Pediatric Annals

Laparoscopic Gastrostomy and Fundoplication

Keith E Georgeson, MD

Abstract

Gastrostomy and fundoplication are used to treat infants and children with failure to thrive, gastroesophageal reflux, and both primary and secondary aspiration.1'4 These problems are most commonly encountered in children with impairment of the central nervous system. 1,,5,6 Neurologically normal children with failure to thrive and/or gastroesophageal reflux include patients with esophageal disorders, chronic lung diseases, congenital heart disease, and short bowel syndrome.

Children considered for gastrostomy and fundoplication should be thoroughly evaluated prior to surgical intervention.5,7 A careful history and physical examination are followed by a radiographic upper gastrointestinal series and a radionuclide study for reflux and gastric emptying. Table 1 lists other studies that are helpful in selected patients. Children with failure. to thrive and gastroesophageal reflux should be managed medically whenever appropriate. Nasoenteric tube feedings, metoclopramide, and ranitidine are useful therapeutic agents in some of these patients. Those children who do not respond to medical management, who have life-threatening reflux, or who have a chronic need for enteric feeding are considered candidates for surgical intervention.8

Children needing a feeding gastrostomy must be evaluated as to their need for an adjunctive fundoplication. Many articles discussing the advantages and disadvantages of prophylactic fundoplication are available in the literature.3'5,7,9,12 The author uses the following guidelines in determining the need for simultaneous fundoplication in gastrostomy candidates. If a candidate for gastrostomy has symptomatic or demonstrable gastroesophageal reflux, a fundoplication is performed in addition to the gastrostomy. Moreover, if the gastrostomy candidate has primary aspiration, a prophylactic fundoplication is performed along with the gastrostomy even though gastroesophageal reflux cannot be demonstrated.

Table

Fifty percent to 70% of asymptomatic patients will develop gastroesophageal reflux after gastrostomy placement.3-9,12 Children with unprotected airways are vulnerable to serious aspiration. Gastrostomies are performed without protective fundoplication only in those patients without demonstrable reflux and without primary aspiration. Additionally, children with significantly delayed emptying (less than 50% at 2 hours) are treated with pyloromyotomy. Patients with severely delayed gastric emptying (less than 20% at 2 hours) undergo pyloroplasty.

Laparoscopic fundoplication and gastrostomy are attractive alternatives to open procedures. One would anticipate the same benefits as seen with laparoscopic cholecystectomy. These benefits include less postoperative pain, faster return of gastrointestinal function, earlier discharge from the hospital, more rapid return to full activity, superior cosmetic result, and decreased overall costs.13"16 The potential disadvantages of laparoscopic surgery include an increased length of time for the intraoperative procedure, reliance on expensive equipment, and a steep learning curve.13

LAPAROSCOPIC GASTROSTOMY

Following creation of a pneumoperitoneum, two 5 -mm cannulas are inserted; one port is placed in the umbilicus and the other in the right upper quadrant. A nasogastric tube is passed into the stomach. The stomach is insufflated with CO2 using an auxiliary CO2 pump. T-fasteners are then passed through the abdominal wall and into the lesser curvature of the stomach to form a square. Lesser curvature placement of the gastrostomy may decrease the incidence of postgastrostomy reflux.17·18 A needle is then passed through the abdominal wall obliquely and into the stomach among the T-fasteners. A guidewire is passed through the needle. The tract is dilated over the guidewire. A Foley catheter is introduced into the stomach over the same guidewire. The sutures attached to the T-fasteners are secured to each other over a bolster. The gastrostomy tube is secured to the skin with a silk suture.

LAPAROSCOPIC FUNDOPLICATION

Laparoscopic fundoplication is performed using four ports (one through the umbilicus, one on each side of the umbilicus in the midclavicular line, and one in the midepigastrium to the right of midline). The liver is retracted and the esophageal hiatus dissected. The vagus nerves…

Gastrostomy and fundoplication are used to treat infants and children with failure to thrive, gastroesophageal reflux, and both primary and secondary aspiration.1'4 These problems are most commonly encountered in children with impairment of the central nervous system. 1,,5,6 Neurologically normal children with failure to thrive and/or gastroesophageal reflux include patients with esophageal disorders, chronic lung diseases, congenital heart disease, and short bowel syndrome.

Children considered for gastrostomy and fundoplication should be thoroughly evaluated prior to surgical intervention.5,7 A careful history and physical examination are followed by a radiographic upper gastrointestinal series and a radionuclide study for reflux and gastric emptying. Table 1 lists other studies that are helpful in selected patients. Children with failure. to thrive and gastroesophageal reflux should be managed medically whenever appropriate. Nasoenteric tube feedings, metoclopramide, and ranitidine are useful therapeutic agents in some of these patients. Those children who do not respond to medical management, who have life-threatening reflux, or who have a chronic need for enteric feeding are considered candidates for surgical intervention.8

Children needing a feeding gastrostomy must be evaluated as to their need for an adjunctive fundoplication. Many articles discussing the advantages and disadvantages of prophylactic fundoplication are available in the literature.3'5,7,9,12 The author uses the following guidelines in determining the need for simultaneous fundoplication in gastrostomy candidates. If a candidate for gastrostomy has symptomatic or demonstrable gastroesophageal reflux, a fundoplication is performed in addition to the gastrostomy. Moreover, if the gastrostomy candidate has primary aspiration, a prophylactic fundoplication is performed along with the gastrostomy even though gastroesophageal reflux cannot be demonstrated.

Table

TABLE 1

TABLE 1

Table

TABLE 2Associated Medical Problems of Open and Laparoscopic Gastrostomy and Fundoplication

TABLE 2

Associated Medical Problems of Open and Laparoscopic Gastrostomy and Fundoplication

Table

TABLE 3Presenting Symptoms for Open and Laparoscopic Gastrostomy and Fundoplication

TABLE 3

Presenting Symptoms for Open and Laparoscopic Gastrostomy and Fundoplication

Table

TABLE 4Postoperative Complications of Open and Laparoscopic Gastrostomy and Fundoplication

TABLE 4

Postoperative Complications of Open and Laparoscopic Gastrostomy and Fundoplication

Fifty percent to 70% of asymptomatic patients will develop gastroesophageal reflux after gastrostomy placement.3-9,12 Children with unprotected airways are vulnerable to serious aspiration. Gastrostomies are performed without protective fundoplication only in those patients without demonstrable reflux and without primary aspiration. Additionally, children with significantly delayed emptying (less than 50% at 2 hours) are treated with pyloromyotomy. Patients with severely delayed gastric emptying (less than 20% at 2 hours) undergo pyloroplasty.

Laparoscopic fundoplication and gastrostomy are attractive alternatives to open procedures. One would anticipate the same benefits as seen with laparoscopic cholecystectomy. These benefits include less postoperative pain, faster return of gastrointestinal function, earlier discharge from the hospital, more rapid return to full activity, superior cosmetic result, and decreased overall costs.13"16 The potential disadvantages of laparoscopic surgery include an increased length of time for the intraoperative procedure, reliance on expensive equipment, and a steep learning curve.13

LAPAROSCOPIC GASTROSTOMY

Following creation of a pneumoperitoneum, two 5 -mm cannulas are inserted; one port is placed in the umbilicus and the other in the right upper quadrant. A nasogastric tube is passed into the stomach. The stomach is insufflated with CO2 using an auxiliary CO2 pump. T-fasteners are then passed through the abdominal wall and into the lesser curvature of the stomach to form a square. Lesser curvature placement of the gastrostomy may decrease the incidence of postgastrostomy reflux.17·18 A needle is then passed through the abdominal wall obliquely and into the stomach among the T-fasteners. A guidewire is passed through the needle. The tract is dilated over the guidewire. A Foley catheter is introduced into the stomach over the same guidewire. The sutures attached to the T-fasteners are secured to each other over a bolster. The gastrostomy tube is secured to the skin with a silk suture.

LAPAROSCOPIC FUNDOPLICATION

Laparoscopic fundoplication is performed using four ports (one through the umbilicus, one on each side of the umbilicus in the midclavicular line, and one in the midepigastrium to the right of midline). The liver is retracted and the esophageal hiatus dissected. The vagus nerves are carefully preserved. Once the dissection of the hiatus has been completed, the crura are approximated with laparoscopic hernia staples.

The fundus then is mobilized. The short gastric vessels may need to be divided to adequately mobilize the fundus, but this is not usually necessary. The fundus is brought behind the esophagus and the 360° wrap is secured with 2-0 silk sutures. Hernia staples are used to reinforce the wrap and also to secure the fundus to the diaphragm so it will not slip into the chest. The wrap should be 2 cm to 3 cm in length.

GASTRIC OUTLET PROCEDURE

A pyloromyotomy is performed in those patients with poor gastric emptying. Electrocautery is used to divide the pylorus near the duodenum. A right angle clamp is used to spread the pylorus, exposing but not injuring the underlying mucosa. A 2 -cm pyloromyotomy usually is sufficient. Pyloroplasty can be performed through a small right upper quadrant incision or laparoscopically.

Postoperatively, the patients have their gastrostomy tube clamped for 12 hours and are given clear liquids 24 hours after surgery. The feedings are rapidly advanced so that discharge occurs 48 to 72 hours postoperatively. An adequate gastrostomy training and support mechanism must be in place to aid the family after discharge from the hospital.

DISCUSSION

This author recently has reviewed the first 60 patients to undergo laparoscopic fundoplication and/or gastrostomy at The Children's Hospital of Alabama and compared these children with a similar group of 60 consecutive children undergoing open fundoplication and/or gastrostomy. Associated illnesses, presenting symptoms, and morbidity and mortality for both groups are listed in Tables 2, 3, and 4.

The most notable difference between the two groups was median postoperative stay, which averaged 3 days less in the laparoscopic patients when compared with the open surgery patients. The median time for tolerating tube feeding was 2 days less in the laparoscopic group as compared to the open group.

These findings suggest that laparoscopic fundoplication is associated with a more rapid recovery and discharge from the hospital, and the cosmetic result in the laparoscopic patients was superior. Although cost data could not be reliably extracted from the hospital records, the significantly shorter hospital stay suggests that the laparoscopic procedure is associated with lower overall costs.

SUMMARY

Laparoscopic gastrostomy and fundoplication are a useful alternative to open fundoplication and gastrostomy in pediatric patients. Laparoscopic fundoplication appears to decrease the length of hospital stay and allow a more rapid recovery.

REFERENCES

1. Glue EG, Parrick J. Identification of children with cerebral palsy unable to maintain a normal nutritional state. Lancet. 1986;1:283-286.

2. Shapiro BK, Green P, Krick J, Allen D, Capute AJ. Growth of severely impaired children: neurological vs nutritional factors. Dev Med Child Neurol. 1986;28:729-733.

3. Hassen JM, Sunby C, Hint LM. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet. 1988;167:383-482.

4. Rempel GR1 Colwell SO, Nelson RP. Growth in children with cerebral palsy fed via gastrostomy. Pediatrics. 1988;82:857-862.

5. Wesley JR, Coran AG, Sarahan TM, Klein MD, White SJ. The need for evaluation of gastroesophageal reflux in brain-damaged children referred for feeding gastrostomy. J Pediatr Surg. 1982;16(6):866-870.

6. Sullivan PB. Gastrostomy and the disabled child. Dev Med Child Neurol. 1992:34:547555.

7. Jolley SG, Tunell WR Leonard JC, Hoelzer DJ, Smith EL Gastric emptying in children with gastroesophageal reflux, H: the relationship to retching symptoms following antireflux surgery. ] Pediatr Surg. 1987;22:927-930.

8. Tunell WP. Gastroesophageal reflux in childhood. Pediatr Ann. 1989;18:192-196.

9. Mollitt DL, Golladay S, Seibert JJ. Symptomatic gastroesophageal reflux following gastrostomy in neurologically Impaired patients. Pediatrics. 1985;75:1 124-1 126.

10. Langer JC, Wesson DE, Eiin HS, et al. Feeding gastrostomy in neurologically impaired children: is an antireflux procedure necessary?/ Pediatr Gastroenterol Nutr. 1988;7:837-841.

11. Wheatley MJ1 Wesley JR, Tkach DM, Coran AC Long-term follow-up of braindamaged children requiring feeding gastrostomy: should an antireflux procedure always be performed?; Pediatr Surg. 1991;26:301-305.

12. Berezin S, Schwan S, Hatata MS, Newman LJ. Gastroesophageal reflux secondary to gastrostomy tube placement. AmJ Dis Chad. 1986;14O-.699-701.

13. Rogers DA, Lobe TE, Schropp KP. Evolving uses of laparoscopy in children. Surg Clin North Am. 1992;72:1299-1313.

14- Sigman HH, Laberge JM, Croitoru D, et al. Laparoscopic cholecystectomy: a treatment option for gallbladder disease in children. J Pediatr Surg. 1991;26:118l1183.

15. Newman KD Marmorn LM, Attorri R, Evans S. Laparoscopic cholecystectomy in pediatric patients. J Pediatr Surg. 1991;26:1184-1185.

16. Holcomb GW1 Olsen DO, Sharp KW. Laparoscopic cholecystectomy in the pediatric patient. J Pbtim Surg. 199 1 ;26: 1 186- 1 190.

17. Stringe! G. Gastrostomy with antireflux properties. J Pediatr Surg. 1990;25:10191021.

18. Seekri IK, Rescorla Fj, Canal DF, Zollinger TW, Saywell R, Grosfcld JL Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux. J Pediatr Surg. 1991;26:982-985.

TABLE 1

TABLE 2

Associated Medical Problems of Open and Laparoscopic Gastrostomy and Fundoplication

TABLE 3

Presenting Symptoms for Open and Laparoscopic Gastrostomy and Fundoplication

TABLE 4

Postoperative Complications of Open and Laparoscopic Gastrostomy and Fundoplication

10.3928/0090-4481-19931101-08

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