Achieving
a Diagnostic and Therapeutic Picture
Diagnostic surveys represent a crucial phase prior to surgery.
The instrumental surveys to be carried out for an accurate surgical approach
are basically four: 24 hour pH metrics, manometry, barium X-rays of the digestive
tract and, lastly, an endoscopy, in cases of suspected esophagitis or of Barrett’s
esophagus. (20,23). 24 hour pH metrics allows to quantify reflux incidence
within a 24-hour period (GERD > 4% is defined as pathologic), to identify
the number and duration of refluxes and related alimentary practices, as well
as the patient’s sleeping-waking rhythm. The manometric test is extremely
important, in that, first of all, it allows an analysis of the tone of the
inferior esophageal sphincter (normally 15-20 mm Hg), but above all it allows
a study of the peristalsis of the esophageal body, which may prove altered
and therefore further worsen the GERD picture (2).
Endoscopy makes it possible to check the presence of esophagitis, due to contact
between the gastric contents and the esophageal mucosa, and to identify the
cardia gaping degree. Barium X-rays basically allow attainment of a morphological
picture of the gastroesophageal junction and identification of any cardio-tuberous
malpositioning. Over the last few years echography has become part of the
GERD diagnostic practice, since with many patients, especially with encephalopathic
patients, an antroduodenal motory incoordination has been detected, which
is responsible for delayed gastric evacuation (20).
Whilst medical treatment of GERD, even though effective, does not eliminate
the anatomical component of the disease, but only modifies the quality of
the refluxed mass, possibly reducing the contact time so as to make the esophageal
mucosa more resistant to the chemical attack, the surgical treatment of the
gastroesophageal reflux disease provides for the reconstruction of the anatomical
mechanisms offering resistence to reflux.
This correction needs to be as physiological as possible, allowing, especially
during the paediatric age, physiological phenomena such as eructation, or
paraphysiological phenomena, such as vomit (1).
Medical or postural therapy represent the first stage of treatment for children
affected by GERD, especially during the first year of life, when, thanks to
the acquisition of the upright posture, the reflux may disappear spontaneously.
Surgery is only required in the cases in which medical therapy is unable to
control the disease.
Laparoscopic Surgical Treatment
Before dealing with the details of the process, it is important to stress
that the techniques employed in laparoscopy do not differ from those employed
in traditional surgery, the only differing factor being the approach route,
which causes to the patient more limited traumatism to the abdominal wall
and enables the surgeon to carry out a more precise and accurate operation
(4,7).
Numerous surgical techniques exist for the operation of GERD patients, but
most surgeons prefer the adoption of a total or partial fundoplication of
the terminal part of the esophagus, so that the gastric cuff or “tie” can
exert a sphincter-type action around the esophagus end (8,18).
As far as the laparoscopic technique is concerned, a 10 mm-trocar is introduced
through the umbilical orifice, and, through this, the optical fibre is inserted
and the pneumoperitoneum is created.
The other trocars are positioned according to the diagram shown in Fig
1. Having attracted the stomach downwards by means of an atraumatic
forceps, the pars condensa of the small epiploon and subsequently the Laimer-Bertelli
phreno-esophageal membrane on the apex of the hiatus, are incised.
At this stage, first of all the crus dextrum is isolated from the esophagus
margin, then the crus sinistrum is also isolated by means of a mounted tampon,
after which the optical fibre is positioned so as to view the mediastinal
space and identify the right vagus nerve which is left at the back, so as
to avoid its inclusion in the fundoplication.
For a successful outcome of every fundoplication operation, a dissection of
the esophagus pushed upwards into the mediastinum is always essential, so
as to allow a sufficiently long esophageal segment to be brought into the
abdomen. (9). The dissection must be carried out with absolute accuracy, especially
in patients with esophagitis, where, owing to the inflammation, the esophagus
is tenaciously adherent to the crura, with a consequent high risk of bleeding.
(10). In the event in which the hiatus proves expanded, a posterior hiatoplasty
is carried out with one or two detached stitches in non–absorbable material.
Fig 2
Having created a broad window behind the esophagus, a forceps is inserted
through it, moving from right to left, to get hold of the gastric fundus and
move it behind the esophagus up to its left margin. At this stage the surgical
procedure differs, depending on the type of fundoplication the surgeon is
to perform. In children displaying through manometry hypo and/or an esophageal
dyskinesia, we prefer to perform Toupet 180-270° posterior fundoplication,
whereas in all other cases we perform a Nissen 360° total fundoplication.
The Toupet technique consists in the accomplishment of a 180-270° posterior
fundoplication, by fixing the fundus to the right and left esophagus walls
with detached stitches, after which the valve is fixed to the crus dextrum
with detached stitches. (18).
Fig. 3
On the other hand, the Nissen technique is a 360° total fundoplication. Our
team performs a variant of the Nissen operation, without sectioning the short
vessels, by fixing with one or two stitches the valve to the crus dextrum.
In our opinion, this represents a good device to prevent the most fearful
complication: the migration of the antireflux valve into the thorax. The Nissen
must have a 3-4 cm length and has to be carried out with at least 4 stitches
in 2/0 non-absorbable material (13). Fig
4
As regards valve calibration, following several experiences with manometry
and with the positioning of large nasogastric tubes, we do not feel there
is one method which is better than the other, but reckon that the surgeon’s
experience must suggest the guidelines to prevent the production of a “tie”
that is too tight or too loose. Intraoperatory complications are in the range
of 2-3% and chiefly depend on the experience of the laparoscopy surgeon: these
are represented by bleeding, esophagus or stomach perforation, pleura opening,
etc. (11,12,14). In most cases, the post-operative course does not involve
any complication, and children are usually discharged from hospital during
the 2nd or 3rd day. Most complications are solved laparoscopically, and only
rarely is the resort to open surgery required. Post-operative complications
(approx. 3-4%) are chiefly represented by dysphagia, which however spontaneously
disappears during the first year following the operation (15,16).
Post-operative GERD relapse occurs in approximately 2% of cases and, if symptoms
persist, it is usually possible to control them through medical therapy. (3,
17,18,21,22). After the operation, all patients are able to belch, but only
60-70% are able to vomit (5,18). The complications and outcome of GERD surgery
on patients suffering from neurological deficits need to be dealt with separately.
Post-Operative
Course and Follow-up
During the post-operative period, medical treatment is gradually reduced and
is finally interrupted after approximately one month (20). As regards diet,
parents are advised to administer semi-liquid nourishment for the first 3
weeks after the operation, and are warned as to the possibility that the child
may experience dysphagia episodes during the first three months after operation,
especially once more solid food is reintroduced in the diet, such as chicken
breast, bread, biscuits, etc. Follow-up represents a crucial stage for GERD
operated children, and it provides for a clinical examination one month after
the operation, after which there will be one every 3 months for the first
year, followed by one check-up a year for the first 5 years (20). A complete
check-up through instrumental tests (pH-metrics, manometry, endoscopy, barium
X-rays) is carried out after a month from the operation, then after 2 years
and finally after 5 years from the operation (19).
Management of Neurological GERD Patients
Encephalopathic children represent a very specific issue. 25% of GERD patients
subject to surgery display various degrees of neurological deficits, usually
as a result of prolonged asphyxia neonatorum at time of delivery (6)).
In addition to GERD, such patients display other associated malfunctions and
they are often obliged to hold absolutely unnatural postures which deform
their bone structure. If we take into account that patients displaying a neurological
deficit also suffer from chronic malnutrition associated with the inability
to swallow correctly (which is why, in addition to the antireflux operation,
they also require a gastrostomy in order to be able to follow a healthy diet),
it is quite obvious that in these cases a medical and/or postural therapy
is doomed to failure. (6,19). Furthermore, traditional surgery is extremely
hard to perform, owing to the postural habits characterising such patients.
For such reasons, over the last years, GERD laparoscopic surgery represents
an indication of choice for this very category of children. Nevertheless,
the outcome of antireflux operations in such patients is definitely less brilliant
compared to non-neurological patients. Indeed, whereas normal patients achieve
total recovery from GERD after surgery in 90-95% of cases, neurological patients
display an improvement in symptomatology only in 60-65% of cases (2,6,19).
Personal Case History
Over a 7-year period, we have accomplished a laparoscopic antireflux procedure
on 95 children affected by GERD, within an age bracket ranging from 6 months
to 17 years (average age 5-7 years). In 20 cases the patients displayed a
neurological deficit and 12 patient where under one year of age. In 90 cases
we performed a Nissen 360° fundoplication and in 5 case a posterior Toupet
fundoplication. As regards the 20 neurological patients, in 12 cases we associated
gastrostomy. The length of the operation ranged from 45 minutes to 180 minutes
(average duration 90 minutes). The average patients’ stay in hospital was
of 3 days. We experienced 8 intraoperatory complications and only in once
case was the operation converted to open surgery.
With a follow-up ranging from 1 to 7 years, 5 children were lost during follow
up, in 2 cases we had to perform a second operation owing to migration of
the antireflux valve into the thorax, 2 patients have displayed a GERD relapse
and are subject to sporadic medical therapy.
Conclusions
In conclusion, laparoscopic surgery displays several advantages compared to
traditional surgery: first of all, it reduces parietal traumatism to a minimum,
with a reduction of post-operative pain, and it consequently allows a more
rapid recovery and an early discharge from hospital. Furthermore, with the
laparoscopic approach, it is possible to avoid excessive manipulation of intestinal
loops, which allows, on one side, immediate recovery of canalisation and,
on the other, it prevents the formation of adherences or bands, which are
responsible for one of the most frequent and feared complications: post-operative
intestinal obstruction. Image magnification represents another advantage of
the laparoscopic technique: indeed, the possibility of bringing the optic
fibre close to the anatomical structures which are under surgery allows greater
accuracy of surgical gestures and correct calibration of the antireflux plasty,
without having to resort to the use of multiple nasogastric tubes or to intraoperatory
manometry. Last but not lest, we ought to take into account, especially for
girls, the aesthetic results, ensured by micro-scars which a virtually invisible,
especially if compared to the xyphoumbelical incisions practiced in traditional
surgery.
As regards complications, parietal infections are practically absent in laparoscopy,
whereas the rate of reflux relapse coincides with that involved by open surgery,
since both access routes employ the same technique. The duration of an operation
performed by an expert laparoscopy surgeon is similar or even shorter than
that involved by traditional surgery and ranges between 80 and 100 minutes.
The only drawback involved by the laparoscopic approach would depend on the
surgeon’s experience, since only an experienced surgeon can perform these
operations correctly and reduce complications to a minimum.
Lastly, based on both our own experience and the analysis of existing international
literature, we believe that laparoscopy represents the “gold standard” for
non-neurological patients affected by GERD refractory to medical treatment,
with a success percentage nearing 100 %.
On the other hand, in neurological patients, despite the progress made so
far, indication for surgery needs to be carefully evaluated, especially in
view of the reduced life expectancy of such patients, of the presence of several
associated malformations and of the not always satisfactory results.
(traslated by Interpres Sas)
Ciro
Esposito
Alessandro
Settimi
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