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Laparoscopic redo fundoplication in children: Failure causes and feasibility

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Abstract

Purpose

This retrospective study reports our experience in laparoscopic approach after failure of antireflux surgery. It evaluates the results and circumstances of failure of the initial procedure to understand indications of refundoplication.

Methods

Four hundred seventeen patients were operated on for a gastroesophageal reflux disease (GERD) by laparoscopy in our unit from August 1993 to February 2005. Thirty redo procedures (7.19%) were performed. The indications were 24 (80%) recurrent reflux resistant to the medical treatment and 6 (20%) severe dysphagia resistant to iterative dilatations. The average age was 57.6 months. Nineteen patients (63%) were males and 11 patients (37%) were females. The time between the first and the redo procedure was an average of 16 months. Ten (33%) of them were neurologically impaired (NI); in 7 patients, a percutaneus gastrostomy was also associated. The techniques previously used were 13 Nissen, 7 Nissen-Rossetti, and 10 Toupet.

Results

The redo procedure was performed by laparoscopy in 27 cases. A conversion was necessary in 3 children because of a difficult dissection. In the 24 cases of recurrent reflux, we realized a valve disassembly, reconstruction of hiatus and Nissen refundoplication. In 3 cases of dysphagia, the release of the hiatus needed a complete valve redo. The mean operative time was 140 minutes (110 to 240 minutes). The sole complication was a pleural perforation. All patients were fed on the first day. The mean duration of hospitalization was 3.1 days. The follow-up was from 48 months to 12 years. A new recurrent reflux occurred in 6 patients; 5 of them were NI.

Conclusion

The failure rate of the antireflux laparoscopic surgery is similar to the conventional surgery. The redo procedure is possible by laparoscopic with a success rate similar to the open redo surgery. The rate and morbidity of complications are acceptable and decrease with experienced surgeons. The indications of redo procedures should be similar to conventional surgery.

Section snippets

Patients and methods

From August 1993 to February 2005, 417 children were operated on for GER in our unit using the laparoscopic approach. There were 152 girls and 265 boys with a mean age of 57 months (from 1 month to 17 years). One hundred forty-nine (36%) of them were NI; 88 (21%) of them presented a significant malnutrition and an indication to place a feeding gastrostomy within the antireflux intervention.

Surgical indication was a GERD either with a resistance to medical treatment or with a life-threatening

Failure rate

Four hundred seventeen children underwent laparoscopic surgery for GERD. Thirty of them had to be reoperated on for recurrence symptoms; the global rate of failure was 7.19%.

The previous procedures used in these patients were 13 (4.7%) Nissen, 10 Toupet (14%), and 7 (10.3%) Nissen-Rossetti. The mean age of patients at the time of redo surgery was 57.6 months old (48-204 months). There was a predominance of boys—19 patients (63%)—and 11 girls (31%).

The mean delay between the initial procedures

Discussion

Laparoscopic fundoplication is successful in preventing reflux in more than 95% of patients. However, over time, there appears to be failure of the fundoplication, which is unlikely that medical management will be successful in controlling the reflux symptoms after either wrap breakdown and/or transmigration. Thus, operative repair for control of recurrent symptoms is required in most cases [14].

Large series of laparoscopic antireflux procedures have included some patients with adverse outcome

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