moderate to severe gastroesophageal reflux in neonates and infants is often a complex interaction of developmental and anatomic conditions that limits adequate enteral intake and may be associated with significant morbidity .
common comorbidities in infants with gastroesophageal reflux include failure to thrive , prematurity , neurological impairment , and chronic respiratory conditions , all of which can be exacerbated by anatomic anomalies that further predispose to the development or progression of gastroesophageal reflux .
although a laparotomy will often correct a congenital or acquired anatomic anomaly , the surgical adhesions that form as a result of a laparotomy may complicate subsequent surgical therapy for gastroesophageal reflux .
many studies document the safety and long - term efficacy of laparoscopic nissen fundoplication for the treatment of gastroesophageal reflux in infants and children .
the laparoscopic approach is feasible as a primary procedure and a secondary procedure after failure of a previous open or laparoscopic reflux operation .
however , few studies have examined the efficacy of laparoscopic nissen fundoplication in infants and children after previous laparotomy for diseases or problems unrelated to reflux .
the purpose of this study is to examine our experience with open and laparoscopic nissen fundoplication in a population of infants with a history of previous neonatal laparotomy for diseases unrelated to gastroesophageal reflux .
an institutional review board - approved retrospective review ( irb # 05091500 ) of our surgical procedure database at the children 's hospital of pittsburgh was conducted to identify all infants with a history of neonatal laparotomy who subsequently required surgical therapy for gastroesophageal reflux .
study dates were january 1 , 2000 through september 1 , 2005 . during the period reviewed ,
32 infants were identified with a history of neonatal laparotomy and subsequent surgical correction of gastroesophageal reflux .
only infants requiring surgical correction of reflux within the first year of life , and therefore less than 12 months after neonatal laparotomy , were included in this study .
this 12-month time frame was selected because we specifically chose to evaluate infants , and it represented a more homogeneous subset of patients when comparing laparoscopic nissen fundoplication ( lnf ) and open nissen fundoplication ( onf ) groups .
the 6 excluded patients were all older than 12 months at the time of nissen fundoplication ( 3 in each group , age range 2 to 15 years old ) .
these 26 infants underwent laparotomy during the neonatal period for multiple different diagnoses including intestinal atresia ( duodenal , jejunal and ileal ) ; necrotizing enterocolitis ; meconium ileus ; gastroschisis ; omphalocele ; malrotation ; congenital diaphragmatic hernia and imperforate anus .
twelve infants underwent lnf and 14 infants underwent onf , thereby forming the 2 study groups .
gastroesophageal reflux was identified clinically , radiographically , or with both methods , and the infants underwent surgical correction of the reflux at the discretion of the attending surgeon .
all infants had either a barium esophagram or a nuclear gastric emptying scan , which documented gastroesophageal reflux before anti - reflux surgery .
a nissen fundoplication was performed in all cases either open or laparoscopically by dividing the short - gastric vessels and creating a 360-degree wrap of the fundus around the esophagus .
ten of 12 infants in the lnf group had concomitant feeding gastrostomy tubes placed laparoscopically .
two infants in the lnf group already had gastrostomy tubes in place at the time of fundoplication , both of which were placed by the open method , one on the first day ( duodenal atresia ) and the other at one month of age ( jejunal atresia ) .
in the first infant , the tube was taken down laparoscopically at the time of fundoplication and replaced in a new position on the gastric wall to accomplish the wrap . in the second infant ,
thirteen of 14 infants in the onf group had a feeding gastrostomy tube placed at the time of fundoplication with 3 of these infants having relocation of an existing gastrostomy tube .
outcome variables included age at initial laparotomy , number of previous laparotomies before surgical correction of the gastroesophageal reflux , age at the time of fundoplication , weight at the time of fundoplication , operative time for fundoplication , length of stay , and time to resumption of enteral feeds after fundoplication , recurrence of gastroesophageal re - flux , and mean follow - up duration . in general ,
infants with these neonatal diagnoses , with or without antireflux surgery , are followed for a minimum of 5 years by our group .
of the 26 infants identified with a history of neonatal laparotomy and subsequent surgical correction of gastroesophageal reflux within 12 months of life , 12 infants underwent laparoscopic nissen fundoplication ( lnf ) , and 14 infants underwent open nissen fundoplication ( onf ) . in the lnf group , diagnoses included 4 neonates with gastroschisis , 3 neonates with intestinal atresia ( 1 duodenal , 1 ileal , 1 jejunal ) , 2 neonates with meconium ileus ( both underwent ileostomy and mucus fistula at day of life # 1 with re - anastomosis at 2 to 3 months of age ) , and 1 each with omphalocele , malrotation , and perforated necrotizing enterocolitis . in the onf group , diagnoses included 4 neonates with congenital diaphragmatic hernia ( all left - sided , repaired by laparotomy ) , 4 neonates with gastroschisis , 2 neonates with perforated necrotizing enterocolitis , 2 neonates with imperforate anus / tracheoesophageal fistula , 1 infant with omphalocele , and 1 infant with intestinal atresia . in the lnf group , 4 infants had intestinal stomas performed at initial operation with subsequent closure before fundoplication . in the onf group , 3 infants had stomas created at initial laparotomy and subsequent takedown before fundoplication .
there was no difference between the 2 groups relative to age at the time of initial laparotomy ( 1 day of life for lnf vs 14 days of life for onf , p=0.08 ) .
what may appear as a large difference in days of life at initial operation may be accounted for by the fact that 2 patients in the onf group had initial laparotomies at ages 51 days ( ileostomy/ mucus fistula for perforated nec in ex-25 week gestation infant ) and 90 days ( duodenoduodenostomy for duodenal atresia in 1.5-kg infant born at 800 g ) .
there was no difference in age at the time of the fundoplication ( 5.5 months for lnf vs 6.6 months for onf , p=0.57 ) , nor was there any difference between the 2 groups with respect to infants ' weight at the time of the fundoplication ( 5.2 kg lnf vs 5.7 kg onf , p=0.51 ) .
the number of previous laparotomies prior to fundoplication was similar in each group ( 1.7 laparotomies for lnf vs 1.9 laparotomies for onf , p=0.36 ) .
additionally , operative time was comparable between the groups with an average operative time of 131 minutes in the lnf group ( range , 77 to 190 ) and 164 minutes in the onf group ( range , 100 to 287 ) ( p=0.10 ) .
infants undergoing lnf did resume enteral feeds earlier than those undergoing onf ( 3.0 days lnf vs 6.3 days onf , p=0.01 ) .
the length of stay after fundoplication was actually shorter in the lnf group ( 14 days lnf vs 26 days onf , p=0.13 ) , but this did not reach statistical significance .
all infants in both groups progressed to tolerate full oral , gastrostomy , or both , feeds with appropriate weight gain during follow - up periods .
subjectively , no infants in either group developed recurrent gastroesophageal reflux or wrap failure during an average follow - up period of 22 months ( range , 1 to 54 ) .
follow - up length of time for the lnf group was not different from that in the onf group ( 1 to 28 months versus 1 to 54 months , respectively , p = ns ) .
however , routine monitoring for recurrent reflux is not done at our institution unless an infant develops feeding intolerance after fundoplication .
our results suggest that laparoscopic nissen fundoplication ( lnf ) is at least as safe and effective as open nissen fundoplication ( onf ) in the surgical treatment of gastroesophageal reflux in a population of infants with a history of a neonatal laparotomy .
additionally , lnf appears to have a distinct advantage by allowing an early resumption of full enteral feeds after nissen fundoplication .
all of the infants in this study required an operation in the neonatal period for surgical diseases unrelated to gastroesophageal reflux .
both the onf and the lnf groups included infants with a variety of neonatal surgical diseases , many of which predispose to the subsequent development of gastroesophageal reflux .
specifically , there is a well - documented increase in the incidence of gastroesophageal reflux in neonates with a history of gastroschisis , congenital diaphragmatic hernia , and omphalocele .
the risk for the development of gastroesophageal reflux in these infants is theorized to be secondary to defects of bowel motility , increased abdominal pressure , and gastroesophageal junction anatomical anomalies .
at least half of the infants in both the onf and lnf groups had a variety of abdominal wall and diaphragmatic defects .
there have been few studies in infants and children that address the safety and efficacy of laparoscopic nissen fundoplication for the treatment of gastroesophageal re - flux in children with previous abdominal surgery .
best studied is the role of laparoscopic nissen fundoplication for recurrent gastroesophageal reflux after either an open or laparoscopic primary fundoplication .
rothenbergs has one of the largest series of laparoscopic redo nissen fundoplications with 118 patients ages 6 months to 19 years . in this study , redo laparoscopic nissen fundoplication was safe and efficacious in these infants , children , and adolescents .
other authors have also documented the safety and efficacy of laparoscopic redo nissen fundoplications in infants and children of a variety of ages .
however , fewer studies have examined the role of laparoscopic nissen fundoplication after neonatal laparotomy for diseases unrelated to gastroesophageal reflux . in a study by liu et al
, the authors concluded that laparoscopic nissen fundoplication was feasible and safe in a population of children with previous ventriculoperitoneal shunt placement , gastrostomy placement , or both .
similarly , lintula et al15 concluded that a pre - existing gastrostomy tube did not preclude a safe and effective laparoscopic nissen fundoplication in children .
van der zee et al both documented the technical feasibility and safety of nissen fundoplication in children with a pre - existing gastrostomy tube .
although these studies do examine redo laparoscopic surgery , none of these studies have examined the role of a laparotomy for primary neonatal surgical disease pre - existing the development of gastroesophageal reflux .
there are distinct nuances in achieving safe minimally invasive access in infants after neonatal laparotomy . for infants with abdominal wall defects
( eg , gastroschisis and omphalocele ) , the umbilicus is avoided because the majority of these infants have dense adhesions in this area from prior repair . in our study , initial access for these patients was achieved through a left upper quadrant cut down approach with a 4-mm port . in patients with congenital diaphragmatic hernia and intestinal atresia , adhesions from a prior laparotomy
thus , access via the umbilicus was attempted and successful for these patients . for some patients ,
extended operative times were due to optimizing port placement and extensive adhesiolysis to complete a laparoscopic nissen fundoplication .
unfortunately , the actual times for this aspect of the study operations were not recorded separately , and therefore , we are unable to determine the exact time for doing the fundoplication portion of the operation . beyond the technical feasibility of a laparoscopic nissen fundoplication at any time point after a neonatal laparotomy
, our study also highlights the feasibility of a laparoscopic nissen fundoplication in a group of very small infants .
specifically , all of the infants in the lnf group underwent fundoplication at an average weight of 5.2 kg ( range , 2.7 to 8.8 ) .
these infants were , on average , smaller than the infants and children in the largest series of redo laparoscopic nissen fundoplication , in which the lowest documented weight was 6.4 kg .
however , we are not aware of any studies that have examined weight as a selection criterion for redo laparoscopic nissen fundoplication .
the study dates include a period of transition in our institution with respect to surgical approaches to gastroesophageal reflux . in 2001 ,
an experienced laparoscopic surgeon joined the surgical group , resulting in a gradual conversion over to advanced laparoscopic approaches to historically open surgical diseases .
the number as well as the approach for surgical anti - reflux operations at our institution increased and changed over the time period of this study from 41 in 2000 ( 37 onf ; 4 lnf ) to 122 in 2005 ( 118 lnf ; 4 onf ) .
as advanced laparoscopic skills have developed in the group , the operative times for primary lnf have ranged from 45 minutes to 135 minutes , depending on staff and resident trainee experience .
more surgeons will now consider primary laparoscopic nissen fundoplication , even in the face of previous abdominal surgery .
we intend to review our experience for all anti - reflux operations in the neonatal age group or in infants under 7 kg to determine the outcomes and benefits of such an approach in this patient population .
currently , a primary laparoscopic approach is our preferred approach to gastroesophageal reflux , regardless of the history of previous operations .
outcomes following laparoscopic or open nissen fundoplication performed in infants after a neonatal laparotomy are similar .
however , a laparoscopic fundoplication did allow for earlier return to enteral feeds compared with the open approach and tends toward shorter hospital length of stay .
therefore , we conclude that laparoscopic nissen fundoplication is technically feasible , safe , and effective in the treatment of gastroesophageal reflux in infants with a previous neonatal laparotomy .
 background : nissen fundoplication is an effective treatment of gastroesophageal reflux in infants . 
 laparoscopic procedures after previous laparotomy are technically more challenging . 
 the role of laparoscopic nissen fundoplication after neonatal laparotomy for diseases unrelated to reflux is poorly described.methods:this was a retrospective review of open vs laparoscopic nissen fundoplication in infants after neonatal laparotomy . of 32 infants who underwent neonatal laparotomy , 
 26 required a surgical antireflux operation within the first year of life . 
 twelve infants underwent laparoscopic nissen fundoplication versus 14 infants who underwent open nissen fundoplication . 
 parameters like age , weight , operative time , number of previous operations , length of stay following fundoplication , time to feedings , and complications were compared between the 2 groups.results:no statistically significant differences existed between most of the parameters compared following laparoscopic vs open nissen fundoplication . 
 no conversions to open procedures were necessary in infants undergoing laparoscopic fundoplication , and these infants resumed enteral feeds earlier than those who underwent the open procedure.conclusion:laparoscopic compared with open nissen fundoplication performed in infants after a neonatal laparotomy were comparable procedures across most data points studied . 
 however , a laparoscopic fundoplication did allow for earlier return to enteral feeds compared with the open approach . 
 laparoscopic nissen fundoplication is technically feasible , safe , and effective in the treatment of gastroesophageal reflux in infants with a previous neonatal laparotomy . 