (3 of 57), undiagnosed severe neurological impairment (3 of 57), ataxia (1 of 57), and extrapyramidal disorder (1 of 57). Only 7 of 57 (12%) could sit independently, and only 3 of 57 (5%) could walk unaided. Outcome measures included growth/anthropometry, nutritional intake, general health, and complications of gastrostomy feeding. At baseline, half of the children were more than 38D below the average weight for their age and sex when compared with the standards for typically-developing children. Weight increased substantially over the study period; the median weight z score increased from -3 before gastrostomy placement to -2.2 at 6 months and -1.6 at 12 months. Almost all parents reported a significant improvement in their child's health after this intervention and a significant reduction in time spent feeding. Statistically significant and clinically important increases in weight gain and subcutaneous fat deposition were noted. Serious complications were rare, with no evidence of an increase in respiratory complications.

Impact of gastrostomy tube feeding on the quality of life of carers of children with cerebral palsy.

The aim of this prospective cohort study was to evaluate the impact of gastrostomy tube feeding on the quality of life of carers of children with cerebral palsy (CP). Short-Form 36 version II was used to measure quality of life in carers of 57 Caucasian children with CP (28 females, 29 males; median age 4y 4mo, range 5mo to 17y 3mo) six and 12 months after insertion of a gastrostomy tube. Responses were calibrated against a normative dataset (Oxford Healthy Life Survey III). Six months after gastrostomy feeding was started, a substantial rise in mean domain scores for mental health, role limitations due to emotional problems, physical functioning, social functioning, and energy/vitality were observed. At 12 months after gastrostomy placement, carers reported significant improvements in social functioning, mental health, energy/vitality (mean increase >9.8 points;p<0.03), and in general health perception (mean increase 6.35 points;p=0.045) compared with results at baseline. Moreover, the values obtained for these domains at 12 months were not significantly different from the normal reference standard. Carers reported a significant reduction in feeding times, increased ease of drug administration, and reduced concern about their child's nutritional status. This study has demonstrated a significant, measurable improvement in the quality of life of carers after insertion of a gastrostomy feeding tube.

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

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.