A Comparison of Laparoscopic Redo Fundoplications for Failed Toupet and Nissen Fundoplications in Children.

PURPOSE: We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs).
METHODS: Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0-3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome.
RESULTS: Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date.
CONCLUSION: Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.

INTRODUCTION

Successful laparoscopic redo fundoplication in adults was first reported as early as 1995,[1] followed by reports of small series of cases,[2] some in children, but the largest involving 307 in adults, a high proportion of whom were treated by laparoscopy with good relief of symptoms.[345] Redo surgery is generally more difficult because anatomic planes are obscured by adhesions from the previous surgery, whether it is open or laparoscopic and the very features that distinguish minimally invasive surgery can be the cause of concern in laparoscopic redo surgery because of adhesions. Thus, the application of laparoscopy to redo surgery, particularly in children, is controversial because of safety concerns associated with small cosmetically appealing wounds and insufflation.

In the previous reports on laparoscopic redo surgery both in adults and children, emphasis was placed more on the mechanism of recurrence, or how to prevent possible recurrence at the time of primary surgery,[678] with little description of technical issues.[9] Here, we describe details of laparoscopic redo fundoplication surgery for failed laparoscopic Toupet fundoplication (LTF) and laparoscopic Nissen fundoplication (LNF).

METHODS

We performed a retrospective cohort study of all children who underwent redo LTF (R-LTF) and redo LNF (R-LNF) at Shizuoka Children's Hospital (SC) or Juntendo University Hospital (JU) between 2007 and 2014. Diagnosis of recurrence was determined objectively by performing an upper gastrointestinal contrast study documenting anatomical recurrence and a pH probe monitoring study documenting reflux in postfundoplication patients with symptoms/signs of gastroesophageal reflux (GER). Children older than 16 years of age at the time of initial surgery were excluded from this study.

Historically, both hospitals have maintained a close working relationship since 1987 involving staff secondment and patient referral. Many surgical at both hospitals have trained under the same supervisors and technical educational exchange is common and encouraged to improve the quality of care at both centers. Joint meetings to plan treatment strategies are frequent and research is conducted at both centers often. Thus, there is a common protocol for treating GER at both centers. At initial fundoplication, all surgical techniques including dissection of the short gastric vessels, dissection around the crus and preparation of a 3–4 cm length of abdominal esophagus, sutures between the right and left crura, and crus and esophagus were the same in principle, except for partial (LTF) or complete (LNF) wraps. For no specific reason, LTF is preferred at SC and LNF at JU. Thus, surgeons from JU perform LTF while at SC and surgeons from SC perform LNF while at JU and vice versa. Surgery at both SC and JU is often supervised by the same board-certified pediatric surgeons because of secondment. Joint meetings are held twice a year to share experiences and discuss ways of improving the surgical management of GER at both centers.

Parameters assessed in this study included intraoperative factors such as severity of intraperitoneal adhesions; identification of the hepatic, anterior, and posterior branches of the vagus nerve); and the extent of their preservation, complications, and operative time as well as postoperative factors such as recovery, outcome, complications, and re-recurrence.

Statistical significance between groups was determined by the standard Student's t-test, Chi-squared test, and Fisher's exact analysis when appropriate. P < 0.05 was considered statistically significant. Institutional research ethics approval was obtained (approval number: 2013–36).

RESULTS

During the study period, 134 LTF and 53 LNF were performed for both normal and neurologically impaired children at both centers. Redo was required for 10 cases, with each case having the original procedure repeated laparoscopically. Thus, 4 R-LTF cases had R-LTF and 6 R-LNF cases had R-LNF. The indication for redo in R-LTF was sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) and in R-LNF was sliding hernia (n = 6; 4 with partial wrap dehiscence). During redo, we did not use prosthetic patches in any of our ten redo fundoplication cases, because we were able to confirm the presence of preserved diaphragmatic crura in each case. Gastrostomies were closed at the start of redo surgery and reconstructed after completion of the repeat fundoplication wrap in all ten redo cases.

Mean ages at redo (7.7 years for R-LTF vs. 7.0 years for R-LNF) and weights at redo (16.1 kg for R-LTF vs. 14.7 kg for R-LNF) were similar. Preredo symptoms and pH-monitoring scores (pH <4 was 6.4% for R-LTF vs. 5.7% for R-LNF) were also similar. Incidences of associated anomalies were similar, that is, cerebral palsy (4 in R-LTF vs. 3 in R-LNF) and cardiac anomalies (1 in R-LTF vs. 0 in R-LNF). The interval between initial and redo fundoplications averaged 34 months in R-LTF and 32 months in R-LNF (P = ns) [Table 1]. The mean intraperitoneal adhesion score was 1.5 in FT and 2.5 in R-LNF (P < 0.05). The mean number of vagus nerve branches identified was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05); all but one branch in R-LTF was preserved. Mean operative times (165 min in R-LTF vs. 188 min in R-LNF) and blood loss (7.0 mL in R-LTF vs. 10.5 mL in R-LNF) were also similar. Postoperative 24 h pH-monitoring was 0.7% in R-LTF vs. 0.8% in R-LNF (P = ns). Intraoperative complications were accidental injury to the esophageal or gastric wall (n = 1 in R-LTF; n = 3 in R-LNF, one requiring conversion to open surgery because the injury was a full-thickness perforation) (P = ns).

Table 1

Demographics

Demographics	R-LTF (n=4)	R-LNF (n=6)	P
Age (year)	7.7	7	NS
Weight (kg)	16.1	14.7	NS
Associated anomaly, n (%)
CP	4 (100)	3 (50)
Cardiac	1 (25)	0
Esophageal atresia	0	1 (16)
Interval* (month)	34	32	NS
24 h pH-monitor
Preredo (%)	6.4	5.7	NS
Postredo (%)	0.8	0.7	NS

*Between initial fundoplication to redo. CP: Cerebral palsy, R-LTF: Redo laparoscopic Toupet fundoplication, R-LNF: Redo laparoscopic Nissen fundoplication, NS: Not significant

As part of our standard protocol to encourage maximum healing around the crura, we prefer a longer period of postoperative decompression at both centers, so enteral feeding was only re-established postoperatively after 3.0 days in R-LTF and 3.7 days in R-LNF (P = ns). Mean postoperative hospital stay was 7.5 days for R-LTF and 9.8 days for R-LNF (P = ns).

At the time of writing, the mean duration of follow-up after redo surgery in R-LTF was 2.8 years and in R-LNF was 4.0 years (P = ns). There have been no rerecurrences to date, but two R-LNF cases developed gastric outlet obstruction that was managed conservatively (P = ns) [Table 2].

Table 2

Outcome

Outcome	R-LTF (n=4)	R-LNF (n=6)	P
Operative time (min)	165	188	NS
Blood loss (ml)	7	10.5	NS
Conversion, n (%)	0	1 (16)	NS
Intraperitoneal adhesion (Grade 0-3)	1.5	2.5	<0.05
VN identification*	2	0.8	<0.05
Complication, n (%)
Intraoperative
Esophageal wall trauma	0	1 (16)	NS
Gastric wall trauma**	1 (25)	2 (33)	NS
Postoperative
Gastric outlet obstruction***	0	2 (33)	NS
Re-recurrence	0	0	NS
Re-establishment of oral intake (POD)	3	3.7	NS
LOS (POD)	7.5	9.8	NS
F/U length (year)	2.8	4	NS

*Whether anterior/posterior/hepatic branches of the vagus nerve were identified, **Including one full-thickness injury, ***Including one pyeloplasty. POD: Postoperative day, LOS: Length of stay, F/U: Follow-up, R-LTF: Redo laparoscopic Toupet fundoplication, R-LNF: Redo laparoscopic Nissen fundoplication, VN: Vagus nerve, NS: Not significant

DISCUSSION

Despite the increasing popularity of laparoscopic fundoplication, there has been relatively slow acceptance and significant criticism of its use for redo laparoscopic fundoplication in children. The most major concern is that at redo surgery, adhesions are usually dense and tissue planes and gross anatomy can be distorted necessitating advanced laparoscopic skills. Pacilli et al.[10] reported a failure rate of 42% for redo fundoplication. Rothenberg insisted that in experienced hands, laparoscopic redo is possible with good results; over a 10-year period, he performed 118 R-LNF in children ranging in age from 6 months to 17 years; in this large series, there were no conversions to open surgery, a 1% intraoperative complication rate, 2.2 day length of hospital stay, and a 6% failure rate at 2-year follow-up.[11] However, in other reports, more serious complications have been reported in relation to redo surgery such as esophageal perforation or gastric leak secondary to difficult dissection, scar tissue, and adhesions from prior surgery.[6] In another report, there was a 21.8% incidence of visceral injury in 307 redo fundoplications.[3] Furnée et al.[12] reported a 13.1% incidence of visceral injury in more than 4500 redo antireflux procedures (fundoplications), and Khajanchee et al.[13] reported a 12.8% incidence in 176 patients.

Despite seemingly encouraging results reported for laparoscopic redo fundoplication,[11] extreme caution is recommended during laparoscopic redo because dissection is tedious and anatomic landmarks are distorted. Successful completion of laparoscopic redo fundoplication requires familiarity with the anatomy of the hiatus as viewed laparoscopically and the appearance of likely findings associated with failed fundoplication such as migration of the wrap through the hiatus and paraesophageal herniation of the stomach. In addition, dense adhesions and scar tissue may also require sharp dissection.[14] Thus, a redo procedure will be facilitated if there are fewer adhesions, tissue planes can be identified and structures can be visualized. In particular, younger trainees should be carefully supervised by surgeons with sufficient experience of redo fundoplication.

In this series, nerve branches were more easily identified and injuries to the esophagus and gastric wall were fewer after failed primary LTF, although when compared with failed primary LNF cases, differences were not significant. We are of the opinion that the denser adhesions observed at R-LNF may have some relationship to belching because accumulated air in the stomach will stress the initial fundoplication causing inflammation that could progress to adhesion formation.[15] Double suturing at the fundoplication site during LTF could also stabilize the hiatus and minimize inflammation and adhesions.

The full-thickness perforation of the gastric wall that occurred during R-LNF was most likely caused by a combination of poor visualization, indistinct tissue planes, sharp dissection, and conversion to open surgery for completion of the fundoplication; an uncommon situation where circumstances compounded to cause a major complication.

Georgeson and Holcomb have both advocated minimal dissection of the hiatus, minimal mobilization of the esophagus, and omission of esophagocrural sutures as a means of reducing the risk for recurrence after laparoscopic fundoplication.[1617] This trend will alter the operative findings at redo to some extent compared with cases treated by conventional dissection and mobilization. We prefer to be more conservative and perform conventional dissection and mobilization of the crura and esophagus because we are familiar with the outcome in both neurologically normal and impaired children.[1518] However, as more cases are treated minimally, a comparison of redos after conventional and minimal surgical intervention may become necessary. At present, we have no plan to change our orthodox approach.

CONCLUSION

By comparing outcomes of laparoscopic redo surgery for failed LNF and failed LTF, focusing on the safety and stability of redo surgery performed laparoscopically, surgeons should be conscious that redo surgery for recurrence of GER will be more challenging after LNF than LTF because anatomic landmarks will be harder to identify because of adhesions. Although our series is small, the abdomen was more conducive to redo surgery after LTF than after LNF.

Consent

Informed consent was obtained from all the patient's parents for this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.