Pimpalwar A, Najmaldin A
Department of Paediatric Surgery, The Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
Semin Laparosc Surg. 2002 Sep;9(3):190-6.
Although laparoscopic fundoplication is now performed commonly in children, its long-term results in neurologically impaired (NI) children is unknown. We present a single surgeon's experience. During an 8.5 year period, 54 consecutive NI children (age 5 months to 16 years; weight 2.7 to 42 kg) who had failed medical treatment for severe gastroesophageal reflux (GER) underwent laparoscopic Nissen fundoplication without (7) or with (47) gastrostomy. Indications for surgery included failure to thrive and feeding difficulties in all, major vomiting in 42, recurrent chest infections in 44, and inability to take oral medication in 14. Hiatus hernia was present in 14 and delayed gastric emptying in 6 patients. Eight (15%) had undergone previous abdominal surgery. Access was modified according to individual anatomy and 4 or 5 cannulae were used in each patient. Postoperative epidural/morphine analgesia was used in the first 12 to 24 hours, and fluid intake and feeding were started on day 1 and 2, respectively. The average operating time for fundoplication was 2.2 hours (range 1.05 to 3) and for fundoplication and gastrostomy 2.3 hours (range 1.22 to 4.10). Three patients had conversion to open surgery (1 perforated esophagus, 1 hypercarbia and hepatomegaly, 1 camera failure). There were no other operative complications or mortality. One child with Down syndrome developed a food bolus obstruction 3 days postoperatively. The vast majority of patients were discharged home 3 to 4 days following fundoplication and 5 to 7 days following fundoplication and gastrostomy. Postoperative gas bloat was common, diarrhea developed in 4, dumping in 3, and major gastrostomy infection in 1 case. During follow-up (median 5.2, range 3 months to 8.6 years), 9 (16%) children showed signs of persistent/recurrent problems. Investigations showed a recurrent hiatus hernia in 1 (requiring re-operation) and minor reflux in 3 patients. To date 6 (11%) children have died of their background conditions. In NI children, laparoscopic fundoplication is safe and successful. Awareness of the differences in access and risks for NI and normal children is important. Compared with historical data for open technique, laparoscopic fundoplication produces lower mortality and morbidity and similar intermediate and long-term results.
尽管腹腔镜胃底折叠术目前在儿童中已普遍开展，但其在神经功能受损（NI）儿童中的长期效果尚不清楚。我们介绍一位外科医生的经验。在8.5年期间，54例连续的NI儿童（年龄5个月至16岁；体重2.7至42千克）因严重胃食管反流（GER）内科治疗失败而接受了腹腔镜Nissen胃底折叠术，其中7例未行胃造口术，47例行胃造口术。手术指征包括所有患儿均有生长发育不良和喂养困难，42例有严重呕吐，44例有反复肺部感染，14例无法口服药物。14例有食管裂孔疝，6例有胃排空延迟。8例（15%）曾接受过腹部手术。根据个体解剖结构调整入路，每位患者使用4或5个套管针。术后前12至24小时使用硬膜外/吗啡镇痛，分别在术后第1天和第2天开始进水和喂养。胃底折叠术的平均手术时间为2.2小时（范围1.05至3小时），胃底折叠术加胃造口术的平均手术时间为2.3小时（范围1.22至4.10小时）。3例患者中转开腹手术（1例食管穿孔，1例高碳酸血症和肝肿大，1例摄像头故障）。无其他手术并发症或死亡病例。1例唐氏综合征患儿术后3天出现食物团块梗阻。绝大多数患者在胃底折叠术后3至4天、胃底折叠术加胃造口术后5至7天出院。术后腹胀常见，4例出现腹泻，3例出现倾倒综合征，1例发生严重胃造口感染。在随访期间（中位时间5.2年，范围3个月至8.6年），9例（16%）儿童出现持续/复发问题的迹象。检查发现1例复发性食管裂孔疝（需再次手术），3例有轻度反流。迄今为止，6例（11%）儿童因基础疾病死亡。在NI儿童中，腹腔镜胃底折叠术安全且成功。了解NI儿童与正常儿童在入路和风险方面的差异很重要。与开放技术的历史数据相比，腹腔镜胃底折叠术死亡率和发病率更低，中期和长期效果相似。
