www.elsevier.com/locate/jpedsurg

Revision Nissen fundoplication can be completedlaparoscopically with a low rate of complications:a single-institution experience with 72 children

Ahmet Celik, Tara J. Loux, Carroll M. Harmon, Jacqueline M. SaitoKeith E. Georgeson, Douglas C. Barnhart*

Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2006.08.011

Presented at the 39th Annual Meet

Pediatric Surgeons, May 14–18, 2006, T

* Corresponding author. Division o

Alabama at Birmingham, AL 35233, US

205 975 4972.

E-mail address: barnhart@uab.edu (

Index words:Fundoplication;

Laparoscopy;

Revision;

Children

AbstractPurpose: Recurrent gastroesophageal reflux is a common complication after fundoplication and is often

treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication.

Methods: The medical records of all patients in whom laparoscopic revision fundoplication was

attempted over a 7 1/2-year period were reviewed.

Results: Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had

undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one

percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of

first-time redo operations and 68% of second revisions with average operative times of 2.2 F 1.0 and

2.6 F 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%)

and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with

dissection or visualization. No patients required intraoperative transfusion. No patients required

reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the

72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth.

Conclusion: Revision laparoscopic fundoplication is a technically challenging operation but can usually

be completed and is characterized by a low rate of complications.

D 2006 Elsevier Inc. All rights reserved.

Recurrent gastroesophageal reflux remains among the

most common complications after fundoplication [1]. Often,

this is treated with revision fundoplication, which has

traditionally been performed via laparotomy. There are

apparent benefits to laparoscopy such as decreased postop-

Elsevier Inc. All rights reserved.

ing of the Pacific Association of

aipei, Taiwan.

f Pediatric Surgery, University of

A. Tel.: +1 205 939 9688; fax: +1

D.C. Barnhart).

erative pain, less physiologic stress, improved pulmonary

toilet, and cosmesis. There is a significant appeal of using

laparoscopy to perform revision fundoplication in children

because these patients often have significant comorbidities

and, therefore, are likely to benefit from the avoidance of

a laparotomy.

The purpose of this study was to retrospectively review

our experience with laparoscopic redo fundoplication to

characterize its rate of success as measured by comple-

tion of the procedure, relief of symptoms, and avoidance

of complications.

Journal of Pediatric Surgery (2006) 41, 2081–2085

A. Celik et al.2082

1. Methods

After approval by the Institutional Review Board, all

patients who underwent an attempted laparoscopic revision

fundoplication were identified by review of the operative

logs and billing database at The Children’s Hospital of

Alabama. The study period included January 1997 to

September 2004. This study period was selected to allow

at least 1-year follow-up duration on all patients. Both the

electronic and paper-based medical records were reviewed.

This review included outpatient clinic notes, diagnostic

study results, and inpatient hospital records. Preoperative

data included demographics, comorbidities, presenting

symptoms, results of preoperative diagnostic evaluation,

and operative details of initial fundoplication. Operative

details that were collected included operative times,

variations in procedure, and complications. Postoperative

course including immediate complications, recurrent gas-

troesophageal reflux, and subsequent operations for gastro-

esophageal reflux was detailed. Data are presented for the

initial laparoscopic revision fundoplication as well as all

subsequent antireflux operations.

Results are reported as mean F SD or as percentages as

appropriate, and 95% confidence intervals (CIs) are reported

as appropriate. Results of first revision fundoplication,

second revision fundoplication, and third revision antireflux

operations are compared. Continuous variables were ana-

lyzed by using analysis of variance (ANOVA), and categor-

ical variables were compared by using Cochran-Armitage

trend test.

Table 1 Presenting complaints in 72 patients undergoing first

revision fundoplication

Vomiting/retching

with feeding

59 (82%; 95% CI, 73%-91%)

Exacerbation of respiratory

condition (asthma,

bronchopulmonary dysplasia)

32 (44%; 95% CI, 33%-56%)

Dyspepsia (epigastric or

chest pain)

11 (15%; 95% CI, 7%-24%)

Dysphagia 3 (4%; 95% CI, 0%-9%)

Feeding difficulties/

failure to thrive

9 (12%; 95% CI, 5%-20%)

2. Operative technique

A similar operative approach was used throughout the

series. The technique used is similar to that reported by our

group for primary fundoplication [2,3]. In brief, the infant or

child is positioned in either frog-leg position at the foot of the

operating table or in dorsal lithotomy with an esophageal

dilator in place. Five ports are placed: one in the umbilicus,

1 in the right upper quadrant for liver retraction, 1 in the

midepigastrium and 2 in the left upper quadrant. Adhesions

between the left lateral segment of the liver and the

fundoplication are divided sharply to allow visualization of

the fundoplication and right crus. The fundoplication and

esophagus are then separated from the crura by using sharp

dissection. The fundoplication is completely taken down to

allow identification of the gastroesophageal junction for

recreation of the fundoplication.

The crura are then reapproximated posteriorly with

nonabsorbable suture. In cases with large hiatal hernias, a

suture may be placed in the anterior margin of the hiatus as

well. Mesh was not placed during this series. The esophagus

is tacked to the crura bilaterally with nonabsorbable suture.

A 3608 fundoplication is created and fixed it in place with

anterolaterally placed nonabsorbable sutures which incor-

porate the esophagus as well as both sides of the stomach.

The length of the fundoplication is varied from 1.5 to 2.5 cm

depending on the patient’s size.

3. Results

3.1. Demographics and comorbidities

Laparoscopic revision Nissen fundoplication was attemp-

ted in 72 patients during the 93-month period of the study.

Throughout the study period, there was an increasing annual

rate of these operations to be attempted laparoscopically,

with 50% of the cases done in the last 33 months of the

study period. The mean age of patients undergoing first-time

revision fundoplication was 5.0 F 5.0 years with a

minimum of 4 months and maximum of 19.6 years.

Thirty-four children (47%; 95% CI, 36%-59%) were

neurologically impaired, with 7 patients having ventriculo-

peritoneal shunts. Five children (7%) had bronchopulmonary

dysplasia, and 6 other children (8%) had tracheostomies.

Eight patients (11%) had asthma. One child had under-

gone repair of an esophageal atresia with tracheoesopha-

geal fistula.

3.2. Initial fundoplication (before firstlaparoscopically attempted revision fundoplication)

The initial fundoplication had been performed using a

laparoscopic technique in 62 (86%) children, with 19 being

partial fundoplications (Thal or Toupet) and the remainder

Nissen fundoplications. In 10 patients (14%), the initial

operation had been performed via laparotomy, with 2 being

partial fundoplications. Thirty-five (49%) patients under-

went gastrostomy tube placement at the time of initial

fundoplication. The average time from the initial fundopli-

cation to the laparoscopic revision fundoplication was

1.9 F 2.1 years.

3.3. Presenting symptoms and results ofpreoperative diagnostic studies

Symptoms at presentation for revision fundoplication are

summarized in Table 1. Many patients presented with

Table 2 Summary of operative data for laparoscopic revision fundoplications

Revision 1 (n = 72) Revision 2 (n = 19) Revision 3 (n = 3) P for global test

by ANOVA or

Cochran-Armitage

trend test

Completed

laparoscopically

64 (89%; 95% CI, 82%-96%) 13 (68%; 95% CI, 48%-90%) 2 (66%) .027

Operative time (h) 2.2 F 1.0 2.6 F 0.9 3.4 F 0.3 .095

Estimated blood

loss (mL)

31 F 40 54 F 80 14 F 24 .19

Intraoperative

transfusion

0 (0%; 95% CI, 0%-4%) 1 (5%; 95% CI, 0%-15%) 0 .18

Postoperative

transfusion

2 (3%; 95% CI, 0%-7%) 1 (5%; 95% CI, 0%-15%) 0 .87

Postoperative

length of stay (d)

5.0 F 4.8 4.9 F 3.2 6.0 F 3.0 .93

Revision laparoscopic fundoplication 2083

multiple complaints. The routine initial diagnostic test was

an upper gastrointestinal contrast study, which was per-

formed in all patients. The results of these were available for

review in 68 patients. These demonstrated a hiatal hernia in

45 (66%; 95% CI, 55%-77%) patients. Other findings such

as dehiscence of the fundoplication, esophageal dysmotility

and delayed gastric emptying were noted in less than 5% of

cases. Other diagnostic studies were used selectively.

Endoscopy was used in only 6 patients but showed

esophagitis in all cases. Similarly, extended esophageal pH

monitoring was used in 7 patients and confirmed pathologic

gastroesophageal reflux disease (GERD) in all cases.

Esophageal manometry was not used in any patient. At

the time of the first revision fundoplication, 69% of

patients were being treated medically for recurrent gastro-

esophageal reflux.

3.4. Operative details and intraoperativeand postoperative complications

Laparoscopic revision fundoplication was successfully

completed laparoscopically in 64 of the 72 in whom it was

attempted for an overall conversion to laparotomy of 11%

(4%-18%). Seven of 10 patients who had undergone prior

open fundoplication underwent laparoscopic revision fundo-

Table 3 Summary of complications and outcomes after attempted la

Revision 1 (n = 72) Rev

Reoperation within 30 d 0 0

Wound complications 1 (1%; 95% CI, 0%-4%) 0

Pulmonary complications 4 (5%; 95% CI, 0%-11%) 0

Duration of follow-up 3.8 F 2.2 3.0

Subsequent GERD operation 19 (26%; 95%

CI, 16%-37%)

4 (2

CI,

N/A, not applicable.

plication successfully. Of these 72 patients, 19 developed

recurrent gastroesophageal reflux requiring a third fundopli-

cation. This third procedure was completed laparoscopically

in 13 of the 18 patients in whom it was attempted, and

1 patient underwent laparotomy without attempt at laparos-

copy. Four of the 19 patients required a fourth antireflux

operation, with 2 undergoing laparoscopic Nissen fundopli-

cation, 1 undergoing an open fundoplication, and 1 under-

going esophagogastric dissociation. Six different surgeons

performed these operations with similar successful laparo-

scopic completion rates. The details of these procedures are

summarized in Table 2.

The most common operative finding was hiatal hernia

with an intrathoracic fundoplication or paraesophageal

hernia in 75% of patients undergoing initial revision

fundoplication. Dehiscence of the prior fundoplication was

a less common cause of recurrent gastroesophageal reflux.

Intact fundoplications were found in 35 patients (49%; 95%

CI, 37%-60%) of the 72 patients undergoing initial revision

fundoplication. Twenty-one patients (29%; 95% CI, 19%-

40%) had partial dehiscence of the wrap, and 1 suffered

complete dehiscence of the wrap. In 6 other patients (8%;

95% CI, 2%-15%), the fundoplication had slipped from the

esophagus onto the stomach.

paroscopic revision fundoplication

ision 2 (n = 19) Revision 3 (n = 3) P for global test

by ANOVA or

Cochran-Armitage

trend test

0 N/A

0 N/A

0 N/A

F 2.1 3.5 F 2.3 .37

1%; 95%

3%-39%)

0 .32

A. Celik et al.2084

There were no intraoperative or perioperative deaths in

these 72 patients who underwent a total of 95 antireflux

procedures. Intraoperative complications were uncommon.

In the 72 patients undergoing first-time revision fundoplica-

tion, 8 were converted to laparotomies because of difficulty in

establishing a clear plane of dissection to allow reduction of

the hiatal hernia or mobilization of the prior fundoplication.

In taking down the prior fundoplication, small gastrot-

omies that were immediately recognized occurred in 5 (7%)

children. In 4 of these cases, the gastrotomy was closed

laparoscopically, and 1 patient’s procedure was converted to

an open operation because of difficulty with the dissection.

There was 1 (1.4%) anterior vagal nerve injury identified. A

phrenic vein was entered in one case, which was controlled

laparoscopically. No pneumothoraces occurred but 3 (4%)

children were noted to have pneumomediastinum on

postoperative chest radiograph.

Similarly, postoperative complications were uncommon

(Table 3). Postoperative contrast studies were done selec-

tively in 9 (12%) patients. There were no postoperative

esophageal or gastric leaks in any of the patients who

underwent revision fundoplication. Despite the large number

of patients with neurologic impairment and other comorbid-

ities, pulmonary complications were infrequent. Two (3%)

children who were neurologically impaired developed

pneumonias in the perioperative period, which did not

require ventilatory support. Two others had brief spells of

apnea presumably related to narcotic analgesia. One patient

developed a trocar site hernia.

3.5. Success at controlling recurrentgastroesophageal reflux and other gastrointestinalsymptoms

Laparoscopic revision fundoplication was effective at

eliminating gastroesophageal reflux even when done as a

second-time redo operation as judged by need for subse-

quent antireflux surgery (Table 3). Seventy-four percent of

patients who underwent laparoscopic revision fundoplica-

tion did not require an additional procedure. Similar results

were obtained after a third fundoplication in 79% of these

19 patients. The length of follow-up is comparable in these

groups. Given the liberal use of proton pump inhibitors and

H2 blockers without clear documentation of recurrent

gastroesophageal reflux by our referring physicians, it is

difficult to assess the occurrence of recurrent GERD using

medication use as an indicator.

Gastrointestinal symptoms remained prominent after

apparently uneventful revision fundoplication in some cases.

Parents reported problems with retching in 35% of children

after first-time redo fundoplication occurring in both

neurologically impaired and nonimpaired children. Epigas-

tric pain or chest pain were not common after revision

fundoplication, occurring in only 3 (4%) patients. Dysphagia

was reported after the first revision in 7 (10%; 95% CI, 3%-

17%) patients, and 2 required esophageal dilatation. One

patient developed a distal esophageal stricture, which was

unresponsive to dilation requiring distal esophagectomy.

4. Discussion

The most common surgical therapy for pathologic

gastroesophageal reflux is fundoplication. Unfortunately,

recurrent gastroesophageal reflux is among the most

common complications of this operation and often is treated

with revision fundoplication [1]. The rate of recurrent

fundoplication can be as high 24% in infants [4]. Success

with laparoscopic revision fundoplication in adults was

reported as early as 1995 [4] with subsequent reports of small

case series [5]. The largest series in adult shows a high rate

of laparoscopic completion and good symptom relief in

307 patients [6]. Several smaller experiences in children

have been previously reported [7-10]. Our report of

72 patients is the largest series of redo laparoscopic

fundoplication reported in pediatric patients to date and

provides information about feasibility, rate of complications,

and success at symptom relief.

Surgeons reporting these revision laparoscopic fundopli-

cations consistently report that these are more technically

challenging than primary fundoplication. This is our

conclusion as well and is confirmed by the average

operative time of over 2 hours for the second fundoplica-

tion. Successful completion of these operations requires

familiarity with the hiatal anatomy as viewed by laparos-

copy and the expected findings (transhiatal migration of the

fundoplication and paraesophageal herniation of the stom-

ach). At times, the scar tissue can be quite dense and,

therefore, sharp dissection is required.

In performing these operations, knowledge of the

expected pathology is helpful. Most of our patients had

hiatal hernia by preoperative contrast study, which were

confirmed at operation. A high incidence of hiatal hernia has

been reported in both children [7] and adults [6]. Lower

incidences (26%-33%) have been reported in smaller

pediatric series [8,10], but these differences may just be

because of sampling errors. Dehiscence of the wrap occurred

less frequently but was still a significant factor in the need for

reoperation in our patients. This is comparable with other

reports in children [7,8] and adults [11]. We believe this is

sufficiently common to justify complete dissection of the

prior fundoplication to clarify the anatomy in most cases.

Conversion to laparotomy for completion of the fundo-

plication is relatively uncommon in the larger series in

adults [6] and children [7]. Similarly, 89% of patients in our

series underwent successful laparoscopic completion of

their second fundoplication, and 68% were completed

laparoscopically in third-time fundoplications. All patients

in our experience were converted because of difficulty with

dissection or visualization; none were converted for repair

of operative injury. In addition, as there were no patients in

the series who had to be converted to open procedure owing

Revision laparoscopic fundoplication 2085

to inability to tolerate insufflation of the peritoneum, we do

not restrict its use in patients with chronic pulmonary

disease or congenital heart disease.

Complications in our series were rare. More importantly,

there were no significant intraoperative or postoperative

complications that we would attribute to the use of the

laparoscopic technique. Although there is no control group,

we suspect that the rate of pulmonary complications is lower

than would be expected after laparotomy in patients with

this degree of comorbidity. We believe that this is likely

because of improved pulmonary toilet owing to decreased

postoperative pain seen with laparoscopy as has been shown

in primary fundoplication [12].

Most patients in our series did experience relief of their

primary presenting problem, whether it was symptoms or

medical complications of gastroesophageal reflux. However,

a significant minority continued to have gastrointestinal

symptoms. Notably, 35% continued to have retching. It is

unclear on retrospective review whether these symptoms

were owing to gastroesophageal reflux before or after the

revision surgery. The largest series of open revision

fundoplication in children also shows a 25% incidence of

continued gastrointestinal symptoms after revision fundopli-

cation, some of which were relieved by third-time fundopli-

cation [13].

Operative management of recurrent gastrosesophageal

reflux after fundoplication remains a topic of considerable

debate, with a wide range of therapeutic options including

feeding jejunostomy, esophagogastric dissociation [14,15],

and gastrojejunal feeding [16]. More recently, radiofre-

quency ablation of the lower esophageal sphincter (Stretta

procedure) has been used in a limited number of children

[17]. Given the high rate of completion laparoscopically

and the good relief of symptoms and infrequency of

complications seen in our series, we believe that laparo-

scopic revision fundoplication should be the cornerstone of

management of recurrent gastroesophageal reflux. It may

be reasonable to consider the use of mesh in the hiatal

hernia repair in children with a postoperative hiatal hernia.

Early results from a randomized controlled trial in adults

show a significant decrease in the rate of recurrent hiatal

hernia if mesh is placed [18]. Similar data do not exist

in children.

An obvious limitation to this study is its retrospective

nature, which does affect the reliability of the data. This is

likely to be particularly true when dealing with subjective

criteria such as symptoms, or complex issues such as

comorbidity or rationale for surgery. There is a greater

degree of confidence in dealing with issues such as surgical

complications. We recognize the value of a prospective,

standardized data collection particularly with regard to

symptoms and severity of comorbidities.

In summary, this experience demonstrates that revision

laparoscopic Nissen fundoplication can usually be complet-

ed even after 2 prior operations. Complications are

infrequent and are not related to the choice of the

laparoscopic technique. The need for revision surgery

remains acceptable even after 2 prior fundoplications. Given

these conclusions, it is our current practice to offer

laparoscopic revision fundoplication to all patients under-

going redo fundoplication, including infants and those who

have had prior laparotomies.

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