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Background: There is no generally accepted standard surgical approach to gastrooesophageal reflux disease (GERD) at present. However, laparoscopic fundoplication has been advocated to be the procedure of choice for gastrooesophageal reflux disease in children. We aimed to assess the standards of the diagnostic workup and operative techniques in paediatric surgical institutions in Germany., Material and Methods: A questionnaire including 14 items was sent to all 71 departments of paediatric surgery in Germany. Forty (56 %) took part in the survey. Concepts of routine diagnostic workup, operative techniques, number of procedures, and conversions were assessed., Results: The average annual frequency of fundoplications was less than 20 in 36 units (90 %). Experience with laparoscopic fundoplication was present in 24 institutions (60 %). In 19 out of these (79 %) fewer than 50 laparoscopic fundoplications had been performed altogether up to the time of the survey. Out of 584 fundoplications performed in the year 2002, 184 (32 %) had been done laparoscopically. The ratio of conventional versus laparoscopic fundoplication was 170/130 (57/43 %) in academic, and 226/54 (81/19 %) in non-academic departments. The preferred technique of fundoplication, irrespective of the approach, was the Nissen wrap in 28 (70 %) of the departments. The number of paediatric surgeons performing laparoscopic fundoplication was 1 - 2 in 16 institutions (67 %), 3 or 4 in 6 (25 %), and 5 in 2 (8 %) departments. The conversion rate was reported to be less than 5 % in 15 departments (63 %), and 5 - 10 % in 3 (13 %)., Conclusion: The laparoscopic approach for surgical repair of GERD in children is not yet generally accepted in Germany. In most departments, training remains problematic due to low numbers of procedures. However, the feasibility of laparoscopic fundoplication in Germany is excellent, with a low rate of conversions.

Topic: Laparoscopic fundoplication is the preferred surgical procedure for children with gastro-oesophageal reflux. Little data exist on the feasibility of laparoscopic fundoplication after placement of a percutaneous endoscopic gastrostomy (PEG)., Patients and Methods: Thirty-nine children aged 4 months to 18 years (median 3.6 years) presented for an antireflux procedure between November 2000 and July 2003. The surgical technique used was the Thal (270 degrees ) fundoplication. Clinical data, technical aspects of the operation, and the postoperative course were collected prospectively., Results: Twenty-two children (56 %), all of them neurologically impaired, already had a PEG in place due to feeding problems irrespective of gastro-oesophageal reflux symptoms. In all cases, laparoscopic fundoplication was performed immediately after gastroscopic removal of the PEG tube. In two cases, conversion to an open procedure became necessary, due to reasons unrelated to the PEG. In one case conversion was necessary because of adhesions of an intrathoracic stomach and in the other case because of circulatory problems due to congenital cardiomyopathy. In one patient, the gastrostomy was moved at the end of the procedure because it was too close to the antrum. In two further cases, the gastrostomy detached during fundoplication. In this case, the gastrostomy catheter was replaced and secured laparoscopically with a purse-string suture. All other cases were without any complications and a balloon tube or a button was placed into the existing gastrostomy channel at the end of surgery., Conclusion: No adverse effects are associated with PEG placement prior to a consecutive laparoscopic antireflux procedure. Possible detachment of the pre-existing gastrostomy must be excluded at the end of the procedure.