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Transthoracic nissen fundoplication for gastroesophageal reflux in patients with severe kypho-roto-scoliosis
Transthoracic Nissen Fundoplication for Gastroesophageal Reflux in Patients With Severe Kypho-Roto-Scoliosis By David E.M. Drucker, Barbara A. Michna, Thomas M. Krummel, Patricia K. Hunt, Michael A. Hartenberg, and Arnold M. Salzberg Richmond and Petersburg, Virginia 9 Transthoracic Nissen fundoplication was used for the correction of gastroesophageal reflux in five mentally retarded patients with severe kypho-roto-scoliosis. This deformity may result in a gastroesophageal junction so high above the left costal margin that transabdominal fundoplication is extremely difficult. Operative morbidity was minimal. One wrap disruption occurred that required reoperation. Results have been satisfactory 6 to 24 months postoperatively. 9 1 9 8 9 b y Grune & S t r a t t o n , Inc.
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]eal dilator
INDEX W O R D S : Gastroesophageal reflux; Nissen fundoplication; kypho-roto-scoliosis.
ASTROESOPHAGEAL REFLUX in the retarded patient is best treated surgically, and Nissen fundoplication, performed through the abdomen, has become the standard procedure. ~'2 In five patients with severe mental retardation and kypho-roto-scoliosis, the high level of the gastroesophageal junction, hidden beneath a costal margin that approaches the iliac crest, prevents adequate exposure and precludes transabdominal fundoplication. Each patient underwent a transthoracic Nissen fundoplication without technical problems.
short gastrics ligated
G
MATERIALS AND METHODS The patients, in a pediatric ward of a state mental facility, were bedridden with severe mental retardation, head trauma, anoxic encephalopathy, or spastic quadriparesis. The patients' ages ranged from 14 to 26 years, and each had developed severe trunk and extremity contractures and kypho-roto-scoliosis. Indications for surgery included aspiration pneumonia in three, bleeding from esophagitis in two, and weight loss from vomiting in one. Reflux was grade II to III (noted on an esophagram) in all five; manometry and pH probe data were confirmatory. A lead marker was placed on the left costal margin during the upper gastrointestinal (GI) series to permit measurement of the distance between the gastroesophageal junction and the costal margin.
From the Divisions of Pediatric Surgery and Radiology, Departments of Surgery and Radiology, Medical College of Virginia, Virginia Commonwealth University, Richmond," and Southside Virginia Training Center, Petersburg, VA. Presented at the 19th Annual Meeting of the American Pediatric Surgical Association, Tucson, Arizona, May 11-14, 1988. Address reprint requests to Arnold M. Salzberg, MD, Division of Pediatric Surgery, Box 15, MCV Station, Richmond, VA 232980001. 9 1989 by Grune & Stratton, Inc. 0022-3468/89/2401-0011503.00/0
46
Fig 1. With the dissection completed, the fundic wrap is ready to be secured around the esophagus.
Because of the high-riding gastroesophageal junction, fundoplication was performed transthoracically. These patients cannot he placed in a right lateral decubitus position, therefore an anterolateral incision was used through the seventh or eighth interspace. The esophagus and vagi were mobilized together from the hiatus to the aortic arch. The peritoneum was entered circumferentially at the hiatus with ligation of a branch of the left gastric artery that enters the right side of the esophagus. Only once was it necessary to incise the hiatus in order to improve exposure. A suture was placed at the gastroesophageal junction. The short gastrics were divided, the congenital adhesions to the pancreas were lysed, and the anterior gastric fat pad was removed. The fundus was wrapped around the esophagus, which contained the largest bougie that could be passed comfortably (Fig 1). The wrap was placed in the abdomen, and the hiatus was closed with crural sutures. A Stamm feeding gastrostomy was performed through a separate abdominal incision.
RESULTS
Postoperative morbidity was minimal. There was one early wrap disruption that required reoperation. All patients had a postoperative GI series that showed no reflux. Clinical and radiologic follow-up from 6 to 24 months has failed to detect recurrence of reflux. DISCUSSION The Nissen fundoplication has become the standard
surgical therapy for gastroesophageal reflux in pediatrics, and is superior to medical regimens in mentally retarded patients. 3'4Though most are performed transabdominally, some surgeons routinely use the trans-
Journal of Pediatric Surgery, Vol 24, No 1 (January), 1989: pp 46-47
TRANSTHORACIC FUNDOPLICATION FOR GER
47
thoracic approach and report excellent results. 5 The transthoracic route facilitates the operation in cases of reoperation or a short esophagus. The thoracic approach is almost mandatory in the patient with kypho-roto-scoliosis who has a gastroesophageal junction >8 cm above the costal margin. A transabdominal fundoplication can be performed in these patients if the gastroesophageal junction is more normally situated. The single incidence of wrap disruption led to a modification of the procedure; four pledgets are used to buttress the fundoplication, which is fashioned with two horizontal monofilament nonabsorbable mattress sutures. This method, suggested by DeMeester et al, 6 has been used extensively in adults with minimal complications.
In these uncommunicative patients, the problem of occult postoperative small bowel obstruction is a concern. 7,s Because of their inability to either vomit or complain of pain, the possibility of delay in diagnosis and bowel infarction exists. The placement of a feeding gastrostomy is at least partially protective, since a route of gastric decompression is provided. CONCLUSION
In the kypho-roto-scoliotic patient with a gastroesophageal junction more than 8 cm above the left costal margin, transabdominal exposure of the gastroesophageal junction is inadequate. In such patients, a Nissen fundoplication may be more easily and safely performed through the left side of the chest.
REFERENCES 1. Scharli AF: Gastroesophageal reflux and severe mental retardation. Prog Pediatr Surg 18:96-100, 1985 2. Byrne W J, Euler AR, Ashcraft E, et al: Gastroesophageal reflux in the severely retarded who vomit: Criteria for and results of surgical intervention in twenty-two patients. Surgery 91:95-98, 1982 3. Wilkinson JD, Dudgeon DL, Sondheimer JM: A comparison of medical and surgical treatment of gastroesophageal reflux in severely retarded children. J Pediatr 99:202-205, 1981 4. Randolph J: Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants. Ann Surg 198:579584, 1983
5. Maher JW, Hocking MP, Woodward ER: Supradiaphragmatic fundoplication: Long term follow-up and analysis of complications. Am J Surg 147:181-186, 1984 6. DeMeester TR, Bonavina L, Albertucci M: Nissen fundoplication for gastroesophageal reflux disease: Evaluation of primary repair in 100 consecutive patients. Ann Surg 204:9-20, 1986 7. Glick PL, Harrison MR, Adzick NS, et al: Gastric infarction secondary to small bowel obstruction: A preventable complication after Nissen fundoplication. J Pediatr Surg 22:941-943, 1987 8. Jolley SG, Tunell WP, Hoelzer D J, et al: Postoperative small bowel obstruction in infants and children: A problem following Nissen fundoplication. J Pediatr Surg 21:407-409, 1986
Discussion E. Fonkalsrud (Los Angeles): We have had three such patients and did not have the wisdom to attempt transthoracic repair. It can be extremely difficult to approach these patients through the abdomen. In the latter two, we used the follow-up approach so we did not have to go completely around the esophagus; and found that somewhat helpful, but I think your approach through the chest is certainly a very good one for this type of problem. I wonder if, in your approach, you have encountered any injury of the vagus nerves and delayed gastric emptying following the procedure. Postoperatively, have any of these patients had delay in gastric emptying? T. Canty (San Diego): I rise only to mention a word of caution in this group of patients and to suggest some coordination with your orthopedic colleagues because
many of these youngsters will have an orthopedic scoliosis operation of the Dwyer sort. This requires an anterior thoracoabdominal approach, in which the diaphragm may have to be taken down; this can greatly jeopardize the previously performed Nissen fundoplication. This happened to us on one occasion, and we had to actually back out of the operation because of the problem of taking down the diaphragm. D.E.M. Drucker (Richmond, VA): Gastric emptying has not been assessed other than by the upper GI showing no reflux and a stomach that emptied promptly. There has been no clinical evidence of delay. The vagus is mobilized along with the esophagus, and traction is placed on the esophagus with a penrose drain; though some stretch is applied, this did not appear to cause any clinical problem.
/
]eal dilator
INDEX W O R D S : Gastroesophageal reflux; Nissen fundoplication; kypho-roto-scoliosis.
ASTROESOPHAGEAL REFLUX in the retarded patient is best treated surgically, and Nissen fundoplication, performed through the abdomen, has become the standard procedure. ~'2 In five patients with severe mental retardation and kypho-roto-scoliosis, the high level of the gastroesophageal junction, hidden beneath a costal margin that approaches the iliac crest, prevents adequate exposure and precludes transabdominal fundoplication. Each patient underwent a transthoracic Nissen fundoplication without technical problems.
short gastrics ligated
G
MATERIALS AND METHODS The patients, in a pediatric ward of a state mental facility, were bedridden with severe mental retardation, head trauma, anoxic encephalopathy, or spastic quadriparesis. The patients' ages ranged from 14 to 26 years, and each had developed severe trunk and extremity contractures and kypho-roto-scoliosis. Indications for surgery included aspiration pneumonia in three, bleeding from esophagitis in two, and weight loss from vomiting in one. Reflux was grade II to III (noted on an esophagram) in all five; manometry and pH probe data were confirmatory. A lead marker was placed on the left costal margin during the upper gastrointestinal (GI) series to permit measurement of the distance between the gastroesophageal junction and the costal margin.
From the Divisions of Pediatric Surgery and Radiology, Departments of Surgery and Radiology, Medical College of Virginia, Virginia Commonwealth University, Richmond," and Southside Virginia Training Center, Petersburg, VA. Presented at the 19th Annual Meeting of the American Pediatric Surgical Association, Tucson, Arizona, May 11-14, 1988. Address reprint requests to Arnold M. Salzberg, MD, Division of Pediatric Surgery, Box 15, MCV Station, Richmond, VA 232980001. 9 1989 by Grune & Stratton, Inc. 0022-3468/89/2401-0011503.00/0
46
Fig 1. With the dissection completed, the fundic wrap is ready to be secured around the esophagus.
Because of the high-riding gastroesophageal junction, fundoplication was performed transthoracically. These patients cannot he placed in a right lateral decubitus position, therefore an anterolateral incision was used through the seventh or eighth interspace. The esophagus and vagi were mobilized together from the hiatus to the aortic arch. The peritoneum was entered circumferentially at the hiatus with ligation of a branch of the left gastric artery that enters the right side of the esophagus. Only once was it necessary to incise the hiatus in order to improve exposure. A suture was placed at the gastroesophageal junction. The short gastrics were divided, the congenital adhesions to the pancreas were lysed, and the anterior gastric fat pad was removed. The fundus was wrapped around the esophagus, which contained the largest bougie that could be passed comfortably (Fig 1). The wrap was placed in the abdomen, and the hiatus was closed with crural sutures. A Stamm feeding gastrostomy was performed through a separate abdominal incision.
RESULTS
Postoperative morbidity was minimal. There was one early wrap disruption that required reoperation. All patients had a postoperative GI series that showed no reflux. Clinical and radiologic follow-up from 6 to 24 months has failed to detect recurrence of reflux. DISCUSSION The Nissen fundoplication has become the standard
surgical therapy for gastroesophageal reflux in pediatrics, and is superior to medical regimens in mentally retarded patients. 3'4Though most are performed transabdominally, some surgeons routinely use the trans-
Journal of Pediatric Surgery, Vol 24, No 1 (January), 1989: pp 46-47
TRANSTHORACIC FUNDOPLICATION FOR GER
47
thoracic approach and report excellent results. 5 The transthoracic route facilitates the operation in cases of reoperation or a short esophagus. The thoracic approach is almost mandatory in the patient with kypho-roto-scoliosis who has a gastroesophageal junction >8 cm above the costal margin. A transabdominal fundoplication can be performed in these patients if the gastroesophageal junction is more normally situated. The single incidence of wrap disruption led to a modification of the procedure; four pledgets are used to buttress the fundoplication, which is fashioned with two horizontal monofilament nonabsorbable mattress sutures. This method, suggested by DeMeester et al, 6 has been used extensively in adults with minimal complications.
In these uncommunicative patients, the problem of occult postoperative small bowel obstruction is a concern. 7,s Because of their inability to either vomit or complain of pain, the possibility of delay in diagnosis and bowel infarction exists. The placement of a feeding gastrostomy is at least partially protective, since a route of gastric decompression is provided. CONCLUSION
In the kypho-roto-scoliotic patient with a gastroesophageal junction more than 8 cm above the left costal margin, transabdominal exposure of the gastroesophageal junction is inadequate. In such patients, a Nissen fundoplication may be more easily and safely performed through the left side of the chest.
REFERENCES 1. Scharli AF: Gastroesophageal reflux and severe mental retardation. Prog Pediatr Surg 18:96-100, 1985 2. Byrne W J, Euler AR, Ashcraft E, et al: Gastroesophageal reflux in the severely retarded who vomit: Criteria for and results of surgical intervention in twenty-two patients. Surgery 91:95-98, 1982 3. Wilkinson JD, Dudgeon DL, Sondheimer JM: A comparison of medical and surgical treatment of gastroesophageal reflux in severely retarded children. J Pediatr 99:202-205, 1981 4. Randolph J: Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants. Ann Surg 198:579584, 1983
5. Maher JW, Hocking MP, Woodward ER: Supradiaphragmatic fundoplication: Long term follow-up and analysis of complications. Am J Surg 147:181-186, 1984 6. DeMeester TR, Bonavina L, Albertucci M: Nissen fundoplication for gastroesophageal reflux disease: Evaluation of primary repair in 100 consecutive patients. Ann Surg 204:9-20, 1986 7. Glick PL, Harrison MR, Adzick NS, et al: Gastric infarction secondary to small bowel obstruction: A preventable complication after Nissen fundoplication. J Pediatr Surg 22:941-943, 1987 8. Jolley SG, Tunell WP, Hoelzer D J, et al: Postoperative small bowel obstruction in infants and children: A problem following Nissen fundoplication. J Pediatr Surg 21:407-409, 1986
Discussion E. Fonkalsrud (Los Angeles): We have had three such patients and did not have the wisdom to attempt transthoracic repair. It can be extremely difficult to approach these patients through the abdomen. In the latter two, we used the follow-up approach so we did not have to go completely around the esophagus; and found that somewhat helpful, but I think your approach through the chest is certainly a very good one for this type of problem. I wonder if, in your approach, you have encountered any injury of the vagus nerves and delayed gastric emptying following the procedure. Postoperatively, have any of these patients had delay in gastric emptying? T. Canty (San Diego): I rise only to mention a word of caution in this group of patients and to suggest some coordination with your orthopedic colleagues because
many of these youngsters will have an orthopedic scoliosis operation of the Dwyer sort. This requires an anterior thoracoabdominal approach, in which the diaphragm may have to be taken down; this can greatly jeopardize the previously performed Nissen fundoplication. This happened to us on one occasion, and we had to actually back out of the operation because of the problem of taking down the diaphragm. D.E.M. Drucker (Richmond, VA): Gastric emptying has not been assessed other than by the upper GI showing no reflux and a stomach that emptied promptly. There has been no clinical evidence of delay. The vagus is mobilized along with the esophagus, and traction is placed on the esophagus with a penrose drain; though some stretch is applied, this did not appear to cause any clinical problem.