Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study.

INTRODUCTION: Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS. METHODS: Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a 13C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS. RESULTS: After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001). CONCLUSIONS: In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.

Perioperative hospital mortality at a tertiary paediatric institution.

BACKGROUND: Research in postoperative mortality is scarce. Insight into mortality and cause of death might improve and innovate perioperative care. The objective for this study was to report the 24-hour and 30-day overall, and surgery and anaesthesia-related, in-hospital mortality at a tertiary paediatric hospital. METHODS: All patients <18 yr old who underwent anaesthesia with or without surgery between January 1, 2006, and December 31, 2012, at the Wilhelmina Children's Hospital, Utrecht, The Netherlands, were included in this retrospective cohort study. Causes of death within 30 days were identified and tabulated into four major categories according to principal cause. RESULTS: A total of 45,182 anaesthetics were administered during this 7-yr period. The all-cause 24-hour hospital mortality was 13.1 per 10,000 anaesthetics (95% CI: 9.9-16.8) and the all-cause 30-day in-hospital mortality was 41.6 per 10,000 anaesthetics (95% CI: 35.9-48.0). In total five patients were partially contributable to anaesthesia (30-day mortality: 1.1/10,000, 95% CI: 0.4-2.6) and four patients were partially contributable to surgery (30-day mortality: 0.9/10,000, 95% CI: 0.2-2.3). Mortality was higher in neonates and infants, children with ASA physical status III and IV, and emergency- and cardiothoracic surgery. CONCLUSIONS: Neonates and infants, children with ASA physical status III or poorer, and emergency- and cardiothoracic surgery are associated with a higher postoperative mortality. Anaesthesia- or surgery-related complications contribute to mortality in only a small amount of the deaths, indicating the relative safety of paediatric surgical and anaesthetic procedures.

Is complete surgical resection of stage 4 neuroblastoma a prerequisite for optimal survival or may >95 % tumour resection suffice?

Numerous studies have shown that for optimal survival in localized International Neuroblastoma Staging System stage 1-3 neuroblastoma, complete tumour resection (CR, macroscopic total tumour removal) is usually mandatory. In contrast, it is conceivable that in stage 4 disseminated disease, less extensive surgery [gross total resection (GTR), >95 % tumour removal] may suffice. This review shows substantial survival benefit in studies reporting on stage 4 patients undergoing CR, but also in studies reporting on patients undergoing GTR. Comparison between these studies is severely hampered by treatment heterogeneity. We found only four studies that explicitly compared survival between patients undergoing either CR or GTR. Two of these studies showed favourable results for patients treated with CR, while the other two did not show differences in survival.

Quality of life after esophageal replacement in children.

PURPOSE: Assessing quality of life (QoL) after esophageal replacement (ER) for long gap esophageal atresia (LGEA). METHODS: All patients after ER for LGEA with gastric pull-up (GPU n = 9) or jejunum interposition (JI n = 14) at the University Medical Center Groningen and Utrecht (1985-2007) were included. QoL was assessed with 1) gastrointestinal-related QoL using the Gastrointestinal Quality of Life Index (GIQLI)), 2) general QoL (Child Health questionnaire CHF87-BREF (children)/World Health Organization questionnaire WHOQOL-BREF (adults)), and 3) health-related QoL (HRQoL) (TNO AZL TACQoL/TAAQoL). Association of morbidity (heartburn, dysphagia, dyspnea on exertion, recurrent cough) and (HR)QoL was evaluated. RESULTS: Six patients after GPU (75%) and eight patients after JI (57%) responded to the questionnaires (mean age 15.7, SD 5.9, 12 male, two female). Mean gastrointestinal, general and health-related QoL total scores of the patients were comparable to healthy controls. However, young adults reported a worse physical functioning (p = 0.02) but better social functioning compared to peers (p = 0.01). Morbidity was not associated with significant differences in (HR)QoL. CONCLUSIONS: With the current validated QoL most patients after ER with GPU and JI for LGEA have normal generic and disease specific QoL scores. Postoperative morbidity does not seem to influence (HR)QoL. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: III.

Prolonged antibiotic treatment does not prevent intra-abdominal abscesses in perforated appendicitis.

BACKGROUND: Children with perforated appendicitis have a relatively high risk of intra-abdominal abscesses. There is no evidence that prolonged antibiotic treatment after surgery reduces intra-abdominal abscess formation. We compared two patient groups with perforated appendicitis with different postoperative antibiotic treatment protocols. METHODS: We retrospectively reviewed patients younger than age 18 years who underwent appendectomy for perforated appendicitis at two academic hospitals between January 1992 and December 2006. Perforation was diagnosed during surgery and confirmed during histopathological evaluation. Patients in hospital A received 5 days of antibiotics postoperatively, unless decided otherwise on clinical grounds. Patients in hospital B received antibiotics for 5 days, continued until serum C-reactive protein (CRP) was <20 mg/l. Univariate logistic regression analysis was performed on intention-to-treat basis. p < 0.05 was considered significant. RESULTS: A total of 149 children underwent appendectomy for perforated appendicitis: 68 in hospital A, and 81 in hospital B. As expected, the median (range) use of antibiotics was significantly different: 5 (range, 1-16) and 7 (range, 2-32) days, respectively (p < 0.0001). However, the incidence of postoperative intra-abdominal abscesses was similar (p = 0.95). Regression analysis demonstrated that sex (female) was a risk factor for abscess formation, whereas surgical technique and young age were not. CONCLUSIONS: Prolonged use of antibiotics after surgery for perforated appendicitis in children based on serum CRP does not reduce postoperative abscess formation.

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident's training.

BACKGROUND: In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training. METHODS: A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005. RESULTS: The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates. CONCLUSIONS: Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.

The laparoscopic approach toward hyperinsulinism in children.

Hyperinsulinemic hypoglycemia (HH) in children requiring surgery is rare. Early HH can be the result of focal or diffuse pancreatic pathology. A number of genetic abnormalities in early HH have been identified, but in the majority of patients no abnormality is found. The sporadic focal and diffuse forms as well the autosomal recessive form are particularly therapy-resistant and demand for early surgery. Preoperative discrimination between focal and diffuse disease in early HH is difficult. 18 F DOPA PET in combination with CT is promising as is laparoscopic exploration of the pancreas. Frozen section biopsy analysis has not been uniformly beneficial. If macroscopically no focal lesion is found, limited laparoscopic distal pancreatectomy provides tissue for definitive pathologic examination. Subsequent near total laparoscopic spleen-saving pancreatectomy surgery is not particularly difficult. Later HH may occur in the context of the MEN-1 syndrome and is then multifocal in nature. In MEN-1 patients, a distal spleen-saving pancreatectomy with enucleation of lesions in the head seems justified. Insulin-producing lesions in non-MEN-1 patients should be enucleated. There should always be a suspicion of malignancy. Also, in older children, surgery for hyperinsulinism should be performed laparoscopically.

Thoracoscopic tracheoaortopexia for the treatment of life-threatening events in tracheomalacia.

BACKGROUND: Life-threatening events resulting from tracheomalacia are a well-known complication of infants with esophageal atresia. Aortopexy is accepted as the most effective method for managing severe life-threatening and localized tracheomalacia with a success rate of 85% to 90%. Since the advent of minimally invasive surgery (MIS), the procedure also can be performed using thoracoscopic MIS. METHODS: Between January 2002 and November 2005, six children with esophageal atresia were treated using MIS for life-threatening events attributable to tracheomalacia. RESULTS: The patients tolerated the thoracoscopic procedure well, and all tracheoaortopexies could be performed thoracoscopically. There were two recurrences, which could be treated using thoracoscopy. After a follow-up period of 27 months (range, 10-45 months), all the patients are doing well and have had no more life-threatening events. CONCLUSIONS: Although this is the largest thoracoscopic series to date, the series is too small for any conclusions yet to be drawn. Thoracoscopic tracheoaortopexia is feasible and offers the advantages of MIS.

Duhamel procedure: a comparative retrospective study between an open and a laparoscopic technique.

BACKGROUND: Few studies are available comparing open with laparoscopic treatment of Hirschsprung's disease. This study compares a laparoscopic series of 30 patients with a historical open series of 25 patients. METHODS: The charts of all patients having had a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively reviewed. Open procedures were performed until March 1994. Patients with extended aganglionosis, pre-Duhamel ostomy, or syndrome were excluded from the study. End points were intraoperative complications, postoperative complications, time to first feeding, hospital stay, and outcome at follow-up such as stenosis, enterocolitis, constipation, fecal incontinence, and enuresis. RESULTS: Twenty-five patients had an open Duhamel (OD) and 30 had a laparoscopic one (LD). There were no differences in patient characteristics and there were no intraoperative complications in either group. Time to first oral feeds was significantly longer in the OD group as was the duration of hospital stay. No significant differences at follow-up were observed but there was a tendency for a higher enterocolitis rate in the LD group. In contrast, the adhesive obstruction and enuresis rates were higher in the OD group. Cosmetic results were superior in the LD group. CONCLUSIONS: Except for a significantly shorter hospital stay and shorter time to first oral feeds in favor of LD, no significant differences could be observed. The cosmetic result was not an end point but there was no doubt that it was better in the LD group. Although not statistically significant different, there were no adhesive bowel obstructions in the LD group compared with 3 of 25 in the OD group. Fecal incontinence was not encountered in either group.

Construct validity of the LapSim: can the LapSim virtual reality simulator distinguish between novices and experts?

BACKGROUND: Virtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden). METHODS: Forty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer. RESULTS: The higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters. CONCLUSIONS: Our results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.

[Invagination in children: not always ileocaecal]. / Invaginaties bij kinderen: niet altijd ileocoecaal.

Three patients, two girls aged 10 and a boy aged 11, suffered from secondary intussusception. Two of the cases were mistakenly managed as an idiopathic or classic intussusception. Hydrostatic reduction with a contrast enema was thought to be successful when retrograde influx in the ileum was seen. As the intussusception recurred, a diagnostic laparoscopy was performed followed by laparotomy and surgical treatment. In both cases an ileo-ileal intussusception was found. In one case the lead point was a malignant lymphoma, in the other case probably an area of vasculitis associated with Henoch Schönlein purpura. The enema had only repositioned the ileocolic part of the intussusception. In the third patient, the ileo-ileal intussusception resolved spontaneously. Due to the location of the intus-susception, a lead point was suspected and a laparoscopy was performed. A Meckel's diverticulum was found and resected. The importance of looking for a lead point is emphasized when dealing with an intussusception in children over the age of 3, or with evidence of underlying disease. In such cases, the relative value of a contrast enema for diagnosis and reposition is emphasised. There should be a low threshold for further investigation, including diagnostic laparoscopy.

Predictive Role of F2-Isoprostanes as Biomarkers for Brain Damage after Neonatal Surgery.

OBJECTIVE: Neonates have a high risk of oxidative stress during anesthetic procedures. The predictive role of oxidative stress biomarkers on the occurrence of brain injury in the perioperative period has not been reported before. METHODS: A prospective cohort study of patients requiring major surgery in the neonatal period was conducted. Biomarker levels of nonprotein-bound iron (NPBI) in plasma and F2-isoprostane in plasma and urine before and after surgical intervention were determined. Brain injury was assessed using postoperative MRI. RESULTS: In total, 61 neonates were included, median gestational age at 39 weeks (range 31-42) and weight at 3000 grams (1400-4400). Mild to moderate brain lesions were found in 66%. Logistic regression analysis showed a significant difference between plasma NPBI in patients with nonparenchymal injury versus no brain injury: 1.34 umol/L was identified as correlation threshold for nonparenchymal injury (sensitivity 67%, specificity 91%). In the multivariable analysis, correcting for GA, no other significant relation was found with the oxidative stress biomarkers and risk factors. CONCLUSION: Oxidative stress seems to occur during anaesthesia in this cohort of neonates. Plasma nonprotein-bound iron showed to be associated with nonparenchymal injury after surgery, with values of 1.34 umol/L or higher. Risk factors should be elucidated in a more homogeneous patient group.

Carbon dioxide differentially affects the cytokine release of macrophage subpopulations exclusively via alteration of extracellular pH.

BACKGROUND: The improved outcome after endoscopic surgery has been attributed to less surgical trauma. However, the underlying mechanisms are not fully understood, and direct effects of CO2 used for pneumoperitoneum, cellular acidification, and/or the lack of air contamination have been postulated to additionally modulate immune functions during endoscopic surgery. We investigated the effects of CO2 incubation, extracellular acidification, and air contamination on the inflammatory response of two distinct macrophage populations. METHODS: R2 and NR 8383 rat macrophage cell lines were used. Interleukin-6 (IL-6) and nitric oxide after lipopolysaccharide (LPS) stimulation were determined in these sets of experiments: incubation in 100% CO2, 5% CO2, and room air for 2h; incubation at pH 7.4, 6.5, and 5.5 for 2 h in 5% CO2; and incubation in 100% CO2, 5% CO2 and room air in fixed pH 6.3. The extracellular pH was monitored during incubation. We determined the alteration of intracellular pH in cells subjected to extracellular acidification by fluorescence microscopy. RESULTS: Extracellular pH decreased to 6.3 during 100% CO2 incubation. IL-6 release was reduced after CO2 incubation in NR 8383 cells and increased in R2 cells (p < 0.05). It was not altered by air incubation. Decreasing the extracellular pH to 6.5 mimicked the effects of CO2 and a decrease to 5.5 suppressed IL-6 release in both cell lines. In fixed pH at 6.3, CO2 and air incubation had no effect. CO2 and pH had no impact on nitric oxide release and vitality. Intracellular pH decreased with extracellular acidification without significant difference between the two cell lines. CONCLUSIONS: A decrease in extracellular pH during incubation in CO2 differentially affects IL-6 release in macrophage subpopulations. This may explain contradictory results in the literature. Moreover, we demonstrated that air contamination does not affect macrophage cytokine release. The decrease in extracellular pH is the primary underlying mechanism of the alteration of macrophage cytokine release after CO2 incubation, and it appears that the ability to maintain intracellular pH is not determined by the effects of CO2 or extracellular acidification.

Impact of laparoscopic antireflux surgery on belching in pediatric GERD patients.

BACKGROUND: Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pomp inhibitor (PPI)-resistant gastroesophageal reflux disease (GERD). Besides preventing reflux of gastric fluid and solid content, LARS may also impair the ability of the stomach to vent intragastric air (i.e. gastric belching) and induce gas-related complications, such as bloating and/or hyperflatulence. Furthermore, it was previously hypothesized that LARS induces a behavioral type of belching, not originating from the stomach, called supragastric belching. The aim of this study was to objectively evaluate the impact of LARS on gastric (GB) and supragastric belching (SGB) in children with GERD. METHODS: We performed a prospective, Dutch multicenter cohort study including 25 patients (12 males, median age 6 (range 2-18) years) with PPI-resistant GERD who were scheduled for LARS. Twenty-four-hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after fundoplication. Impedance pH tracings were analyzed for reflux episodes and GBs and SGBs. KEY RESULTS: LARS reduced acid exposure time from 8.5% (6.0-16.2%) to 0.8% (0.2-2.8%), p < 0.001. The number of GBs also significantly decreased after LARS (59 [43-77] VS 5 [2-12], p < 0.001). The number of air swallows remained unchanged after LARS. SGBs were infrequent before LARS with no change in the number of SGB observed after the procedure. Postoperative belching symptoms were associated with GBs, not with SGBs. CONCLUSION & INFERENCES: LARS significantly reduces the number of GBs in children with GERD, whereas the number of air swallows remains unchanged. Postoperative symptomatic belching is associated with GBs, but not with SGBs. These findings suggest that LARS does not induce the occurrence of SGBs in children, but longer follow-up is required.

Management of pediatric esophageal perforation.

Esophageal perforation is a serious complication necessitating immediate therapy. In a retrospective study we have evaluated the results in 13 children treated for esophageal perforation. Eleven of 13 perforations could be managed conservatively. In one child with extrapleural effusion, tube drainage was performed. The only death in this series occurred in a child who was brought for treatment after a 60-hour delay. Thoracotomy and multiple abscess drainage eventually proved unsuccessful. On the basis of our experience with children with esophageal perforation or with complications after esophageal atresia repair, we conclude that management of esophageal perforation in children differs substantially from therapy in adults and necessitates restrictive treatment guided by clinical symptoms.

Thoracoscopic repair of esophageal atresia with distal fistula.

BACKGROUND: Esophageal atresia (EA) has always been considered the hallmark of pediatric surgery. In the past decade, mortality was primarily the result of associated diseases, and operative morbidity had greatly improved. Yet the consequences of opening the thoracic cavity remained unchanged. In the era of endoscopic surgery, a thoracic approach to EA has become feasible, but is it of benefit for the patient? METHODS: Between May 2000 and June 2002, 13 neonates underwent thoracoscopic repair of EA. There were 12 boys and 1 girl. Mean gestational age was 36.9 weeks. Mean weight was 3093 g. Eleven children had associated anomalies. RESULTS: All of the procedures were performed thoracoscopically. There were no intraoperative complications, although anastomosis was difficult in one patient due to an extensive distance between the two stumps. Mean operating time was 2.6 h (range, 1.45-3.5). Five short-term postoperative complications occurred. Four of the early patients had stenosis due to a too-small incision in the proximal pouch, which needed one or more dilatations. One of these children, as well together as one other child, had anastomotic leakage, which was treated conservatively. Late complications consisted of gastroesophageal reflux ( n = 5) and tracheomalacia ( n = 1); these conditions required endoscopic correction in, respectively, two and one cases. Feeding by nasogastric tube was started after 3.5 days (mean), and total oral feeding was possible after 8.6 days (mean). Mean hospitalization was 12.2 days. Mean follow-up was 15.2 months. Scar formation was minimal, and the thoracic cage was preserved. CONCLUSION: The feasibility of thoracoscopic repair of EA has already been demonstrated. Today, its results in terms of operating time, feeding, hospital stay, and postoperative complications are equal to open procedures. Its advantages include better cosmesis and preservation of the thorax.

The laparoscopic approach to sacrococcygeal teratomas.

BACKGROUND: Sacrococcygeal teratomas (SCT) are classically approached posteriorly through an inverted chevron incision. In large, external, mainly solid SCT, prior interruption of the arterial supply is warranted because of impending heart failure and life-threatening hemorrhagic diathesis. Hitherto, this has required prior laparotomy. A laparotomy is also added when the tumor extends presacrally into the pelvis. The presacral region is, however, difficult to access. A laparoscopic-assisted approach seems to offer a solution for both problems. METHODS: A laparoscopic-assisted approach was used in five patients with SCT. In one neonate, it was used to interrupt the arterial blood supply only; in the other four patients, it was used to dissect the internal extension of the tumor. RESULTS: Laparoscopic interruption of the median sacral artery proved to be simple in the neonate with a large, external, mainly solid SCT. In three of the remaining four patients with presacral extension of the tumor, good visualization and dissection of the intrapelvic portion of the tumor was obtained. In one patient, the procedure had to be converted because of a lack of working space due to extensive intraabdominal growth of the tumor. CONCLUSION: A laparoscopic-assisted approach seems to be ideal for SCT. It provides the opportunity to interrupt the median sacral artery before the dissection. Moreover, it enables far better access to the presacral area than the conventional surgical approach when the SCT extends presacrally into the pelvis. Such a meticulous laparoscopic dissection may improve the functional results.

Laparoscopic identification and removal of focal lesions in persistent hyperinsulinemic hypoglycemia of infancy.

BACKGROUND: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a heterogeneous condition. A number of children have focal lesions, and removal of these lesions is curative. However, these lesions are difficult to detect, even during surgery. A laparoscopic approach is beneficial. METHODS: Two children with PHHI underwent laparoscopic pancreatic inspection at 32 and 29 days of age, respectively. RESULTS: In both children, a lesion was easily found in the head of the pancreas. The lesions looked more lobular, had a more pronounced blood supply, and appeared to have a firmer texture than the remaining pancreas. Enucleation was curative. CONCLUSION: A laparoscopic approach seems to be ideal for patients with PHHI not only because of the magnification but also because of the delicate surgery it allows and the avoidance of major abdominal wall problems.

The role of laparoscopy in the management of childhood intussusception.

BACKGROUND: Some authors have argued that intussusception is best treated via a laparoscopic approach. As we did not have this impression, we reviewed our experience with this condition. METHODS: : We reviewed all patients with intussusception who were treated at our hospital over the past 10 years. The choice of whether to use a laparoscopic or open approach depended on the patient's clinical condition and the availability of surgeons with laparoscopic expertise. RESULTS: A total of 72 patients were identified. Based on age, two subgroups were distinguished-one comprised of patients under the age of 3 years and one of patients over the age of 3 years. Sixty-five patients were under 3 years of age. Thirty-five had surgery, and 19 required resection. Of the 10 patients who were treated with a laparoscopic approach, only three could be reduced laparoscopically. After conversion in the other seven patients, the intussusception was reduced in five whereas a resection was required in two cases. Seven patients were 3 years of age or older. All of them underwent surgery, and all but one required resection. All four children who were laparoscoped subsequently had a bowel resection at open surgery. CONCLUSIONS: Patients 3 years of age or older usually need resection and will not benefit from the laparoscopic approach. Under 3 years of age, little is to be gained from a laparoscopic approach, provided good nonsurgical reduction facilities are available. There is a place for the laparoscopic approach in cases of recurrent intussusception or doubtful reduction.

Risks and benefits of surgical management of gastroesophageal reflux in neurologically impaired children.

BACKGROUND: The aim of this study was to investigate the feasibility and results of laparoscopic antireflux procedure in neurologically impaired children. METHODS: Over a 5-yr period, 259 children affected by gastroesophageal reflux disease underwent laparoscopic antireflux procedure. Eighty of them (30.8%) were neurologically impaired. In 58 children we performed an anterior fundoplication according to Thal and in 22 patients a 360 degrees fundoplication according to Nissen. Forty-eight children underwent an associated gastrostomy placement at the same time as the laparoscopic antireflux procedure. RESULTS: We recorded 4/80 intraoperative complications; in all cases the complication was managed laparoscopically and no conversion was needed. Follow-up ranged from 6 months to 6 yrs (median 3 yrs). We recorded 24/80 postoperative complications, 5 of which required a redo procedure. We have a mortality rate of 17.5% but in only one case was the event related to the antireflux procedure. CONCLUSIONS: Laparoscopic fundoplication can be performed safely and with acceptable results in neurologically impaired children. The indication to add a gastrostomy should be tailored to the needs of the individual patient. Mortality rate in neurologically impaired children patients with gastroesophageal reflux disease is high but in most cases unrelated to the antireflux procedure.