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Laparoscopic modified Thal fundoplication for gastroesophageal reflux in a patient with severe scoliosis and sliding esophageal hiatal hernia
Journal of Pediatric Surgery (2006) 41, E15 – E18
www.elsevier.com/locate/jpedsurg
Laparoscopic modified Thal fundoplication for gastroesophageal reflux in a patient with severe scoliosis and sliding esophageal hiatal hernia Yukihiro Tatekawa*, Hiromichi Kanehiro, Yoshiyuki Nakajima Department of Surgery, Nara Medical University, Nara 634-8522, Japan Index words: Gastroesophageal reflux; Laparoscopic; Thal fundoplication; Scoliosis; Sliding esophageal hiatal hernia
Abstract A 14-year-old girl with severe scoliosis and sliding esophageal hiatal hernia underwent laparoscopic fundoplication for gastroesophageal reflux. Of various fundoplication procedures, anterior partial fundoplication (Thal fundoplication) was performed because it is effective, with less postoperative gas bloat syndrome. Laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach. In our bmodified anterior partial fundoplication,Q the sutures between the crura and the esophagus and the sutures on the left of esophageal wall with the fundus of the stomach could be exactly performed by laparoscopic surgical technique. The wrapping of the esophagus in fundoplication was done over the ventral 1808 to 2708. Six months postoperatively, the patient did not develop gas bloat syndrome, distal esophageal obstruction from fundoplication, and delayed gastric emptying. Modified anterior partial fundoplication achieves effective control of reflux symptoms. D 2006 Elsevier Inc. All rights reserved.
In operative procedures for gastroesophageal reflux, anterior partial fundoplication (Thal fundoplication) is effective, with less postoperative gas bloat syndrome [1-3]]. However, long-term results after Thal fundoplication described the recurrence of reflux in patients with central nervous system disorders [4]. Recently, the laparoscopic approach was introduced in pediatric surgery and was beneficial [5-10]. Especially, laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach [5].
* Corresponding author. Tel.: +81 744 22 3051; fax: +81 744 24 6866. E-mail address: [email protected] (Y. Tatekawa). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.06.025
1. Case report A 14-year-old girl had developed central paralysis because of encephalitis owing to Reye syndrome at the age of 3 years. Furthermore, the patient had suffered asthma attack since she was 10 years old and had been repeatedly admitted in the hospital. At the age of 14 years, the bloody sputum was noticed in aspiration, and then reflux gastritis was suspected. The patient was referred to our hospital, with suspicion of gastroesophageal reflux. Esophageal pH monitoring for 24 hours and upper gastrointestinal series were done. Pathological reflux was defined as a pH less than 4 during 5% or more of the total time measured (24 hours). The pH-monitoring data showed 28.5%, and the upper gastrointestinal series revealed the gastroesophageal reflux and sliding esophageal hiatal hernia (Fig. 1A). The patient underwent laparoscopic anterior partial fundoplication and
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Y. Tatekawa et al.
Fig. 1 The upper gastrointestinal series before and after fundoplication. The upper gastrointestinal series before fundoplication revealed the gastroesophageal reflux and sliding esophageal hiatal hernia (A). On postoperative 1 week, the upper gastrointestinal series showed no reflux, no distal esophageal obstruction from fundoplication, and no delayed gastric emptying (B).
Fig. 2 Operative procedures. The hiatal hernia was huge (A). The posterior hiatal closure (B) and the sutures between the crura and the esophagus (C) were performed. After the apical anchoring suture between the fundus and the diaphragm in the left side, the sutures on the left of esophageal wall with the fundus of the stomach (D) and the sutures between the anterior wall of the stomach and the lower intraabdominal esophagus (E) were done. Furthermore, the apical anchoring suture between the fundus and the diaphragm in the right side and then the sutures on the right side of esophageal wall with the fundus of the stomach (F) were performed. The partial wrapping around the anterior esophagus with the fundus of the stomach was done over the ventral 1808 to 2708.
Laparoscopic modified Thal fundoplication for gastroesophageal reflux
E17
Fig. 3 Operative scheme of anterior partial fundoplication. indicates the posterior hiatal closure; `, the sutures between the crura and the esophagus; ´ and ¯, the apical anchoring suture between the fundus and the diaphragm; ˆ, the sutures on the left of esophageal wall with the fundus of the stomach; ˜, the sutures between the anterior wall of the stomach and the lower intraabdominal esophagus; ˘, the sutures on the right side of esophageal wall with the fundus of the stomach.
gastrostomy in July 2005. In laparoscopic anterior partial fundoplication (Thal fundoplication), the hiatal hernia was huge (Fig. 2A). The esophagus was freed from the cura until approximately its lower 3 cm could be pulled down into the abdominal cavity. The posterior hiatal closure (Figs. 2B and 3) and the sutures between the crura and the esophagus (Figs. 2C and 3`) were performed. First, the apical anchoring suture between the fundus and the diaphragm in the left side (Fig. 3´), the sutures on the left of esophageal wall with the fundus of the stomach (Figs. 2D and 3ˆ), and the sutures between the anterior wall of the stomach and the lower intraabdominal esophagus (Figs. 2E and 3˜) were done. Next, the apical anchoring suture between the fundus and the diaphragm in the right side (Fig. 3¯) and the sutures on the right side of esophageal wall with the fundus of the stomach (Figs. 2F and 3˘) were done, and then the partial wrapping around the anterior esophagus with the fundus of the stomach could be exactly performed. The wrapping of the esophagus in our bmodified Thal fundoplicationQ was done over the ventral 1808 to 2708. In the upper gastrointestinal series on 1 week postoperative, no reflux, no distal esophageal obstruction from fundoplication, and no delayed gastric emptying were noticed (Fig. 1B). Twenty-four-hour esophageal pH-monitoring data on 6 months postoperative showed 1.9%. At present, the patient is doing well and mainly takes oral feedings and partially gastrostomy feedings.
2. Discussion By adding fixation of the stomach to the lower end of the esophagus, the anterior fundoplication creates an acute angle of His, and thus, the intragastric pressure is transmitted directly against the lower portion of the
esophagus. Furthermore, the short gastric vessels do not necessarily need to be divided. On the other hand, primary Thal fundoplication in conventional (open) and laparoscopic surgical technique does not perform the sutures between the crura and the esophagus, and primary laparoscopic fundoplication performs only the sutures on the right side of esophageal wall. The reasons of failed fundoplication were identified: herniation of the gastroesophageal junction through the hiatus with or without the wrap; paraesophageal hernia; and malformation of the wrap [11,12]. Most of the failures were managed within 2 years of the initial operation, and wrap herniation has become the most common mechanism of failure requiring redo [13]. The probability of reoperation for fundoplication increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions [14]. Our laparoscopic modified technique (anterior fundoplication) adds the sutures between the crura and the esophagus and the sutures on the left side of esophageal wall with the fundus of the stomach in comparison with the primary laparoscopic Thal fundoplication, which could prevent the wrap herniation. However, there are important things to be considered: first, do not close the posterior hiatus extremely because that would result in the obstruction or stenosis of esophagus. Next, do not make a tension on suturing between the right side of esophageal wall and the fundus of the stomach because the injury of the esophageal wall would occur by overtension on wrapping. Our modified Thal fundoplication could be performed exactly by laparoscopic surgical technique as well as conventional surgical technique. We are sure that our laparoscopic modified Thal fundoplication achieves more effectiveness than the other fundoplications.
E18
References [1] Ludemann R, Watson DI, Jamieson GG, et al. Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication. Br J Surg 2005;92:240 - 3. [2] Baigrie RJ, Cullis SN, Ndhluni AJ, et al. Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication. Br J Surg 2005;92:819 - 23. [3] Esposito C, Van Der Zee DC, Settimi A, et al. Risks and benefits of surgical management of gastroesophageal reflux in neurologically impaired children. Surg Endosc 2003;17:708 - 10. [4] Tuggle DW, Tunell WP, Hoelzer DJ, et al. The efficacy of Thal fundoplication in the treatment of gastroesophageal reflux: the influence of central nervous system impairment. J Pediatr Surg 1988; 23:638 - 40. [5] van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in severely scoliotic children. Surg Endosc 1995;9:1197 - 8. [6] Martinez-Frontanilla LA, Sartorelli KH, Haase GM, et al. Laparoscopic Thal fundoplication with gastrostomy in children. J Pediatr Surg 1996;31:275 - 6.
Y. Tatekawa et al. [7] van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in mentally retarded children. Surg Endosc 1996;10:659 - 61. [8] Van der Zee DC, Bax NMA. Laparoscopic Thal fundoplication in infants and children. In: Bax NMA, Pace RA, Prieto G, editors. Endoscopic surgery in children. Berlin-Heidelberg7 Springer-Verlag; 1999. p. 184 - 90. [9] van der Zee DC, Bax KN, Ure BM, et al. Long-term results after laparoscopic Thal procedure in children. Semin Laparosc Surg 2002; 9:168 - 71. [10] Kneist W, Heintz A, Trinh TT, et al. Anterior partial fundoplication for gastroesophageal reflux disease. Langenbecks Arch Surg 2003;388: 174 - 80. [11] Hatch KF, Daily MF, Christensen BJ, et al. Failed fundoplications. Am J Surg 2004;188:786 - 91. [12] van der Zee DC, Bax NM, Ure BM. Laparoscopic refundoplication in children. Surg Endosc 2000;14:1103 - 4. [13] Smith CD, McClusky DA, Rajad MA, et al. When fundoplication fails: redo? Ann Surg 2005;241:861 - 9. [14] Diaz DM, Gibbons TE, Heiss K, et al. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol 2005; 100:1844 - 52.
www.elsevier.com/locate/jpedsurg
Laparoscopic modified Thal fundoplication for gastroesophageal reflux in a patient with severe scoliosis and sliding esophageal hiatal hernia Yukihiro Tatekawa*, Hiromichi Kanehiro, Yoshiyuki Nakajima Department of Surgery, Nara Medical University, Nara 634-8522, Japan Index words: Gastroesophageal reflux; Laparoscopic; Thal fundoplication; Scoliosis; Sliding esophageal hiatal hernia
Abstract A 14-year-old girl with severe scoliosis and sliding esophageal hiatal hernia underwent laparoscopic fundoplication for gastroesophageal reflux. Of various fundoplication procedures, anterior partial fundoplication (Thal fundoplication) was performed because it is effective, with less postoperative gas bloat syndrome. Laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach. In our bmodified anterior partial fundoplication,Q the sutures between the crura and the esophagus and the sutures on the left of esophageal wall with the fundus of the stomach could be exactly performed by laparoscopic surgical technique. The wrapping of the esophagus in fundoplication was done over the ventral 1808 to 2708. Six months postoperatively, the patient did not develop gas bloat syndrome, distal esophageal obstruction from fundoplication, and delayed gastric emptying. Modified anterior partial fundoplication achieves effective control of reflux symptoms. D 2006 Elsevier Inc. All rights reserved.
In operative procedures for gastroesophageal reflux, anterior partial fundoplication (Thal fundoplication) is effective, with less postoperative gas bloat syndrome [1-3]]. However, long-term results after Thal fundoplication described the recurrence of reflux in patients with central nervous system disorders [4]. Recently, the laparoscopic approach was introduced in pediatric surgery and was beneficial [5-10]. Especially, laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach [5].
* Corresponding author. Tel.: +81 744 22 3051; fax: +81 744 24 6866. E-mail address: [email protected] (Y. Tatekawa). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.06.025
1. Case report A 14-year-old girl had developed central paralysis because of encephalitis owing to Reye syndrome at the age of 3 years. Furthermore, the patient had suffered asthma attack since she was 10 years old and had been repeatedly admitted in the hospital. At the age of 14 years, the bloody sputum was noticed in aspiration, and then reflux gastritis was suspected. The patient was referred to our hospital, with suspicion of gastroesophageal reflux. Esophageal pH monitoring for 24 hours and upper gastrointestinal series were done. Pathological reflux was defined as a pH less than 4 during 5% or more of the total time measured (24 hours). The pH-monitoring data showed 28.5%, and the upper gastrointestinal series revealed the gastroesophageal reflux and sliding esophageal hiatal hernia (Fig. 1A). The patient underwent laparoscopic anterior partial fundoplication and
E16
Y. Tatekawa et al.
Fig. 1 The upper gastrointestinal series before and after fundoplication. The upper gastrointestinal series before fundoplication revealed the gastroesophageal reflux and sliding esophageal hiatal hernia (A). On postoperative 1 week, the upper gastrointestinal series showed no reflux, no distal esophageal obstruction from fundoplication, and no delayed gastric emptying (B).
Fig. 2 Operative procedures. The hiatal hernia was huge (A). The posterior hiatal closure (B) and the sutures between the crura and the esophagus (C) were performed. After the apical anchoring suture between the fundus and the diaphragm in the left side, the sutures on the left of esophageal wall with the fundus of the stomach (D) and the sutures between the anterior wall of the stomach and the lower intraabdominal esophagus (E) were done. Furthermore, the apical anchoring suture between the fundus and the diaphragm in the right side and then the sutures on the right side of esophageal wall with the fundus of the stomach (F) were performed. The partial wrapping around the anterior esophagus with the fundus of the stomach was done over the ventral 1808 to 2708.
Laparoscopic modified Thal fundoplication for gastroesophageal reflux
E17
Fig. 3 Operative scheme of anterior partial fundoplication. indicates the posterior hiatal closure; `, the sutures between the crura and the esophagus; ´ and ¯, the apical anchoring suture between the fundus and the diaphragm; ˆ, the sutures on the left of esophageal wall with the fundus of the stomach; ˜, the sutures between the anterior wall of the stomach and the lower intraabdominal esophagus; ˘, the sutures on the right side of esophageal wall with the fundus of the stomach.
gastrostomy in July 2005. In laparoscopic anterior partial fundoplication (Thal fundoplication), the hiatal hernia was huge (Fig. 2A). The esophagus was freed from the cura until approximately its lower 3 cm could be pulled down into the abdominal cavity. The posterior hiatal closure (Figs. 2B and 3) and the sutures between the crura and the esophagus (Figs. 2C and 3`) were performed. First, the apical anchoring suture between the fundus and the diaphragm in the left side (Fig. 3´), the sutures on the left of esophageal wall with the fundus of the stomach (Figs. 2D and 3ˆ), and the sutures between the anterior wall of the stomach and the lower intraabdominal esophagus (Figs. 2E and 3˜) were done. Next, the apical anchoring suture between the fundus and the diaphragm in the right side (Fig. 3¯) and the sutures on the right side of esophageal wall with the fundus of the stomach (Figs. 2F and 3˘) were done, and then the partial wrapping around the anterior esophagus with the fundus of the stomach could be exactly performed. The wrapping of the esophagus in our bmodified Thal fundoplicationQ was done over the ventral 1808 to 2708. In the upper gastrointestinal series on 1 week postoperative, no reflux, no distal esophageal obstruction from fundoplication, and no delayed gastric emptying were noticed (Fig. 1B). Twenty-four-hour esophageal pH-monitoring data on 6 months postoperative showed 1.9%. At present, the patient is doing well and mainly takes oral feedings and partially gastrostomy feedings.
2. Discussion By adding fixation of the stomach to the lower end of the esophagus, the anterior fundoplication creates an acute angle of His, and thus, the intragastric pressure is transmitted directly against the lower portion of the
esophagus. Furthermore, the short gastric vessels do not necessarily need to be divided. On the other hand, primary Thal fundoplication in conventional (open) and laparoscopic surgical technique does not perform the sutures between the crura and the esophagus, and primary laparoscopic fundoplication performs only the sutures on the right side of esophageal wall. The reasons of failed fundoplication were identified: herniation of the gastroesophageal junction through the hiatus with or without the wrap; paraesophageal hernia; and malformation of the wrap [11,12]. Most of the failures were managed within 2 years of the initial operation, and wrap herniation has become the most common mechanism of failure requiring redo [13]. The probability of reoperation for fundoplication increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions [14]. Our laparoscopic modified technique (anterior fundoplication) adds the sutures between the crura and the esophagus and the sutures on the left side of esophageal wall with the fundus of the stomach in comparison with the primary laparoscopic Thal fundoplication, which could prevent the wrap herniation. However, there are important things to be considered: first, do not close the posterior hiatus extremely because that would result in the obstruction or stenosis of esophagus. Next, do not make a tension on suturing between the right side of esophageal wall and the fundus of the stomach because the injury of the esophageal wall would occur by overtension on wrapping. Our modified Thal fundoplication could be performed exactly by laparoscopic surgical technique as well as conventional surgical technique. We are sure that our laparoscopic modified Thal fundoplication achieves more effectiveness than the other fundoplications.
E18
References [1] Ludemann R, Watson DI, Jamieson GG, et al. Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication. Br J Surg 2005;92:240 - 3. [2] Baigrie RJ, Cullis SN, Ndhluni AJ, et al. Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication. Br J Surg 2005;92:819 - 23. [3] Esposito C, Van Der Zee DC, Settimi A, et al. Risks and benefits of surgical management of gastroesophageal reflux in neurologically impaired children. Surg Endosc 2003;17:708 - 10. [4] Tuggle DW, Tunell WP, Hoelzer DJ, et al. The efficacy of Thal fundoplication in the treatment of gastroesophageal reflux: the influence of central nervous system impairment. J Pediatr Surg 1988; 23:638 - 40. [5] van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in severely scoliotic children. Surg Endosc 1995;9:1197 - 8. [6] Martinez-Frontanilla LA, Sartorelli KH, Haase GM, et al. Laparoscopic Thal fundoplication with gastrostomy in children. J Pediatr Surg 1996;31:275 - 6.
Y. Tatekawa et al. [7] van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in mentally retarded children. Surg Endosc 1996;10:659 - 61. [8] Van der Zee DC, Bax NMA. Laparoscopic Thal fundoplication in infants and children. In: Bax NMA, Pace RA, Prieto G, editors. Endoscopic surgery in children. Berlin-Heidelberg7 Springer-Verlag; 1999. p. 184 - 90. [9] van der Zee DC, Bax KN, Ure BM, et al. Long-term results after laparoscopic Thal procedure in children. Semin Laparosc Surg 2002; 9:168 - 71. [10] Kneist W, Heintz A, Trinh TT, et al. Anterior partial fundoplication for gastroesophageal reflux disease. Langenbecks Arch Surg 2003;388: 174 - 80. [11] Hatch KF, Daily MF, Christensen BJ, et al. Failed fundoplications. Am J Surg 2004;188:786 - 91. [12] van der Zee DC, Bax NM, Ure BM. Laparoscopic refundoplication in children. Surg Endosc 2000;14:1103 - 4. [13] Smith CD, McClusky DA, Rajad MA, et al. When fundoplication fails: redo? Ann Surg 2005;241:861 - 9. [14] Diaz DM, Gibbons TE, Heiss K, et al. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol 2005; 100:1844 - 52.