The Lortat-Jacob operation by laparoscopic access to treat gastroesophageal reflux in pediatric patients. Preliminary results.
BACKGROUND
Even in the pediatric field, the technique most commonly used in the laparoscopic treatment of GERD is 360 degrees fundoplication (according to Nissen and variants), but this is not devoid of serious complications or sequelae, such as persistent dysphagia or the "gas bloat syndrome." In fact, there has been no lack of proposals of alternative techniques in literature aiming to reduce these negative postoperative events, especially in pediatric patients. At our pediatric surgical clinic at Bari University, the first choice technique is the Lortat-Jacob operation, used in traditional surgery for over 20 years and that has yielded excellent results both as regards control of GER and the complication and sequelae rate. Aim of this study, based on purely preliminary results, was to demonstrate the feasability of the Lortat-Jacob operation by laparoscopic access in pediatric patients, even younger than 1 year old. To our knowledge, there are no other references in literature to the use of this technique by laparoscopic access in pediatric patients.


METHODS
Antireflux plasty sec. Lortat-Jacob by laparoscopic access was performed in 10 patients of ages ranging between 10 months and 11 years. The technique adopted took into account all the recognized principles of the traditional surgical approach. The most delicate stage was the extensive mobilization of the distal esophagus at the level of the mediastinum, owing to the risk of bleeding, and of pleural and vagal lesions. Mean operative time was 100' (80'-120'). All the operations were performed laparoscopically, and no intraoperative complications were recorded. The nasogastric probe was removed within 24 h postoperatively, and liquid feeding was recommenced within 36 h. All patients were discharged within 72 h.


RESULTS
No complications or short or medium term sequelae were observed. Follow-up is still in the early stages, but the first radiological endoscopic, and pH monitoring controls have shown excellent results.


CONCLUSIONS
The initial data on our recent, limited experience show that the Lortat-Jacob operation can be performed by laparoscopic access in expert hands, provided scrupulous attention is paid to the timing and principles laid down for the traditional surgical approach. Moreover, laparoscopic access allows even greater care to be taken to prevent damage to the vagal nerves during mobilization of the terminal esophagus at the mediastinic level, as they are easier to identify even in children under 1 year old, thanks to the magnification of the image. The good control of GER and absence of complications or short or medium term sequelae justify our choice to use this operation. However, our results are still preliminary and need to be confirmed by an increasing number of patients and longer term follow-up.
Montinaro
L
L
Department of Pediatric Surgery, Bari University Medical School, Bari, Italy. leomontina@libero.it
Paradies
G
G
Leggio
S
S
D016063:Blood Loss, Surgical / Q000517:prevention & control; D002648:Child; D002675:Child, Preschool; D004724:Endoscopy / Q000379:methods; D004947:Esophagus / Q000294:innervation / Q000601:surgery; D005500:Follow-Up Studies; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007223:Infant; D007431:Intraoperative Complications / Q000517:prevention & control; D010535:Laparoscopy / Q000379:methods*; D008365:Manometry; D015641:Radiography, Interventional / Q000379:methods; D013997:Time Factors; D014630:Vagus Nerve / Q000601:surgery