What the Anesthesiologist Should Know before the Operative Procedure
The Nissen fundoplication is one the most common intra-abdominal operations in children. It is performed in patients with severe gastroesophageal reflux disease (GERD) that is refractory to medical and other conservative therapies. The operation is performed to minimize the significant multisystem side effects of GERD and to decrease the long-term sequelae of the disease. Nissen fundoplication is performed in children of all ages and with a wide variety of underlying medical issues.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
A Nissen fundoplication is usually performed as an elective procedure with every attempt made to optimize the patient’s underlying medical issues prior to the operation. In some patients (those with ongoing ailments related to reflux, e.g., recurrent aspiration pneumonia, reactive airways disease, etc.), waiting for these other problems to resolve or improve can be difficult or in some cases impossible due to the severity of the disease. The operation is rarely performed on an emergent basis. All appropriate evaluations should therefore be undertaken prior to coming to the operating room.
2. Preoperative evaluation
There are a variety of underlying medical conditions associated with Nissen fundoplication in children. Some patients may be relatively healthy, whereas others may have significant underlying medical diseases. Neurologic impairment is the most worrisome problem as it may be associated with more complications and a longer, more difficult recovery. GERD can cause or contribute substantially to pulmonary disease including recurrent aspiration pneumonia, asthma/reactive airways disease, and apnea. Some patients with significant cardiac disease, including cyanotic congenital heart disease, may be scheduled for Nissen fundoplication, in many cases shortly after their heart surgery due to difficulties with feeding and nutrition that impair their recovery. All of these conditions put these patients at increased risk of complications perioperatively.
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Medically unstable conditions warranting further evaluation include: Pulmonary issues related to reflux are most likely to need evaluation preoperatively. Physical exam should focus on worsening of asthma/reactive airways disease or possible pulmonary aspiration related to GERD. Recent change in frequency or type of seizures should also be ascertained, as well as any other neurologic changes in children with those underlying issues. Stability of congenital heart disease should be evaluated, if present.
Delaying surgery may be indicated if the patient has a reversible condition that will add to the risk of anesthesia and surgery. For example, current pneumonia, active wheezing or recent increased frequency of seizures may warrant a delay.
3. What are the implications of co-existing disease on perioperative care?
a. Cardiovascular system
Perioperative evaluation
The presence of simple or cyanotic congenital heart disease in infants and children presenting for Nissen fundoplication should be determined. For those with cyanotic congenital heart disease (either repaired or unrepaired), the perioperative risk is likely elevated. In those patients, recent echocardiographic evaluation or cardiac catheterization data should be utilized to evaluate underlying issues and to guide optimization of therapy and perianesthesia care. Cardiology input into optimization of therapy can be helpful in this regard. Much of this will be determined by the underlying cardiac anatomy and physiology. Consultation with those having expertise in pediatric cardiac anesthesia may be useful as well.
Perioperative risk reduction strategies
For children with cyanotic congenital heart disease, management should be directed at maintaining physiologic stability based on the particular cardiac lesion. For patients without congenital heart disease, the primary goal of intraoperative management is maintenance of cardiovascular stability during laparoscopy (see below).
b. Pulmonary
Perioperative evaluation
Pulmonary morbidity can be a significant problem perioperatively as GERD can cause aspiration pneumonia but can also contribute to or worsen asthma/reactive airways disease. GERD can also be associated with apneic episodes in infants. Consultation with pulmonary specialists could be helpful in severe cases to help optimize pulmonary function preoperatively.
Perioperative risk reduction strategies
Pulmonary status should be optimized preoperatively using medical therapies and by fully evaluating the pulmonary system to confirm the lack of acute issues. Strategies to treat underlying GERD (including medical therapy aimed at reducing stomach acid) should be considered preoperatively. Children with significant pulmonary disease, especially those with accompanying neurologic disease should be considered for more close observation post-operatively in an intensive care setting.
c. Renal-GI:
Medical therapy for GERD should be continued preoperatively in order to optimize conditions and minimize the risk of perioperative complications like aspiration pneumonia. Rapid securing of the airway at the induction of anesthesia is advised.
d. Neurologic
Acute issues: Seizures, when present, should be well controlled and antiseizure medications continued preoperatively.
Chronic disease: Children with either congenital or acquired neurologic disease may present for Nissen fundoplication. These problems can include cerebral palsy, hydrocephalus, seizure disorders, chromosomal abnormalities, or developmental delay, among others. The presence or absence of neurologic disease in an important determinant of the success of the Nissen fundoplication procedure. The risk of complications, need for reoperation and the mortality rate may also be increased when these children have neurologic dysfunction so a thorough assessment of neurologic disease is warranted preoperatively.
e. Endocrine:
Endocrine abnormalities are not common in children having Nissen fundoplication except some patients with central neurologic disease, e.g., hypothalamic-pituitary dysfunction, who may require replacement therapy. Stress-dose steroids should be considered when appropriate in those patients.
4. What are the patient's medications and how should they be managed in the perioperative period?
a. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
Most children will remain on medications aimed at treating the symptoms of GERD. Chronic medications should generally be continued perioperatively, especially those aimed at reducing stomach acid, preventing seizures, and maintaining stability of pulmonary function.
b. What should be recommended with regard to continuation of medications taken chronically?
Continue cardiac, pulmonary, renal, neurologic, and psychiatric medications. Antiplatelet medications are not commonly used.
c. How To modify care for patients with known allergies –
N/A
d. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
N/A
e. Does the patient have any antibiotic allergies?
Perioperative antibiotics are usually given for Nissen fundoplication, often from the cephalosporin class. Patients with allergies to these should have alternatives chosen with a similar spectrum of coverage.
f. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia
Family history or risk factors for MH: Some neuromuscular diseases may be associated with malignant hyperthermia. Some of these patients may also present for Nissen fundoplication. A thorough assessment of the risk of MH based on the underlying disorder should be sought and precautions taken accordingly.
Local anesthetics/ muscle relaxants
These risks should be no more common than in the general pediatric surgical population.
5. What laboratory tests should be obtained and has everything been reviewed?
Hemoglobin level: Patient specific. Those with known anemia or ongoing bleeding should have their hemoglobin level checked preoperatively.
Electrolytes: Reflux and frequent vomiting could result in electrolyte abnormalities, although this should be uncommon.
Coagulation panel: Uncommon abnormality although may be considered in those with chronic malnutrition or liver disease.
Imaging: Consider preoperative chest radiograph in children with history of recurrent aspiration or those with signs and symptoms of acute or chronic respiratory disease.
Other tests: Pulmonary function tests may be helpful in children with severe asthma/reactive airways disease.
6. Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
The Nissen fundoplication is now almost exclusively performed laparoscopically, even in infants. As such, there is a low likelihood of large blood loss or severe postoperative pain. General anesthesia with endotracheal intubation is the preferred anesthetic technique. Standard ASA monitors are usually adequate for most patients except where specific disease-related issues suggest more invasive methods of monitoring.
a. Regional anesthesia – Can only be used as an adjunct to but not as a replacement for general anesthesia in this operation.
Neuraxial
Benefits: Epidural anesthesia in combination with general anesthesia has been used in the past for open Nissen fundoplications and is effective for postoperative analgesia and optimization of pulmonary status. It is now uncommonly used with the laparoscopic surgical technique as the pain associated with this method is less significant.
Drawbacks: Not generally useful for laparoscopic procedure. Commonly used caudal epidural techniques may not reliably cover upper abdominal dermatomes. Some practitioners prefer not to perform thoracic epidurals in anesthetized children.
b. General Anesthesia
Benefits: General anesthesia with endotracheal intubation will facilitate the operation by providing a relaxed abdomen and control of ventilation. Balanced anesthesia utilizing inhalation agents and IV supplements is preferred.
Drawbacks: General anesthesia for children with severe GERD may place them at risk for pulmonary aspiration, especially during induction of anesthesia. General anesthesia can also have sedative effects postoperatively that may put the patient at risk for pulmonary complications (hypoxemia, atelectasis). This may be accentuated in children with neurologic disease whose mental status may be diminished at baseline.
Other issues: With laparoscopic techniques, carbon dioxide (CO2) abdominal insufflation commonly results in systemic absorption of CO2 and necessitates increased minute ventilation to avoid respiratory acidosis. Insufflation also decreases overall ventilatory compliance as the diaphragm moves cephalad. Functional residual capacity may also be reduced. For these reasons, endotracheal intubation is required.
Airway concerns: Rapid sequence induction and intubation are preferred in children presenting for Nissen fundoplication due to GERD and the risk of pulmonary aspiration.
c. Monitored Anesthesia Care
N/A
7. What is the author's preferred method of anesthesia technique and why?
What prophylactic antibiotics should be administered?
According to SCIP recommendations 2007, cephalosporin antibiotics are usually preferred and should be administered within 1 hour prior to surgical incision.
What do I need to know about the surgical technique to optimize my anesthetic care?
The surgical procedure entails isolating an intra-abdominal section of lower esophagus and wrapping a portion of the gastric fundus around this part of the esophagus to enhance the closing of the lower esophagus, thereby minimizing esophageal reflux of stomach contents. Depending on the surgeon, the procedure should take between 45 and 120 minutes to complete. Laparoscopic techniques will be utilized in most cases, necessitating intubation. Those surgeons with more experience using laparoscopy are likely to accomplish the surgery more expeditiously. These procedures will usually require a few days of in-hospital recovery. The rare open procedure is likely to be associated with increased postoperative pain and a longer recovery period in the hospital, as well as an increased likelihood of respiratory complications. Nissen fundoplication is sometimes performed in combination with the placement of a gastrostomy tube when there is a concern for adequate nutrition. Although the operation is generally effective in reducing reflux-related problems, some patients may still need medical therapy long-term. In particular, children with swallowing issues related to neurologic disease may still have issues with handling oral secretions despite having minimal residual reflux. This may still predispose the child to potential pulmonary aspiration and other respiratory problems. Most patients can have their tracheas extubated at the end of the operation.
What can I do intraoperatively to assist the surgeon and optimize patient care?
General anesthesia with sufficient muscle relaxation and maintenance of physiologic homeostasis is the most important way to assist the surgeon. In order to prevent wrapping the lower esophagus too tightly and preventing passage of food through the lower esophagus while eating, many surgeons utilize a flexible bougie device to stent the lower esophagus open while the wrap is being performed. Usually, this is placed intraoperatively by the anesthesia provider. Care must be taken in doing this in order to minimize trauma to the mouth or damage to the esophagus. Bougie placement is usually done under the direction of the surgeon and removed near the end of the procedure. The size of the bougie will also be determined by the surgeon. Some surgeons will want a nasogastric tube to remain postoperatively.
What are the most common intraoperative complications and how can they be avoided/treated
Cardiac: Depending on the intra-abdominal pressure utilized, laparoscopy can have a significant impact on hemodynamics intraoperatively through absorption of carbon dioxide and via abdominal insufflation and the increase in abdominal pressure that occurs. This can cause a decrease in cardiac output as well as an increase in systemic and pulmonary vascular resistances and may be accentuated in the head-up position often utilized for Nissen fundoplication. For most patients, including infants, the hemodynamic changes associated with laparoscopy will generally be clinically insignificant, as long as the intra-abdominal pressure is not excessive. However, some patients requiring Nissen fundoplication will have significant heart disease, including cyanotic congenital heart disease. These patients may require special monitoring (e.g., arterial pressure measurement) and consultation with those more familiar with pediatric cardiac anesthesia. Interestingly, although the hemodynamic stability of many of these cyanotic cardiac lesions are dependent on precise regulation of ventilation (and arterial Pco2) and oxygenation, both of which can be impaired by the very nature of laparoscopy, the technique has been utilized successfully in neonates with hypoplastic left heart syndrome. This safety is enhanced by intra-abdominal pressures that do not exceed 8-12 mm Hg.
Pulmonary
1. On induction of anesthesia, care must be taken to secure the airway with an endotracheal tube as rapidly as possible to minimize the risk of pulmonary aspiration in patients with significant GERD that requires a fundoplication. A preoperative intravenous catheter is therefore suggested. Although the routine use of succinylcholine in children has significantly decreased in the past decades, consideration of the severity of GERD and the specific risks of the use of succinylcholine in each patient should be undertaken to determine the appropriateness of its use for this procedure. Alternatively, larger doses of nondepolarizing muscle relaxants (e.g., rocuronium) can be utilized, although these do not precisely mimic the rapid effects of succinylcholine. In any case, an empty stomach achieved through appropriate fasting is a key goal to minimize the risk.
2. Many patients will have underlying pulmonary disease that has been exacerbated by GERD, e.g., asthma/reactive airways disease. Intraoperative or postoperative wheezing should be appropriately treated.
3. To optimize ventilation, especially during laparoscopic insufflation of the abdomen, a cuffed endotracheal tube can be utilized. This should allow for improved ventilation in the face of changing chest compliance (due to laparoscopy) compared to a traditional uncuffed endotracheal tube with a leak. Cuffed endotracheal tubes should be safe in children when the proper size is selected and the cuff location and pressure is managed appropriately.
4. Pneumothorax, pneumomediastinum, or simply subcutaneous air can occur with laparoscopy. Also note that end-tidal CO2 may not accurately reflect arterial Pco2 in children having laparoscopy. Consider arterial monitoring of Pco2 if its regulation is crucial.
Neurologic: Intraoperative neurologic complications are unusual. Note, however, that laparoscopy can cause an increase in intracranial pressure (ICP) so care should be taken in patients with existing ICP issues. This is worsened by head-down position, which fortunately, is not generally utilized for Nissen fundoplication.
a. If the patient is intubated, are there any special criteria for extubation?
Patients having Nissen fundoplication can usually be extubated awake at the end of the operation. A head-up position may be employed for recovery.
b. Postoperative management
What analgesic modalities can I implement?
Fortunately, Laparoscopic Nissen fundoplication is not asociated with severe pain postoperatively. Careful titration of narcotics should be employed to avoid respiratory depression, especially in patients with neurologic dysfunction or respiratory disease. Nonsteroidal anti-inflammatory drugs may be useful adjuncts as they do not contribute to respiratory depression.
What level bed acuity is appropriate?
Most children can be cared for postoperatively on the regular hospital ward. Some children with significant comorbidities may require recovery in an intensive care setting.
What are common postoperative complications, and ways to prevent and treat them?
Nissen fundoplication usually requires several days in the hospital postoperatively. Immediate complications are mostly surgically-related. If appropriate precautions outlined here are taken perioperatively with patients who have underlying medical conditions, the risk of complications should be low, but may be impacted by the preoperative severity of these medical illnesses.
What's the Evidence?
Goldin, AB, Sawin, R, Seidel, KD, Flum, DR. “Do antireflux operations decrease the rate of reflux-related hospitalizations in children?”. Pediatrics. vol. 118. 2006. pp. 2326-33. (This paper suggests that antireflux procedures are effective in reducing reflux-related problems in children less than 4 years of age. Also, children with developmental delay had more complications requiring hospitalization postoperatively.)
Pearl, RH, Robie, DK, Ein, SH. “Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children”. J Pediatr Surg. vol. 25. 1990. pp. 1169-73. (Although an older paper, it is a nice review of the issues that differentiate children with neurologic disease compared to children without neurologic problems and highlights the notion that the success rate of the procedure and complication rate are higher in neurologically impaired children after fundoplication.)
Pennant, JH. “Anesthesia for laparoscopy in the pediatric patient. Anesthesia for minimally invasive surgery: laparoscopy, thoracoscopy, hysteroscopy”. Anesthesiol Clin North Am. vol. 19. 2001. pp. 69-88. (A terrific review of many of the important issues surrounding laparoscopic surgery in children.)
Rothenberg, S. “The first decade's experience with laparoscopic Nissen fundoplication in infants and children”. J Pediatr Surg. vol. 40. 2005. pp. 142-7. (A nice review of a single surgeon's experience with laparoscopic Nissen fundoplication in children. It suggests that 1) there is a learning curve to the surgical procedure but it can be quickly mastered, 2) laparoscopic techniques are effective for this operation, and 3) laparoscopy in children may be better than the traditional open procedure.)
Shah, SR, Jegapragasan, M, Fox, MD. “A review of laparoscopic Nissen fundoplication in children weighing less than 5 kg”. J Pediatr Surg. vol. 45. 2010. pp. 1165-8. (As laparoscopy has been extended to more and more patients, this paper confirms that safety of performing laparoscopic Nissen fundoplication in the smallest patients. They do point out a greater need for postoperative care in the context of prematurity and coexisting disease.)
Slater, B, Rangel, S, Ramamoorthy, S. “Outcomes after laparoscopic surgery in neonates with hypoplastic left heart syndrome”. J Pediatr Surg. vol. 42. 2007. pp. 1118-21. (One of a couple of papers out of Stanford that suggest that with appropriate care, the use of laparoscopy is safe in children with single cardiac ventricles. A review of the important considerations in single ventricle physiology is included.)
Lee, SL, Shabatian, H, Hsu, JW. “Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication”. J Pediatr Surg. vol. 43. 2008. pp. 59-65. (Nice retrospective review paper that suggests the Nissen does not completely diminish admissions for respiratory problems. As in other studies, neurologic disease is associated with poorer outcomes.)
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