AbstractLaparoscopic antireflux procedure for patients with severe scoliosis is often challenging, as the esophageal hiatus lies in an extremely deep position and is frequently rotated. Reports regarding the clinical results of laparoscopic fundoplication are scarce, especially in patients with severe scoliosis. In this study, laparoscopic Nissen fundoplication was applied to seven adolescent patients aged between 19 and 29 years with neurological impairment and gastroesophageal reflux disease (GERD). The scoliosis among them was considerably severe with a median Cobb angle of 131°. Follow-up was conducted with a median period of 7.8 years. There was no intraoperative complication or recurrence of GERD. Two patients required tracheostomy, and one died due to recurrent pneumonia after fundoplication. Our experience suggested the feasibility of laparoscopic Nissen fundoplication with an arrangement of port layout even in neurologically impaired adolescents with severe scoliosis. As recurrent aspiration pneumonia can persist after fundoplication in some patients, an anti-aspiration procedure may be considered to achieve a higher quality of life

Endo, Masao

Mori, Masaharu

Nakano, Miwako

Ohno, Michinobu

Ukiyama, Etsuji

Watanabe, Toshihiko

Yoshida, Fumiko

Laparoscopic antireflux procedure for patients with severe scoliosis is often challenging, as the esophageal hiatus lies in an extremely deep position and is frequently rotated. Reports regarding the clinical results of laparoscopic fundoplication are scarce, especially in patients with severe scoliosis. In this study, laparoscopic Nissen fundoplication was applied to seven adolescent patients aged between 19 and 29 years with neurological impairment and gastroesophageal reflux disease (GERD). The scoliosis among them was considerably severe with a median Cobb angle of 131°. Follow-up was conducted with a median period of 7.8 years. There was no intraoperative complication or recurrence of GERD. Two patients required tracheostomy, and one died due to recurrent pneumonia after fundoplication. Our experience suggested the feasibility of laparoscopic Nissen fundoplication with an arrangement of port layout even in neurologically impaired adolescents with severe scoliosis. As recurrent aspiration pneumonia can persist after fundoplication in some patients, an anti-aspiration procedure may be considered to achieve a higher quality of life

Toshihiko Watanabe

Fumiko Yoshida

Michinobu Ohno

Masaharu Mori

Etsuji Ukiyama

Miwako Nakano

Masao Endo

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Journal of Pediatric Surgery Case Reports

Laparoscopic fundoplication for neurologically impaired adolescents with severe scoliosis

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J Ped Surg Case Reports 2 (2014) 450e453Journal of Pediatric Surgery CASE REPORTS
journal homepage: www.jpscasereports.comLaparoscopic fundoplication for neurologically impaired adolescents
with severe scoliosisq
Toshihiko Watanabe a,b,*, Fumiko Yoshida b, Michinobu Ohno a,b, Masaharu Mori b,
Etsuji Ukiyama b,c, Miwako Nakano b, Masao Endo b
aDivision of Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
bDepartment of Pediatric Surgery, Saitama City Hospital, Saitama, Japan
cDepartment of Pediatric Surgery, Kyorin University Hospital, Tokyo, Japana r t i c l e i n f o
Article history:
Received 5 April 2014
Received in revised form
9 September 2014
Accepted 9 September 2014
Key words:
Gastroesophageal reﬂux
Laparoscopic fundoplication
Neurologically impaired adolescentq This is an open access article under the CC
creativecommons.org/licenses/by-nc-nd/3.0/).
* Corresponding author. Division of Surgery, Depart
National Center for Child Health and Development,
Tokyo 157-8535, Japan. Tel.: þ81 3 3416 0181; fax: þ8
E-mail address: watanabe-ts@ncchd.go.jp (T. Wata
2213-5766/$ e see front matter  2014 The Authors.
http://dx.doi.org/10.1016/j.epsc.2014.09.004a b s t r a c t
Laparoscopic antireﬂux procedure for patients with severe scoliosis is often challenging, as the esoph-
ageal hiatus lies in an extremely deep position and is frequently rotated. Reports regarding the clinical
results of laparoscopic fundoplication are scarce, especially in patients with severe scoliosis. In this study,
laparoscopic Nissen fundoplication was applied to seven adolescent patients aged between 19 and 29
years with neurological impairment and gastroesophageal reﬂux disease (GERD). The scoliosis among
them was considerably severe with a median Cobb angle of 131. Follow-up was conducted with a
median period of 7.8 years. There was no intraoperative complication or recurrence of GERD. Two pa-
tients required tracheostomy, and one died due to recurrent pneumonia after fundoplication. Our
experience suggested the feasibility of laparoscopic Nissen fundoplication with an arrangement of port
layout even in neurologically impaired adolescents with severe scoliosis. As recurrent aspiration pneu-
monia can persist after fundoplication in some patients, an anti-aspiration procedure may be considered
to achieve a higher quality of life.
 2014 The Authors. Published by Elsevier Inc. All rights reserved.Laparoscopic antireﬂux procedures have replaced the open
approach and have since become the standard surgical option for
the treatment of gastroesophageal reﬂux disease (GERD) in the
pediatric population [1]. Although antireﬂux procedures are
recently being applied to neurologically impaired children with
GERD, there remains a high-risk group who actually experienced a
worse outcome after such procedures [2e4]. Neurologically
impaired adolescents who have suffered from GERD since their
pediatric period are included in this high-risk group as well.
Laparoscopic surgery in patients with severe scoliosis can be chal-
lenging because of a limited working space between the subcostal
margins, iliac crests, and the spinal column due to lateral bending of
the trunk [5]. In view of the fact that the esophageal hiatus lies
extremely deep in the subphrenic space and is frequently rotated in
cases of severe scoliosis, the port site arrangement may be key for aBY-NC-ND license (http://
ment of Surgical Specialties,
2-10-1 Okura, Setagaya-ku,
1 3 3416 2222.
nabe).
Published by Elsevier Inc. All rightsuccessful laparoscopic procedure [5,6]. Although long-term
outcome of laparoscopic antireﬂux procedure in neurologically
impaired children is well-documented [7,8], reports concerning the
technical aspect, especially in neurologically impaired adolescents,
are scarce. The aim of this study is to characterize GERD in neuro-
logically impaired adolescents and to investigate whether laparo-
scopic Nissen fundoplication is feasible for such patients.
1. Patients and methods
Seven patients with a neurologically impaired condition lasting
beyond the pediatric period, and who underwent laparoscopic
Nissen fundoplication, were included in this study. The Cobb angles
to evaluate the severity of scoliosis were calculated based on X-ray
of the chest and abdomen. Preoperative diagnosis of GERD was
based on the following: esophagogastric reﬂux revealed by barium
contrast study, endoscopic evidence of esophagitis with patholog-
ical ﬁndings of esophageal biopsy, and reﬂux index of >5% in 24-h
esophageal pH monitoring after the withdrawal of H2-blocker or
proton pump inhibitor. Indications for surgery were persistent
GERD even after pharmacological treatment, as well as feeding
problems or any symptoms associated with GERD.s reserved.
Fig. 1. Two types of port arrangement in scoliotic patients. Less scoliotic patients have
normal port placement (A). Port placement was shifted to the left of the abdomen
using umbilicus for the left working port (B) (U: umbilicus).
T. Watanabe et al. / J Ped Surg Case Reports 2 (2014) 450e453 4511.1. Laparoscopic fundoplication
Five 5-mm ports were placed at the umbilicus, both of the
midquadrants, the right lateral quadrant and the epigastric region
(Fig. 1A). As the abdominal space for the ports was very limited due
to the deformation of the ribs in severe scoliosis, port placement
was shifted to the left to expose the hiatus, allowing a wider
working space (Fig. 1B). The fundus of the stomach was mobilized
with laparoscopic coagulating shears. After surgery to expose the
region around the lower end of the esophagus, the esophagogastric
junction was drawn down intra-abdominally by a vessel loop at a
distance of 3e5 cm from the hiatus. Diaphragmatic crural repair
and esophageal anchoring were accomplished with 3-0 non-
absorbable sutures. Care was taken to avoid injury to the anterior
and posterior vagal nerves as well as the hepatic branches. The 360-
degree fundal wrapping cuff was made 2e3 cm in length with 3-
0 non-absorbable sutures. A Stamm gastrostomy was placed at one
of the port sites, while aWitzel jejunostomywas created in patients
with mal-duodenal passage identiﬁed by contrast study.2. Results
The preoperative characteristics of the seven patients are shown
in Table 1. There were ﬁve males and two females (median age, 27
years). The scoliosis in themwas considerably severewith a median
Cobb angle of 131. In ﬁve patients, the status of GERD was consid-
ered severe due to sliding hernia (resulting in a median reﬂux index
of 18%). Preoperative history involved recurrent pneumonia in allTable 1
Demographics of each patient.
Pt. Age Sex Cobb
angle
Sliding
hernia
1 26 M 168 (þ)
2 19 M 137 (þ)
3 18 F 71 ()
4 28 F 16 ()
5 27 M 151 (þ)
6 27 M 131 (þ)
7 29 M 55 (þ)
N/A: not available, N: malnutrition, P: recurrent pneumonia, E: esophagitis.patients. Esophagitis with hematemesis or bloody gastric ﬂuid was
present in ﬁve patients while malnutrition was present in four.
Operative ﬁndings, post-operative complication and outcome of
each patient are shown in Table 2. The port site was designed as a
type B in four patients with a Cobb angle of >90 (Fig. 2). With the
modiﬁcation of the port placement, laparoscopic operative view
was excellent, allowing meticulous dissection around the deep
esophageal hiatus. The median operative time was 256 min,
including the creation of a nutritional access. In patients 1 and 7, the
adhesion around the esophagogastric junction was severe due to
repeated reﬂux. As a result, detection of the vagal nerve and the
exact layer for dissection was difﬁcult and time-consuming. There
was no intraoperative complication or conversion to an open pro-
cedure required in any of the patients. The median postoperative
hospital stay was 47 days.
Post-operatively, a digestive ﬂuid leakage through the side of the
nutritional access due to bad wound healing was observed in pa-
tients 1, 4 and 6. In patients 1 and 6, severe scoliosis persisted and
resulted in direct aspiration pneumonia. A longer hospital stay was
required for these patients for respiratory management. The me-
dian follow-up was 7.8 years. No recurrence of GERD was observed,
but tracheostomy was required in patients 5 and 6 to control
recurrent aspiration pneumonia. Patient 1 died of septic shock
arising from severe pneumonia that required artiﬁcial ventilation.
3. Discussion
Surgical treatment of gastroesophageal reﬂux in patients with
severe scoliosis can be challenging because of the limited working
space between the subcostal margins, iliac crest, and spinal column.
Furthermore, the esophageal hiatus lies deep in the abdomen and is
frequently rotated, making surgery even more difﬁcult. To resolve
these anatomical problems, Drucker et al. performed transthoracic
Nissen fundoplication in ﬁve mentally retarded patients with se-
vere kypho-roto-scoliosis [6]. Since neurologically impaired pa-
tients remain as a high-risk group for an even worse outcome after
antireﬂux procedures [2e4], total esophagogastric dissociation
(EGD) is elected to be the deﬁnitive solution as it eliminates all risk
of recurrent reﬂux. EGD can be the primary treatment of choice for
severe neurologically impaired patients who are experiencing
GERDwith a total dependence on tube feeds [9]. However, EGDmay
not be an appropriate option for patients with severe scoliosis due
to the problem of visibility of the surgical site. As such, the lapa-
roscopic approach may have an edge in terms of reaching the deep
hiatus [5]. Moreover, a trocar layout is an important factor to
consider in order to achieve awider working space in such patients;
it should be shifted to the left of the trunk to expose the hiatus.
However, intercostal port placement is not recommended due to a
risk of pneumothorax. Even if the stomach is located deep in the
costal arch, it is not difﬁcult to introduce tube gastrostomy in the
epigastric region, although intercostal positioning of a gastrostomyReﬂux
index
(%)
Endoscopy
(Los Angeles
classiﬁcation)
Preoperative
history
18 N/A NPE
46 C PE
8 A P
9 A PN
21 N/A NPE
30 B NPE
15 C NPE
Table 2
Post-operative complication and outcome of each patient.
Pt. Port site Ope time
(min)
Nutritional
access
Operative ﬁndings Hospital
stay (day)
Complication Follow up
(year)
Outcome
1 B 364 G Severe circumesophageal adhesion 370 G leakage 5.8 Died of septic shock
2 B 247 G smooth operative procedure 12 () 9.2 Alive without recurrence
3 A 256 G Smooth operative procedure 50 () 8.7 Alive without recurrence
4 A 282 G Smooth operative procedure 47 G leakage 8.7 Alive without recurrence
5 B 198 G Smooth operative procedure 45 () 7.8 Alive with tracheostomy (6.9 POY)
6 B 249 GJ Smooth operative procedure 64 J leakage 7.7 Alive with tracheostomy (3.1 POY)
7 A 308 GJ Severe circumesophageal adhesion 38 () 7.5 Alive without recurrence
G: gastrostomy, J: jejunostomy, POY: post-operative year.
Fig. 2. (A) A plain X-ray of patient 5 showed considerably severe scoliosis with a Cobb angle of 151. (B), (C) A narrow abdominal space due to the wing-shaped deformation of the
ribs. X beside the left nipple indicates the deep hiatus, and the circles indicate the port placement (U: umbilicus, B: gastrostomy button).
T. Watanabe et al. / J Ped Surg Case Reports 2 (2014) 450e453452has been reported in the literature [10]. Duodenal obstruction due
to vertebral deformity or superior mesenteric artery syndrome in
patients with severe scoliosis is also a demanding aspect to manage
[11]. In such patients, a combined tube jejunostomy for enteral
nutrition should be considered together with a gastrostomy for
gastric drainage.
The high morbidity rate of direct aspiration is one issue in
neurologically impaired patients. Diminished cough reﬂex owing to
chronic intratracheal aspiration is also responsible for progressive
deterioration of an infected respiratory tract in such patients [12].
Kawahara et al. reported that respiratory symptoms remained
poorly controlled in 52% of the patients who underwent laparo-
scopic fundoplication, with some of them requiring further respi-
ratory care including nasal airway tube, tracheostomy and
laryngotracheal separation (LTS) [12]. Two out of the seven patients
in our series required tracheostomy, and one died due to recurrent
pneumonia after fundoplication. Takamizawa et al. stated that
simultaneous LTS with fundoplication and gastrostomy may be
recommended for patients who have impaired swallowing and
GERD [13]. Respiratory resuscitation, including tracheostomy and
LTS, should be considered in the treatment of handicapped patients
with respiratory symptoms when the indication for fundoplication
has been determined or respiratory symptoms remained after
fundoplication [12,13].
In our experience, the outcome of laparoscopic Nissen fundo-
plication in adolescents with severely scoliosis and neurologicalimpairments was satisfactory without recurrence of GERD. How-
ever, recurrent aspiration pneumonia remained in some patients
even after fundoplication. In such cases, an anti-aspiration proce-
dure may be considered to achieve a higher quality of life.
Conﬂict of interest
All authors have no conﬂict of interest.Acknowledgment
Wewould also like to thank Dr. Julian Tang of the Department of
Education for Clinical Research, National Center for Child Health
and Development, for proofreading, editing and rewriting part of
this manuscript.References
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Laparoscopic fundoplication for neurologically impaired adolescents with severe scoliosis 

Laparoscopic fundoplication for neurologically impaired adolescents with severe scoliosis

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