The members of Pedsurg-L are invited to review the actual
article in J Ped Surg for details. I realize that many international
members may not have yet received the Journal, and for that I apologize.
If I can get a better concept of the number of list members who receive
the journal late, then we can perhaps gauge our discussions to this (perhaps
discuss the May issue in
August, for example).
So for this first Journal Club I would like to suggest that we discuss the lead April article:
"Antireflux surgery in children under 3 months of age" by Fonkalsrud
EW, Bustorff-Silva J, Perez CA, et.al.
J Pediatr Surg 34:527-531, 1999.
This was a retrospective review of 110 patients undergoing fundoplication while under three moths of age between January of 1980 and December of 1997. There were 59 boys and 51 girls. Indications for operation were recurrent emesis (62), respiratory symptoms (85) or both (54). One third of the patients had some degree of neurological impairment, a third had associated anomalies, and one fifth were premature. The most common confirmatory test was an UGI, followed closely by esophageal pH monitoring. While six patients had a Thal procedure, all others underwent a Nissen procedure, and thirty one underwent concurrent gastric emptying procedures. Complications were seen in 6.4%.
Allow me to start the discussion with the following questions or observations:
* It has been my impression that over the last twenty years we are doing less antireflux surgery in infants, in part prompted by a rather large complication rate of the operation when done in infants. The authors have a rather modest 6.4% complication rate. Do others have a similar experience?
* The average age at time of surgery in this article was 1.8 months. Do others adhere to operative intervention this young?
* Is an UGI an appropriate test to be used to decide upon performing a Nissen operation? The authors do not discuss milk scans, yet performed gastric emptying procedures in nearly a third of patients. What do others do to assess gastric emptying, especially in the neurologically impaired child? By whatever means used, if gastric emptying is significantly delayed do you perform just a gastric emptying procedure or a concurrent fundoplication?
Please do not be constrained by the questions above but feel free to bring up your concerns and inquiries. I look forward to your collective thoughts on this paper.
Thomas V. Whalen, M.D.
Associate Professor of Surgery & Pediatrics
Head of the Division of Pediatric Surgery
Robert Wood Johnson Medical School at Camden
3 Cooper Plaza, Suite 411 Camden, New Jersey 08103
Voice: 609-342-3018 Fax: 609-541-2634
Indications - too many pts with emesis as sole indication. Does this means FTT was associated or not? This young group of children is generally operated due to respiratory (aspiration) or life-threatening event (apnea, choking spells, etc). The number of infants operated for reflux has also increased in my experience. More reluctance to keep the child in-hospital under strict medical care for six wks before deciding on surgical tx? Maybe...
Diagnosis - as the authors suggest we use UGIS and gastric emptying scans in this age group. Some people have challenged the utility of scintigrams in selecting DGE pts. (JPS 33(4):573-9, 1998) arguing a difference when using solid or liquid phase label. I still don't understand very well what an abnormal pH study in this age group means and would not dare operate an infant using this test alone. How is that, that clinical symptoms alone may be unreliable ? (33(11):1623-7, 1998). Well if you operate by pH study, you will need to f-u by pH study. Something of a mystery...
Management- the never-ending story whether a partial or total fundoplication is needed. With no evidence of esophageal dysmotility I favor a Nissen procedure. With delayed gastric emptying would favor a pyloromyotomy (after all we are experts in this procedure) to avoid entry to the GI tract (pyloroplasty). This same group of investigators has rallied us the need of adding a gastric drainage procedure to reduce the risk of recurrent reflux (JPS 34(1):79-82, 1999). Also, in my experience partial wraps have a shorter half-life than Nissen in NI children.
Overall - When analyzing many of these series the patients should be divided in neurologically impaired (NI) and non-NI, since GERD has different results (failure rate), outcome and complications. Complications and recurrence is higher in NI and children with associated conditions. DGE take more importance in this group of children (Surgery 122(4):690-7, 1997). The Feb 99 JPS issue has an article (34(2):295) describing how fundoplication in early infancy (< 4 mo) is unsuccessful in a high proportion of patients. The highest incidence of failure and redo occurred in infants with associated anomalies and the best results were achieved in infants with emesis and respiratory symptoms.
Historic note - Rudolph Nissen (a German surgeon) flew Hitler catastrophic times and took care of Albert Einstein abdominal aneurysm while working in a Jewish Hospital in NY...
Humberto Lugo-Vicente, MD FACS FAAP
San Juan, Puerto Rico
I know this is anecdotal but I became involved with one patient who had a Nissen at UCLA and one who came for a second opinion. The first patient had a Nissen at age of about one month for what I believed to be questionable reflux. The parents were incredibly nervous about their baby spitting up which I think was partially responsible for the Nissen.Post-op the infant couldn't eat because the Nissen was too tight. I reoperated on this patient and was sorely tempted to take down the NIssen and do nothing else but I didn't have the courage so I did a Toupet fundoplication which I consider a superior operation over the Nissen fundoplication. The patient did fine despite her parents and is now five years old and normal. The second patient was seen for a second opinion mandated by the insurance company. He was a healthy 6 month boy who was constantly spitting up causing the house to smell. His weight gain was normal, he had no couging, had no recurrent pneumonia, no evidence of esophagitis,etc. I told the mother to wait until her child gets older and buy new furniture. She left my office very angry. Having done the first Nissen fundoplication in Los Angeles in 1965 I think I can speak with some authority about the subject. I believe far too many Nissen fundoplications are done. Maybe in a severely brain damaged child it doen't matter but in a mentally normal child there must be clear evidence that this child in the long run will not do well unless he or she has a Nissen.There was a time when antireflux surgery didn't exist and it was a rare child who was normal mentally that eventually didn't get well with no sequelae.
Bucaramanga - Colombia
Kinderklinik und Poliklinik
Does anyone keep older kids who do not have a gastrostomy on a liquid diet after an open or laparoscopic Nissen to address post-op dysphagia?
Most of the patients I do a Nissen on are on a liquid (formula) diet, are too young to talk, are neurologically impaired or are completely tube fed. I am unsure of the incidence of dysphagia in this group. I have had only two other kids (a 1 year old and a 17 year old) who had symptomptomatic dysphagia and got by on a liquid diet for the first few weeks post-op.
If the Nissen is too tight and symptomatic in a child who eats by mouth, how is it best managed?
When would you re-do a Nissen for being too tight?
Department of Surgery
University of North Carolina, Chapel Hill
Chapel Hill, N.C. 27599-7210
1. It is interesting that a paper in the Feb issue (JPS, 34, p295), an article by Spitz's group came to the opposite conclusion, i.e. Not effective in Kids < 4 months old.
2. It is difficult to draw conclusions regarding diagnostic practices from a series spread over 18 years (the paper under discussion), and in which the type of test is not indexed to the reason for the test. For example, in a 1 month old with multiple ALTE (life threatening apneic episodes) temporally related to clinical reflux an UGI study may be enough to document reflux, anatomy and gastric emptying. In contradistinction, a neurologically normal baby who just spits up and has failure to thrive may need a course of medical treatment, UGI, followed by a 24 hr pH probe, and technetium gastric emptying study, prior to a fundoplication.
3. The age at which surgery was performed
to some degree will reflect the practice environment, ie children's hospital
Vs. community private practice. In addition, it is my impression that the
number of neurologically impaired children with feeding, swallowing and
reflux problems is increasing in larger centers with high risk NBICU's,
because of increasing salvage of PTNB micropreemies.
For example, I looked at some data from Arkansas Children's Hospital, in Little Rock, where I did my training. The operative database from 1993 to 1997, showed 427 Fundoplications, of which 32% (137) were in kids < 6 months old and 20% (87) were < 3months old. Although I have not analyzed the follow-up and complication rates by age, it did not appear that there was a significantly higher morbidity or mortality.
4. Based on my review of the institutional experience in Little Rock, as well as the literature, a 5% to 10% complication rate appears to be realistic if there is enough volume of surgery.
#2 The teenager who is having reflux and needs the operation
yesterday but has only soft objective data may be crying out for help in
(parents were both having affairs and pt was involved with a cocaine dealer)
These are just small anecdotes but as a pediatric surgeons
we have the blessing of being able to listen and respond by helping to
problem often with operative skill but also at times with wise counsel when operation is not required.
Daniel P. Croitoru,
Children's Surgical Associates
Children's Hospital of the King's Daughters
601 Children's Lane 5B
Norfolk, VA 23507
(757)668-7703 fax (757)668-8860
In this paper of the March issue the authors describes ten consecutive neonates with biopsy proven HD managed with what they call the POOP (perineal one-stage operative pull-through) procedure. They described their technique, which is no different from what a few of us are doing (transanal endorectal pull-through=TEP) thus far. Have a mean of 105 minutes of operating time, no post-op complication, a mean stay of two days, while late functional results are pending.
In the discussion of the paper the authors bring some
1- Preop colonic irrigation and decompression can blunt a transitional zone during laparoscopic visualization. Many of us have suffered from this blunting.
2- Adequacy of resection is solely dependent on accurate identification of the TZ pathologically using frozen section. The contrast study TZ is very important.
3- You must be very aware that with suspicion of TCA you must establish the diagnosis and TZ with open or lap biopsy before touching the perineum. It could become detrimental to discover TCA after performing the perineal dissection.
The POOP (or TEP) procedure, as you wish, is becoming
an excellent alternative for children with -
1- well delineated (by contrast study) classic HD since you do not want surprises of finding out the child really has a long-segment or TCA.
2- no enterocolitis, as this could easily cause technical dissection problems with complications (i.e., vagina, bladder, nerves).
3- good weight gain > the 4 kgs, after all you might need to change to open and find that his postop recovery is problematic.
4- adequate rectal decompression at home while you wait for that weight to be achieved.
5- adequate pathological support, since findings of no ganglions cell in permanent sections 36 hours later is equivalent to leaving aganglionic bowel.
Let hear some comments/controversy/experience from people using the technique.
PS - notice that I gave our actual PS net-member and one
of the author of this paper (Smith Baird) his @ degree...
The authors main objective was to evaluate the need of pH studies for persistent ENT symptoms and its relationship with GER. Retrospective study. From 3000 pH studies in 16 years! only 105 with ENT sx were referred to r/o GER. Pts with laryngomalacia, stridor and laryngitis were found to have a greater than 50% incidence of reflux. Sinusitis (40%). Resolution of sx occurred in 83% of medically reflux managed cases with stridor, laryngitis (86%) and laryngomalacia (80%). Four cases were operated for reflux. They conclude by recommending a pH study in children with stridor, laryngomalacia and sinusitis when faced with medical-ENT tx failure.
Comments: They did no established a cause/effect relationship in the study. No mention of other simpler and cost-effective study (esophagogram) was done to compare diagnostic yield, structural defects, etc. A pH study is costly and needs at least 20 hours hospitalization to be recommended to a wide variety of ENT manifestations, specially sinusitis which is endemic in some parts of the world.
Jugenburg M, Haddock G, Freedman MH, Ford-Jones L, Ein SH: The Morbidity and Mortality of pediatric Splenectomy: Does Prophylaxis Make a Difference? JPS 34(7): 1064-1067, 1999
While analyzing the incidence of post-splenectomy sepsis between two time periods they found that the number of splenectomies have not decreased (per year) but the incidence of infection and mortality has decreased. They attribute this to the immunization routine.
Comments: the red book recommendation for asplenic individuals are immunization with pneumococcal, Hemophilus and meningitis vaccine. The use of prophylactic antibiotics is questionable as an increase in resistance bacterias is possible. Otherwise URI should be managed with antibiotics. What do others think?
Sandler A, Winkler G, Kimura K, Soper R: The Role of prophylactic Cholecystectomy During Splenectomy in Children with Hereditary Spherocytosis. JPS 34(7): 1077-1078, 1999
In this retrospective study the authors follow for 15 years (even using Internet access!) 33 children who underwent splenectomy without cholecystectomy to evaluate the frequency of symptomatic gallstone development. None developed gallstones or biliary related symptoms. None needed cholecystectomy. They conclude there is no need for prophylactic cholecystectomy at the time of splenectomy in biliary asymptomatic children.
Comments: I bet the use of 'switchboard' to get hold of the patients was a Ken Kimuras'idea. Gallstones I remove the GB, but some of the children have asymptomatic sludge which I generally leave alone at the time of splenectomy. Still other people just do a cholecystostomy and remove the stones. This article seems a reason to do so. Do any of you remove the GB at the time of splenectomy for sludge? Other comments?
Koivusalo A, Rintala R, Lindhal H: Gastroesophageal Reflux in Children with a Congenital Abdominal Wall Defect. JPS 34(7): 1127-1129, 1999
Retrospective study to find incidence and frequency of GER in children with AWD. Endoscopy with biopsy and pH studies done in all patients. GER detected in 13 of 42 cases (Omphalocele 10/23= 43%, gastroschisis 3/19=16%). Primary closure was associated with a lower incidence of GER. Most cases had a benign course with a tendency for spontaneous resolution after medical tx. Only 1 pt needed a fundoplication.
Comment: this has also been our experience: the greater
the defect, the smaller the abd cavity, the higher the incidence of GER.
Most resolved by the age of two. But again, why not use simpler studies
routines as esophagogram, instead of endoscopy and pH study?
Now lets hear reactions from the rest of the list members...
We have had a large number of pediatric patients with hemolytic syndromes that require laparoscopic splenectomy. We only perform combined laparoscopic cholecystectomy if we can document on pre-operative ultrasound that they have cholelithiasis (symptomatic or not). We typically start with the laparoscopic cholecystectomy (supine position) and then change to a lateral decubitus position (left side up) and use the umbilical port and the midline (or left upper quadrant port) for the laparoscopic splenectomy. Three additional ports are typically needed. The average operative time for the combined operations was 240 minutes.
Dr. Rajesh Nathani