Kubiak Rainer, Skerritt Clare, Grant Hugh W
Department of Paediatric Surgery, Oxford University Hospital , Headington, Oxford, United Kingdom.
J Laparoendosc Adv Surg Tech A. 2012 Oct;22(8):840-3. doi: 10.1089/lap.2012.0125.
Children with ventriculo-peritoneal (V-P) shunts have a significant risk of morbidity and mortality from infections. Many of these patients have other co-morbidities and may require subsequent abdominal surgery, including fundoplication with or without gastrostomy placement. The aim of our study was to assess the outcomes of laparoscopic fundoplication in children with a V-P shunt in situ.
A retrospective review of a prospectively maintained database on children who underwent laparoscopic fundoplication with a V-P shunt in situ at the time of surgery between July 1998 and March 2011 was conducted. Primary outcomes included intra- and postoperative complications as well as shunt-related problems within a 6-month period after surgery. The subset of children with V-P shunts was compared with those who underwent fundoplication without shunts. Variables were compared using the two-tailed Student's t test, chi-squared test, or Fisher's exact test. Significance was defined as P≤.05.
Out of a total of 343 children who underwent fundoplication, 11 (6 girls, 5 boys) had a V-P shunt in situ at the time of surgery (3.2%). The median age at laparoscopy was 2.2 years (range, 0.7-13.8 years). Weight at surgery ranged from 5.8 to 39.0 kg (median, 12.0 kg). The operating time (without gastrostomy placement) was 105 minutes (range, 80-140 minutes). In 6 patients (55%) moderate to severe adhesions were documented, but only 1 child required conversion to open surgery because of bleeding from the omentum. In a second patient the colon was perforated during insertion of the percutaneous endoscopic gastrostomy (PEG) and repaired laparoscopically. There was no postoperative shunt dysfunction or infection related to the laparoscopic procedure. There was no significant difference between V-P shunt patients and the main cohort regarding operating time, conversion to open surgery, need for admission to a high-care unit, opiate requirements, time to full feeds, and length of hospital stay.
These data suggest that laparoscopic fundoplication is feasible in children with previous V-P shunt placement. Although there were considerable adhesions in approximately half of these patients, the rate for conversion to open surgery was low. Complications associated with simultaneous PEG insertion occur and should be anticipated by placing the gastrostomy under laparoscopic guidance.
脑室-腹腔（V-P）分流术患儿有因感染导致发病和死亡的重大风险。这些患儿中有许多还患有其他合并症，可能需要后续的腹部手术，包括行或不行胃造口术的胃底折叠术。我们研究的目的是评估原位V-P分流术患儿行腹腔镜胃底折叠术的效果。
对1998年7月至2011年3月期间手术时原位行V-P分流术并接受腹腔镜胃底折叠术患儿的前瞻性维护数据库进行回顾性分析。主要结局包括手术中和术后并发症以及术后6个月内与分流相关的问题。将V-P分流术患儿亚组与未行分流术而行胃底折叠术的患儿进行比较。变量采用双侧t检验、卡方检验或Fisher精确检验进行比较。显著性定义为P≤0.05。
在总共343例行胃底折叠术的患儿中，11例（6例女孩，5例男孩）手术时原位有V-P分流术（3.2%）。腹腔镜检查时的中位年龄为2.2岁（范围0.7 - 13.8岁）。手术时体重范围为5.8至39.0千克（中位值12.0千克）。手术时间（未行胃造口术）为105分钟（范围80 - 140分钟）。6例（55%）记录有中度至重度粘连，但仅1例患儿因网膜出血需要转为开放手术。在另一例患儿中，经皮内镜下胃造口术（PEG）置入期间结肠穿孔并经腹腔镜修复。没有与腹腔镜手术相关的术后分流功能障碍或感染。V-P分流术患儿与主要队列在手术时间、转为开放手术、入住重症监护病房的需求、阿片类药物需求、完全经口喂养时间和住院时间方面没有显著差异。
这些数据表明，既往有V-P分流术的患儿行腹腔镜胃底折叠术是可行的。尽管这些患儿中约一半有大量粘连，但转为开放手术的比例较低。与同时进行PEG置入相关的并发症会发生，应通过在腹腔镜引导下放置胃造口术来加以预见。
