title: Laparoscopic fundoplication in children with ventriculo-peritoneal shunts.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Paediatric Surgery, Oxford University Hospital , Headington, Oxford, United Kingdom. rainerkubiak@hotmail.com
authors.forename: Rainer
authors.initials: R
authors.lastname: Kubiak
authors.forename: Clare
authors.initials: C
authors.lastname: Skerritt
authors.forename: Hugh W
authors.initials: HW
authors.lastname: Grant
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D061887:Conversion to Open Surgery; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005774:Gastrostomy; D006801:Humans; D007223:Infant; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D017287:Ventriculoperitoneal Shunt / Q000009:adverse effects