Novel use of a light-emitting nasogastric tube to enhance oesophageal dissection during laparoscopic fundoplication in children: a case report

Introduction

Laparoscopic Nissen fundoplication is the standard treatment for gastroesophageal reflux disease (GERD) in children (1). The proper dissection of the oesophagus and the hiatus, which leads to a proper wrap, is essential for a successful laparoscopic Nissen fundoplication (2). However, extensive dissection to gain intra-abdominal oesophageal length may be associated with higher morbidities, such as inadvertent oesophageal perforation requiring conversion and repair (3). The careful delineation of the anatomy and borders of the retro-oesophageal triangle during dissection has been the strategy to avoid this complication (3). However, this strategy can be challenging, especially for novice practitioners; therefore, it is necessary to introduce new measures to reduce the incidence of inadvertent oesophageal injury during laparoscopic Nissen fundoplication. We hereby report the first experience of the novel use of a light-emitting nasogastric tube, modified from a light-emitting ureteral catheter, to reduce the risk of ureteral injury during pelvic surgery and improve oesophageal dissection during laparoscopic fundoplication in children. We present this case in accordance with the CARE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2024-584/rc).

Case presentation

The patient was a four-year-old female with known cystic fibrosis. She had feeding difficulties with failure to thrive and thus required supplemental milk to improve nutrition, and medications were administered via a nasogastric tube. Since long-term tube feeding was expected, the patient’s parents were advised of the need for gastrostomy tube insertion and a pre-operative potential of hydrogen (pH) study. The 24-hour pH study revealed significant gastroesophageal reflux; therefore, laparoscopic fundoplication and gastrostomy were planned.

The infrared illumination system urethral kit (IRIS U-Kit) under endoscopic visualisation was used to identify the intra-abdominal part of the oesophagus and aid dissection in real time. The procedure started by administering general anaesthesia. The light-emitting fibre of the IRIS U-Kit system, French (Fr) size 6, was first inserted into the lumen of an 8 Fr feeding tube. The light-emitting oesophageal feeding tube was then inserted in addition to the patient’s original 8 Fr nasogastric tube as a stent to the oesophagus. She underwent fundoplication before gastrostomy. Operation was performed in a 4-port manner, with one camera port, two working ports at both loin region and one assistant port between the camera port and the right-sided working port. After administering carbon dioxide (CO₂) pneumoperitoneum, the liver was retracted with a Nathanson retractor. The boundary of the oesophagus was well delineated from the surrounding tissues with the aid of the IRIS light-emitting nasogastric tube (Figure 1). The intra-abdominal oesophagus was carefully dissected free using hook cauterisation, and a retro-oesophageal window was created with the assistance of the light-emitting nasogastric tube. Nissen fundoplication was performed with the creation of a floppy wrap with the fundus through a retro-oesophageal window and sutured using 2-0 non-absorbable sutures. Gastrostomy was then followed by the fundoplication. Under laparoscopic guidance, two U-stitches were made through the anterior wall of the stomach and the abdominal wall surrounding the chosen location for the installation of the gastrostomy tube. After that, a nasogastric tube was used to insufflate the stomach, and a needle introducer was inserted between the two U-stitches through the abdominal wall. The Seldinger technique was used to serially dilate the tract by passing dilators along a guidewire that was passed through the needle. The balloon was inflated and a 12 Fr gastrostomy tube was inserted into the stomach via the guidewire. The procedure was uneventful, and the light-emitting nasogastric tube was removed upon completion of the operation. The patient resumed feeding 1 day after the procedure and was fit for discharge 3 days after the operation. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Verbal informed consent was obtained from the patient’s parents for publication of this case report and accompanying images.

Figure 1 Operative photos demonstrating the use of light-emitting nasogastric tube during fundoplication. (A) Laparoscopic view of the illuminated oesophagus. (B) Creation of the retro-oesophageal window with the aid of the light-emitting fibre.

Discussion

GERD is not uncommon in children, and its incidence is particularly high among those with underlying neurological impairments or spinal problems (1). GERD must be treated to prevent complications. While various strategies exist to manage GERD, many patients implementing these strategies eventually require laparoscopic fundoplication. Our centre has published our experiences safely performing the procedure even in children with a body weight as low as 3.6 kg (1). The potential risks of the procedure include bleeding, diaphragmatic injury and hiatus hernia. It is reported that GERD recurs in 3–6% of patients receiving laparoscopic Nissen fundoplication, but the adequate dissection of the retro-oesophageal window and the formation of a proper wrap are the major determinants of a successful procedure in adults (1,2). However, extensive dissection of the oesophagus has been challenged in children, given the potential technical difficulty of avoiding inadvertent oesophageal injury. It has been debated whether dissection should be maximal or minimal to avoid possible hiatus hernias and inadvertent oesophageal injury (4). However, adequate oesophageal dissection remains the gold standard and key for achieving functional outcomes.

Strategies to enhance oesophageal dissection to avoid unnecessary oesophageal injury include better defining anatomy landmarks around the retro-oesophageal window and adequately retracting the gastric fundus during dissection (2,3). During operation, the right and left crus should be carefully dissected and exposed; then, a plane should be developed along the lateral border of the left crus leading to the retro-oesophageal window. However, this can be difficult, especially for novices such as surgical trainees. Adjuncts such as the orogastric or nasogastric insertion of a bougie or the use of double feeding tubes have been employed to enhance tactile sensation during oesophageal dissection with laparoscopic surgery. However, the role of traditional tactile sensation is largely limited by the use of minimally invasive approaches, so fluorescence-guided surgery has been advocated to offer excellent visual guidance to provide roadmaps of the anatomy for tissue dissection and lesion localisation (5).

The light-emitting IRIS U-Kit was designed to reduce the risk of ureteral injury during pelvic surgeries. It consists of two light-emitting fibres in one fibre assembly, which could fit into a 6 Fr ureteral catheter and extend three metres outside the patient. The intensity-adjustable blinking bright light allows clear visualisation and safeguards the ureter during tissue dissection in pelvic surgeries. It has been reported to be useful in preventing iatrogenic ureteral injury in patients undergoing gynaecological and colorectal tumour excision (6). Inspired by the use of this light-emitting fibre in adult pelvic surgery, we modified its use by putting the two optic fibres into a transparent 8 Fr feeding tube, as described in the case report, with the aim of aiding the oesophageal dissection.

Conclusions

From our experience, the introduction of optical fibres into the feeding tube was convenient and safe. It did not affect the function of the feeding tube (as a bougie to avoid the over-tightening of the fundoplication wrap), and the modified tube could be inserted into the oesophagus in the usual manner. The bright infrared light clearly demarcated the margin for dissection. The intensity can be adjusted according to the needs of the surgeon and the situation. It would be particularly useful in scenarios where dense adhesions obscuring a clear tissue plane were anticipated, for instance in patients with previous laparotomies, redo-fundoplication, etc. It would also be useful for clear anatomy delineation in children undergoing tumour excisions. Future endeavours are necessary to delineate the actual impact of this method on the outcomes for children receiving laparoscopic fundoplication. Prospective comparative studies could show whether this technique can translate into shorter operative times and fewer complications. Regardless of how technologies evolve, the primary aim of advancement is to provide more holistic and optimal surgical care for patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-584/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-584/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2024-584/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Verbal informed consent was obtained from the patient’s parents for publication of this case report and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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