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Pediatric Surgery: Minimally invasive laparoscopic Nissen fundoplication used to treat infants and children with gastroesophageal reflux

07/01/2005

Mattel Children’s Hospital at UCLA is one of the few centers in the nation where pediatric surgeons use laparoscopic Nissen fundoplication to treat infants and children with gastroesophageal reflux (GERD). On average, UCLA pediatric surgeons perform two to three of these minimally invasive procedures each week on newborns through adolescents.

Identical to open Nissen fundoplication, the minimally invasive procedure strengthens the lower esophageal sphincter between the stomach and esophagus by wrapping the upper portion of the stomach, or fundus, around the bottom of the esophagus.

In most newborns, the lower esophageal sphincter is lax, so that spitting up is common, but over time (usually by age 18 months) becomes more competent. If the reflux is persistent or symptomatic – known as pathologic reflux – the child may need medical or surgical intervention.

Diagnosing GERD in infants and children

Symptoms of pathologic reflux in infants and children may include failure to thrive, recurrent aspiration pneumonia, exacerbation of reactive airway disease, hoarseness, esophagitis with pain and/or difficulty in swallowing, esophageal stricture formation, and the occurrence of an acute, life-threatening event.

Testing for pathologic reflux may include the following studies: 24-hour pH, upper gastrointestinal (GI)series, gastric emptying, and esophagoscopy with biopsy.

Treatments for GERD

Medical therapies to treat reflux in infants in children may include altering feeding habits, or using medications that help speed the emptying of the stomach contents into the intestine or that reduce stomach acid. The failure of medical therapies or a life-threatening event due to reflux are both indications for surgery. Nissen fundoplication may be considered in either situation depending on the individual patient.

Advantages of the laparoscopic technique

Findings from multiple reviews of a large number of children suggest that laparoscopic fundoplication shortens the inpatient postoperative stay (Nissen fundoplication – one to two days; open procedure – three to five days), decreases the average cost, and has an equivalent effectiveness for treating reflux compared to the open procedure.*

Since the procedure requires only five small incisions, pain is less than the open surgery and recovery faster. With the Nissen fundoplication approach, one one-quarter inch incision is made in the fold of the belly button. Four additional one-eighth inch incisions are made along the upper abdomen. Scars from these four incisions are barely visible after healing. The open procedure requires a single incision, four to eight inches in length, depending upon the size of the child.

Neurologically impaired children, who require a gastrostomy for feeding access, should be evaluated for gastroesophageal reflux. Those with demonstrable reflux may require a Nissen fundoplication procedure in addition to a gastrostomy.

Contact information

Through this number, you can reach UCLA pediatric surgeons:

James B. Atkinson, M.D.

James C. Dunn, M.D., Ph.D.

Stephen B. Shew, M.D.

(310) 206-2429

(310) 267-2746

(310) 825-9554


*Rothenberg SS. The first decade’s experience with laparoscopic Nissen fundoplication in infants and children. J Pediatr Surg. 40(1):142-6; discussion 147, January 2005.
Blewett CJ, et. al. Economic implications of current surgical management of gastroesophageal reflux disease. J Pediatr Surg. 37(3):427-30, March 2002.





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