Health benefits and economical aspects on laparoscopic vs open Nissen fundoplication in children

Health benefits and economical aspects on laparoscopic vs open Nissen fundoplication in children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health benefits and economical aspects on laparoscopic vs open Nissen fundoplication in children Niclas Högberg, Johan Danielson, Amanda Westblom, Elisabet Gustafson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5231314/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jan, 2025 Read the published version in Pediatric Surgery International → Version 1 posted 9 You are reading this latest preprint version Abstract Background Nissen fundoplication is one of the most common surgical procedures for gastroesophageal reflux. Current and previous research comparing laparoscopic Nissen fundoplication (LNF) versus open Nissen fundoplication (ONF) in children suggest ambiguous conclusions. The purpose of this retrospective study was to compare the outcome for children operated with LNF or ONF at our institution, and to evaluate the economic aspects. Methods 32 consecutive patients (LNF: n = 18, ONF: n = 14) operated with Nissen fundoplication between the years 2011–2017 were included in the study. Data was collected by examination of the patient journals and preoperative, operative, postoperative, and post-discharge parameters were analyzed. Results Compared to ONF, the LNF group had shorter operating time (165.2 vs 216.6 min, p < 0.05), shorter overall operating room duration (315.0 vs 334.9 min, p < 0.05) and shorter postoperative hospital stay (3.8 vs 8.1 days, p < 0.05). The LNF group also required less morphine (1.2 vs 1.7 mg/kg, p < 0.05) and the total cost per case was 39% lower (261.1 vs 427.4 kSEK, p < 0.05). No difference was seen in postoperative complications and results. Conclusion Laparoscopic Nissen fundoplication is more beneficial for patients compared to open surgery, and at a lower cost. gastroesophageal reflux GERD laparoscopic open Nissen fundoplication cost Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Background Fundoplication for the treatment of gastroesophageal reflux disease (GERD) was first described by Rudolph Nissen in 1956 1 . Since then, several alternative techniques have been proposed, but Nissen’s original open procedure (ONF) is still one of the most widely used methods in surgical practice today. With the evolution of laparoscopy, it became technically feasible to adapt the original technique to a laparoscopic approach. The first paper on laparoscopic Nissen fundoplication (LNF) in adults was published in 1991 2 and the first publication on LNF performed in paediatric surgery soon followed in 1993 3 . Several studies of single-centre experiences, as well as randomised studies, have been published on this subject 2, 4-7 . The conclusion from these studies varies and the main concern is whether the risk of recurrence of gastroesophageal reflux is higher in patients operated with LNF, which has been reported in some studies 4 . Recent reviews on the subject 8, 9 conclude that LNF is an effective surgical alternative to ONF for gastroesophageal reflux in children. In 2014 we performed our first LNF and in 2016 we decided to use LNF as the standard operative procedure for patients with GERD at our tertiary center for pediatric surgery. Aims The aims of this study were to investigate any differences between LNF and ONF in 1. Operative and total theatre time 2. Length of hospital stay 3. The amount of administered morphine during hospital stay 4. Total costs for surgery and hospital stay 5. Complications and results. Materials and Methods Data collection The operative registry at the department of paediatric surgery, Uppsala University hospital, Sweden, was investigated for patients <18 years of age operated with Nissen fundoplication for GERD between January 2011 and December 2017. A total of 32 patients were included in the study. The data was accessed between january 15 th 2018 to may 19 th 2018. The authors had access to patients charts, and therefore individual patients could be identified during data collection. Patient characteristics and indications for surgery 18 patients were operated with LNF (2016-2017) and 14 patients with ONF (2011-2015). The indications for surgery are summarized in Table 1. Each patient could have several indications for surgery. No difference was seen in patient characteristics regarding sex, age, weight or indications for GERD-surgery between the two groups (p>0.05). Preoperative investigation The preoperative investigations are presented in Table 2, and the pathological findings are presented in Table 3. The preoperative workup was more stringent in the LNF-group but there was no difference in the incidence of performed preoperative investigations (p>0.05). Surgical technique For laparoscopic procedures, patients were operated in the prone position with the surgeon standing between the legs of the patient. A 5mm port was introduced in the umbilicus with open technique and pneumoperitoneum was established. Two 5mm ports were introduced, one to the right of the umbilicus and one in the left flank. A 7-8mm STEP-port was introduced between the port in the left flank and the umbilicus. A 5mm trocar was then used to make a wound in the epigastrium, through this wound a Nathanson retractor was introduced and used to retract the liver. The camera was introduced in the umbilical port and the assistant used the left lateral port. The head of the table was elevated to facilitate access to the operative area. Any existing gastrostomy was left in place. For open procedures, patients were operated in the prone position. An upper midline incision was performed, and retractors were applied to the liver and abdominal wall. Any existing gastrostomy was temporarily taken down. The medial aspect of the gastroesophageal junction (GEJ) was then dissected with electrocautery to visualize the left crus. Dissection was continued on the anterior side of the GEJ and then on the lateral side until the right crus was identified. Care was taken to identify and avoid damage to the vagal nerves. A retroesophageal window was created, and a cruroplasty was created with two or three 3:0 braided non-absorbable interrupted sutures (Ethibond, Ehicon). The fundus of the stomach was mobilised from the spleen by dividing the short gastric vessels. When the fundus was deemed mobilised enough, the fundus was pulled through the retroesophageal window to perform a 360-degree wrap. Three interrupted, braided non-absorbable 3:0 sutures (Ethibond, Ethicon) were used to create the wrap and fasten it to the anterior part of the esophagus. A fourth suture was put in the anterior part of the wrap and secured to the anterior part of the diaphragm. For laparoscopic procedures, all ports were taken out under laparoscopic vision and the fascia and subcutis was closed with absorbable sutures. Tissue glue was used to close the skin. For open procedures, incision was closed in layers with absorbable sutures in fascia, subcutis and skin, with a wound catheter placed under the fascia. Ethical considerations The study was approved by the Regional Ethical Committee at Uppsala University, Uppsala, Sweden, approval number 2018/042. The approval did not require individual patient/family consent since the study was based on register data. Statistical Methods Values are presented as proportions, means, medians or range as appropriate. Fisher´s two-tailed exact test was used to compare proportions. The Mann-Whitney U-test was used for unpaired comparisons. A p-value of less than 0.05 was considered statistically significant. Statistica 13.2 software (Dell, Tulsa, USA) was used for the statistical analysis. Results Perioperative parameters The perioperative parameters are presented in Figures 1, 2 and Table 4. Mean operating time and overall operating room duration was shorter for the LNF group compared to in the ONF group (p<0.05). However, more patients in the ONF group underwent simultaneous operations or procedures; 8 patients in the LNF group (44%) and 10 patients in the ONF group (71%), (p<0.05). These included insertion of gastrostomy (n=11), insertion of central venous catheter (n=4), insertion of venous port (n=2), teeth inspection (n=2), incisional hernia repair (n=1), Morgagni-Larrey hernia repair (n=1), adenoidectomy (n=1), Botox injection in peripheral muscles (n=1), loop ileostomy (n=1), removal of jejunostomy (n=1), recanalization of venous port (n=1), change of jejunal tube (n=1) and endoscopic dilation of esophagus (n=1). Postoperative parameters The postoperative parameters are presented in Figures 3, 4 and Table 4. No difference was seen between the two groups in requirement of intensive care. Mean postoperative hospital stay was 3.8 days in the LNF group and 8.1 days in the ONF group. The analgesic measures were registered as presence of wound catheter and requirement of intravenous morphine. All patients in the ONF group (100%) and no patient in the LNF group (0%) were given a wound catheter. Mean morphine requirement was lower in the LNF group compared to the ONF group (1.2mg/kg vs. 1.7 mg/kg, p0.05). Complications and follow-up All patients were followed-up either by return visit, phone call, video conference or a combination of methods. The time for follow-up was not standardized, but all patients had at least one return visit or phone call. After that, continued follow-up was based on clinical symptoms. No difference in follow-up was seen between the two groups. One patient in the ONF group died 6 months after the operation, unrelated to the fundoplication. This patient was therefore not available for follow-up and is excluded from these results. The postoperative complications are presented in Table 4. No difference was seen regarding retching, dysphagia, or need of dilatation or redo fundoplication. The symptomatic incidence of recurrent GERD was higher in ONF-group, but could not be confirmed by pH-monitoring where no difference was seen between the groups. Economical aspects, total c ost The total hospital charges are presented in Figure 5 and Table 6. For each patient, the total cost was calculated based on the local billing charges for the operation (operating time, anesthesia, surgical material, wound catheter) and hospital stay (days in hospital, time in recovery room, admittance at an intensive care unit). Mean total costs were 261.1 kSEK (approximately 26.1 kEuro) in the LNF group and 427.4 kSEK (approximately 42.74 kEuro) in the ONF group. Mean cost was 166.3 kSEK (approximately 16.63 kEuro) or 39% lower for LNF than for ONF (p<0.05). Discussion This study has several interesting findings. Compared to ONF, LNF shortened the mean operating time and the mean overall operating room duration. The LNF group also required less morphine and dramatically shortened the mean hospital stay duration by more than four days. Furthermore, the total cost for LNF was 39% lower while no difference was seen in postoperative results between the two groups. Three randomized trials comparing LNF and ONF in children have previously been published 6 , 7 , 10 . All of them found that LNF was associated with significant longer operating time than ONF. The study by Papandria et al. 10 also declared that the LNF group had longer overall operating room duration. In our study however, laparoscopy was found to shorten both the operating time and the overall operating room duration. In the previously published studies, the mean operating times were 160 minutes 7 , 150 minutes 6 and 173 minutes 10 in the LNF group, and 80 minutes 7 89 minutes 6 and 91 minutes 10 in the ONF group. Thus, our mean operating time for the LNF group was in line with the operating times in the previously published studies, although our data includes a learning curve for performing surgeons, as the LNF technique was introduced at our centre during this study. However, our mean operating time for the ONF group was substantially longer than reported in the previous studies. ONF however had been performed for several years before the first patients in our study were operated, and consequently two of the surgeons were already well experienced with the operative technique. The third surgeon started performing ONFs during the study period, wherefore that learning curve is included in the ONF group. Nevertheless, it should be noted that all surgeons performing the LNFs in our study were already experienced laparoscopists when they started with the LNFs. The previous laparoscopic experience among the surgeons might explain our short operating times, despite the included learning curve for LNF. One factor that possibly could affect our results is that four different surgeons performed the operations. Consequently, the surgeons’ individual skills and rapidity could cause the variation in time. On the other hand, two of the four surgeons performed both the ONFs and the LNFs, hence the individual factor should not be the only cause for the difference in operating time and overall operating room duration. Furthermore, different surgeons have also performed the fundoplications in the three previous studies. This additionally confirms the theory that the individual skill of the surgeon should not affect the results to a great extent. Moreover, another important factor to consider is that our study was retrospective. This caused difficulty in identifying the correct operating times and overall operating room durations, especially for the patients who underwent simultaneous operations or procedures in connection with the Nissen fundoplication. This was particularly difficult for the operations executed before the autumn of 2016, since a new electronic system for registration of surgery was introduced at our hospital. Consequently, this would mainly affect the operating times and overall operating room durations for the ONF group since these operations were all executed before 2016 and 71% of the patients in the ONF group underwent simultaneous operations or procedures, in comparison with 44% in the LNF group. Thus, this could contribute to the difference in operating time and overall operating room duration between the ONF and LNF group in our study. It is well-recognized among surgeons that laparoscopic surgery in general is associated with shorter postoperative hospital stay 11 . In this study, LNF shortened the hospital stay of 4.3 days compared to ONF. In the previous publications, the median hospital stay was 5.0, 7.0, and 6.0 days respectively for the LNF group and 4.5, 7.5, and 4.0 days for the ONF group 6 , 7 , 10 . Accordingly, our study is from what we know the only study demonstrating a dramatically shorter hospital stay for LNF, due to a more rapid patient recovery. Our study also demonstrates decreased costs for the laparoscopy group. Previous studies 6 , 7 did not analyze the costs for GERD surgery. One study found higher operating room costs for LNF, but no difference in total hospital charges between the groups 10 . The main reason for the distinct difference in mean total hospital charges between the two groups in our study, is due to the shorter hospital stay for LNF group. It was also a slightly higher proportion of patients who needed intensive care after ONF, which also increased the costs for that group. Even though the surgical material and equipment was more expensive for LNF, this difference was negligible in the full cost summation. In contrast to the previous randomized trials 7 , 10 , LNF significantly decreased the mean morphine requirements in our study. Hence, our study seems to be the first study published during the last decade that has registered less use of morphine after LNF. It is well-recognized among surgeons that laparoscopy in general is associated with less postoperative pain 12 . In terms of complications after the operation, the previously published studies have presented ambiguous results. Retching was significant more common after ONF 7 , and the difference still remained after four years in the follow-up study 13 . No difference was seen in early complications between the groups 6 , 10 , whereas a follow-up study 4 registered both a higher recurrence rate of GERD and a higher rate of reoperation after LNF. As to our study, no significant difference was seen between the groups in incidence of both postoperative and post-discharge complications. Postoperative investigation was only performed if the patient showed symptoms of recurrence of GERD or was part of a follow-up program for another medical condition (for example long gap esophageal atresia). Only one patient in the LNF group suffered from symptoms of GERD and this patient was also diagnosed with recurrence and re-operated six months after the initial Nissen fundoplication. Of the patients suffering from symptoms of GERD in the ONF group, only one patient was diagnosed with recurrence of GERD by pH-monitoring. Conclusion The present study clearly indicates advantages with LNF over ONF: shorter operating time, shorter total hospital stay and faster recovery, less morphine requirements and lower overall cost, at equal postoperative outcomes. Our results clearly indicates that laparoscopy should be the preferred technique for Nissen fundoplication in children. Declarations Conflicts of interest: The authors declared no conflicts of interest with respect to the research, authorship or publication of this article. Funding : The authors did not receive any financial support for the research, authorship or publication of this article. Author Contribution NH wrote and finalised the main manuscript.AW did the first manuscript draft.JD did the statistics and figures.EG reviewed the final manuscript. References Nissen R. [A simple operation for control of reflux esophagitis]. Schweiz Med Wochenschr 1956; 86: 590-592. 1956/05/18. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1: 138-143. 1991/09/01. Lobe TE, Schropp KP and Lunsford K. Laparoscopic Nissen fundoplication in childhood. J Pediatr Surg 1993; 28: 358-360; discussion 360-351. 1993/03/01. Fyhn TJ, Knatten CK, Edwin B, et al. Randomized Controlled Trial of Laparoscopic and Open Nissen Fundoplication in Children. Ann Surg 2015; 261: 1061-1067. 2015/08/21. DOI: 10.1097/SLA.0000000000001045. Kellokumpu I, Voutilainen M, Haglund C, et al. Quality of life following laparoscopic Nissen fundoplication: assessing short-term and long-term outcomes. World J Gastroenterol 2013; 19: 3810-3818. 2013/07/11. DOI: 10.3748/wjg.v19.i24.3810. Knatten CK, Fyhn TJ, Edwin B, et al. Thirty-day outcome in children randomized to open and laparoscopic Nissen fundoplication. J Pediatr Surg 2012; 47: 1990-1996. 2012/11/21. DOI: 10.1016/j.jpedsurg.2012.05.038. McHoney M, Wade AM, Eaton S, et al. Clinical outcome of a randomized controlled blinded trial of open versus laparoscopic Nissen fundoplication in infants and children. Ann Surg 2011; 254: 209-216. 2011/07/05. DOI: 10.1097/SLA.0b013e318226727f. Ru W, Wu P, Feng S, et al. Laparoscopic versus open Nissen fundoplication in children: A systematic review and meta-analysis. J Pediatr Surg 2016; 51: 1731-1736. 2016/08/16. DOI: 10.1016/j.jpedsurg.2016.07.012. Zhang P, Tian J, Jing L, et al. Laparoscopic vs. open Nissen's fundoplication for gastro-oesophageal reflux disease in children: A meta-analysis. Int J Surg 2016; 34: 10-16. 2016/10/21. DOI: 10.1016/j.ijsu.2016.08.017. Papandria D, Goldstein SD, Salazar JH, et al. A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age. J Pediatr Surg 2015; 50: 267-271. 2015/02/02. DOI: 10.1016/j.jpedsurg.2014.11.014. Billingham MJ and Basterfield SJ. Pediatric surgical technique: laparoscopic or open approach? A systematic review and meta-analysis. Eur J Pediatr Surg 2010; 20: 73-77. 2009/11/03. DOI: 10.1055/s-0029-1241871. Darzi SA and Munz Y. The impact of minimally invasive surgical techniques. Annual review of medicine 2004; 55: 223-237. 2004/01/30. DOI: 10.1146/annurev.med.55.091902.105248. Pacilli M, Eaton S, McHoney M, et al. Four year follow-up of a randomised controlled trial comparing open and laparoscopic Nissen fundoplication in children. Arch Dis Child 2014; 99: 516-521. 2014/02/18. DOI: 10.1136/archdischild-2013-304279. Tables Table 1. Indications for GERD-surgery. LNF (n=18) ONF (n=14) p Recurrent vomiting; n (%) 16 (89%) 11 (79%) 0.38 Aspiration pneumonia; n (%) 7 (39%) 5 (36%) 0.57 Esophagitis; n (%) 9 (50%) 9 (64%) 0.33 Failure to thrive; n (%) 6 (33%) 6 (43%) 0.43 Apnea; n (%) 2 (11%) 2 (14%) 1.00 Table 2. Performed preoperative investigations LNF (n=18) ONF (n=14) p Endoscopy (+/- biopsies); n (%) 17 (94%) 11 (79%) 0.30 Esophageal pH monitoring; n (%) 17 (94%) 11 (79%) 0.30 Upper GI series; n (%) 11 (61%) 10 (71%) 0.71 Gastric emptying scintigraphy; n (%) 6 (33%) 3 (21%) 0.69 Table 3. Pathological findings in the preoperative investigations. LNF ONF p Endoscopy (+/- biopsies); n/total (%) 9/17 (53%) 9/11 (82%) 0.23 Esophageal pH monitoring; n/total (%) 16/17 (94%) 6/11 (55%) <0.05 Upper GI series; n/total (%) 0/11 (0%) 0/10 (0%) 1.00 2/6 (33%) 1/3 (33%) 1.00 Table 4. No difference was seen between groups regarding postoperative complications, except GERD symtoms that was reported more frequently in ONF group. LNF (n=18) ONF (n=13) P Retching; n (%) 4 (22%) 3 (23%) 1.00 Dysphagia; n (%) 6 (33%) 5 (38%) 1.00 GERD symptoms; n (%) 1 (6%) 5 (38%) 0.06 Diagnosed GERD; n (%) 1 (6%) 2 (15%) 0.57 Reoperation; n (%) 1 (6%) 0 (0%) 1.00 Dilation; n (%) 1 (6%) 1 (8%) 1.00 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Jan, 2025 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Revision requested 29 Oct, 2024 Reviews received at journal 29 Oct, 2024 Reviews received at journal 28 Oct, 2024 Reviewers agreed at journal 21 Oct, 2024 Reviewers agreed at journal 20 Oct, 2024 Reviewers invited by journal 20 Oct, 2024 Editor assigned by journal 15 Oct, 2024 Submission checks completed at journal 15 Oct, 2024 First submitted to journal 09 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5231314","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371923307,"identity":"ee9a555d-1a20-4359-844a-780f762354fe","order_by":0,"name":"Niclas Högberg","email":"data:image/png;base64,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","orcid":"","institution":"Uppsala University","correspondingAuthor":true,"prefix":"","firstName":"Niclas","middleName":"","lastName":"Högberg","suffix":""},{"id":371923309,"identity":"df6b36be-d294-4e41-8431-c76412501346","order_by":1,"name":"Johan Danielson","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Johan","middleName":"","lastName":"Danielson","suffix":""},{"id":371923311,"identity":"9e8aa680-b03b-46a1-8d6b-a940489fb251","order_by":2,"name":"Amanda Westblom","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Westblom","suffix":""},{"id":371923313,"identity":"c913851b-d9ea-4ef7-8878-82b3f67116ae","order_by":3,"name":"Elisabet Gustafson","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Elisabet","middleName":"","lastName":"Gustafson","suffix":""}],"badges":[],"createdAt":"2024-10-09 09:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5231314/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5231314/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-025-05968-1","type":"published","date":"2025-01-16T15:57:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71727302,"identity":"130d52b9-18ca-4ea6-8f71-9bba01a7fe27","added_by":"auto","created_at":"2024-12-18 06:22:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11071,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMean operating time was shorter for LNF vs ONF, p\u0026lt; 0.05.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5231314/v1/d569ac23392ad19b222a03c2.png"},{"id":71727300,"identity":"7fa51a8d-6d08-42cb-87e7-e374f507b6ac","added_by":"auto","created_at":"2024-12-18 06:22:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17426,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe mean total operating room duration was shorter for the LNF than ONF, p\u0026lt;0.05.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5231314/v1/6cc06db308f9b1d226f5cc5c.png"},{"id":71726524,"identity":"10ae0ebb-af9b-41c1-bf17-1831000af705","added_by":"auto","created_at":"2024-12-18 06:14:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":13960,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMean postoperative hospital stay was shorter for LNF \u0026nbsp;\u0026nbsp;vs ONF, p\u0026lt;0.05.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5231314/v1/c56d0b3e9ff5a0463f84709f.png"},{"id":71726527,"identity":"ea83dcf0-4add-4ba5-ae0b-171d970ac65e","added_by":"auto","created_at":"2024-12-18 06:14:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":17439,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe mean intravenous morphine requirement was lower for the LNF group than for the ONF group, p\u0026lt;0.05.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5231314/v1/ef656e18ccd599053b664ff1.png"},{"id":71727301,"identity":"1d428eee-557a-403d-a5ca-8d21b0781b90","added_by":"auto","created_at":"2024-12-18 06:22:29","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":19868,"visible":true,"origin":"","legend":"\u003cp\u003eMean total hospital cost was 39% lower for LNF vs ONF, p\u0026lt;0.05.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5231314/v1/1560813b521245baa5532c7c.png"},{"id":74284709,"identity":"661b3412-cf02-4ec2-814c-9b1c2073d45e","added_by":"auto","created_at":"2025-01-20 16:11:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":556815,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5231314/v1/e9350209-446e-4bd4-87df-799194af3992.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eHealth benefits and economical aspects on laparoscopic vs open Nissen fundoplication in children\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFundoplication for the treatment of gastroesophageal reflux disease (GERD) was first described by Rudolph Nissen in 1956 \u003csup\u003e1\u003c/sup\u003e. Since then, several alternative techniques have been proposed, but Nissen\u0026rsquo;s original open procedure (ONF) is still one of the most widely used methods in surgical practice today. With the evolution of laparoscopy, it became technically feasible to adapt the original technique to a laparoscopic approach. The first paper on laparoscopic Nissen fundoplication (LNF) in adults was published in 1991 \u003csup\u003e2\u003c/sup\u003e and the first publication on LNF performed in paediatric surgery soon followed in 1993 \u003csup\u003e3\u003c/sup\u003e. Several studies of single-centre experiences, as well as randomised studies, have been published on this subject \u003csup\u003e2, 4-7\u003c/sup\u003e. The conclusion from these studies varies and the main concern is whether the risk of recurrence of gastroesophageal reflux is higher in patients operated with LNF, which has been reported in some studies \u003csup\u003e4\u003c/sup\u003e. \u0026nbsp;Recent reviews on the subject \u003csup\u003e8, 9\u003c/sup\u003e conclude that LNF is an effective surgical alternative to ONF for gastroesophageal reflux in children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2014 we performed our first LNF and in 2016 we decided to use LNF as the standard operative procedure for patients with GERD at our tertiary center for pediatric surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAims\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe aims of this study were to investigate any differences between LNF and ONF in 1. Operative and total theatre time 2. Length of hospital stay 3. The amount of administered morphine during hospital stay 4. Total costs for surgery and hospital stay 5. Complications and results.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe operative registry at the department of paediatric surgery, Uppsala University hospital, Sweden, was investigated for patients \u0026lt;18 years of age operated with Nissen fundoplication for GERD between January 2011 and December 2017. A total of 32 patients were included in the study. The data was accessed between january 15\u003csup\u003eth\u003c/sup\u003e 2018 to may 19\u003csup\u003eth\u003c/sup\u003e 2018. The authors had access to patients charts, and therefore individual patients could be identified during data collection.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient characteristics and indications for surgery\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e18 patients were operated with LNF (2016-2017) and 14 patients with ONF (2011-2015). The indications for surgery are summarized in Table 1. Each patient could have several indications for surgery. No difference was seen in patient characteristics regarding sex, age, weight or indications for GERD-surgery between the two groups (p\u0026gt;0.05). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePreoperative investigation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe preoperative investigations are presented in Table 2, and the pathological findings are presented in Table 3. The preoperative workup was more stringent in the LNF-group but there was no difference in the incidence of performed preoperative investigations (p\u0026gt;0.05). \u0026nbsp;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgical technique\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor laparoscopic procedures, patients were operated in the prone position with the surgeon standing between the legs of the patient. A 5mm port was introduced in the umbilicus with open technique and pneumoperitoneum was established. Two 5mm ports were introduced, one to the right of the umbilicus and one in the left flank. \u0026nbsp;A 7-8mm STEP-port was introduced between the port in the left flank and the umbilicus. A 5mm trocar was then used to make a wound in the epigastrium, through this wound a Nathanson retractor was introduced and used to retract the liver. The camera was introduced in the umbilical port and the assistant used the left lateral port. The head of the table was elevated to facilitate access to the operative area. Any existing gastrostomy was left in place.\u003c/p\u003e\n\u003cp\u003eFor open procedures, patients were operated in the prone position. An upper midline incision was performed, and retractors were applied to the liver and abdominal wall. Any existing gastrostomy was temporarily taken down.\u003c/p\u003e\n\u003cp\u003eThe medial aspect of the gastroesophageal junction (GEJ) was then dissected with electrocautery to visualize the left crus. Dissection was continued on the anterior side of the GEJ and then on the lateral side until the right crus was identified. Care was taken to identify and avoid damage to the vagal nerves. A retroesophageal window was created, and a cruroplasty was created with two or three 3:0 braided non-absorbable interrupted sutures (Ethibond, Ehicon). The fundus of the stomach was mobilised from the spleen by dividing the short gastric vessels. When the fundus was deemed mobilised enough, the fundus was pulled through the retroesophageal window to perform a 360-degree wrap. Three interrupted, braided non-absorbable 3:0 sutures (Ethibond, Ethicon) were used to create the wrap and fasten it to the anterior part of the esophagus. A fourth suture was put in the anterior part of the wrap and secured to the anterior part of the diaphragm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor laparoscopic procedures, all ports were taken out under laparoscopic vision and the fascia and subcutis was closed with absorbable sutures. Tissue glue was used to close the skin. For open procedures, incision was closed in layers with absorbable sutures in fascia, subcutis and skin, with a wound catheter placed under the fascia. \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical considerations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Regional Ethical Committee at Uppsala University, Uppsala, Sweden, approval number 2018/042. The approval did not require individual patient/family consent since the study was based on register data. \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Methods\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eValues are presented as proportions, means, medians or range as appropriate. Fisher\u0026acute;s two-tailed exact test was used to compare proportions. The Mann-Whitney U-test was used for unpaired comparisons. A p-value of less than 0.05 was considered statistically significant. Statistica 13.2 software (Dell, Tulsa, USA) was used for the statistical analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cem\u003ePerioperative parameters\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe perioperative parameters are presented in Figures 1, 2 and Table 4. Mean operating time and overall operating room duration was shorter for the LNF group compared to in the ONF group (p\u0026lt;0.05). However, more patients in the ONF group underwent simultaneous operations or procedures; 8 patients in the LNF group (44%) and 10 patients in the ONF group (71%), (p\u0026lt;0.05). These included insertion of gastrostomy (n=11), insertion of central venous catheter (n=4), insertion of venous port (n=2), teeth inspection (n=2), incisional hernia repair (n=1), Morgagni-Larrey hernia repair (n=1), adenoidectomy (n=1), Botox injection in peripheral muscles (n=1), loop ileostomy (n=1), removal of jejunostomy (n=1), recanalization of venous port (n=1), change of jejunal tube (n=1) and endoscopic dilation of esophagus (n=1).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003ePostoperative parameters\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe postoperative parameters are presented in Figures 3, 4 and Table 4. No difference was seen between the two groups in requirement of intensive care. Mean postoperative hospital stay was 3.8 days in the LNF group and 8.1 days in the ONF group. The analgesic measures were registered as presence of wound catheter and requirement of intravenous morphine. All patients in the ONF group (100%) and no patient in the LNF group (0%) were given a wound catheter. Mean morphine requirement was lower in the LNF group compared to the ONF group (1.2mg/kg vs. 1.7 mg/kg, p\u0026lt; 0.05. Two patients in the LNF group (11%) and one patient in the ONF group (7%) suffered from postoperative infection (p\u0026gt;0.05).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eComplications\u003c/em\u003e\u003cem\u003e\u0026nbsp;and follow-up\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAll patients were followed-up either by return visit, phone call, video conference or a combination of methods. The time for follow-up was not standardized, but all patients had at least one return visit or phone call. After that, continued follow-up was based on clinical symptoms. No difference in follow-up was seen between the two groups. One patient in the ONF group died 6 months after the operation, unrelated to the fundoplication. This patient was therefore not available for follow-up and is excluded from these results.\u003c/p\u003e\n\u003cp\u003eThe postoperative complications are presented in Table 4. No difference was seen regarding retching, dysphagia, or need of dilatation or redo fundoplication. The symptomatic incidence of recurrent GERD was higher in ONF-group, but could not be confirmed by pH-monitoring where no difference was seen between the groups.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eEconomical aspects, total c\u003c/em\u003e\u003cem\u003eost\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe total hospital charges are presented in Figure 5 and Table 6. For each patient, the total cost was calculated based on the local billing charges for the operation (operating time, anesthesia, surgical material, wound catheter) and hospital stay (days in hospital, time in recovery room, admittance at an intensive care unit). Mean total costs were 261.1 kSEK (approximately 26.1 kEuro) in the LNF group and 427.4 kSEK (approximately 42.74 kEuro) in the ONF group. Mean cost was 166.3 kSEK (approximately 16.63 kEuro) or 39% lower for LNF than for ONF (p\u0026lt;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study has several interesting findings. Compared to ONF, LNF shortened the mean operating time and the mean overall operating room duration. The LNF group also required less morphine and dramatically shortened the mean hospital stay duration by more than four days. Furthermore, the total cost for LNF was 39% lower while no difference was seen in postoperative results between the two groups.\u003c/p\u003e \u003cp\u003eThree randomized trials comparing LNF and ONF in children have previously been published \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. All of them found that LNF was associated with significant longer operating time than ONF. The study by Papandria et al. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e also declared that the LNF group had longer overall operating room duration. In our study however, laparoscopy was found to shorten both the operating time and the overall operating room duration. In the previously published studies, the mean operating times were 160 minutes \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, 150 minutes \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e and 173 minutes \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e in the LNF group, and 80 minutes \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e 89 minutes \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e and 91 minutes \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e in the ONF group. Thus, our mean operating time for the LNF group was in line with the operating times in the previously published studies, although our data includes a learning curve for performing surgeons, as the LNF technique was introduced at our centre during this study. However, our mean operating time for the ONF group was substantially longer than reported in the previous studies.\u003c/p\u003e \u003cp\u003eONF however had been performed for several years before the first patients in our study were operated, and consequently two of the surgeons were already well experienced with the operative technique. The third surgeon started performing ONFs during the study period, wherefore that learning curve is included in the ONF group. Nevertheless, it should be noted that all surgeons performing the LNFs in our study were already experienced laparoscopists when they started with the LNFs. The previous laparoscopic experience among the surgeons might explain our short operating times, despite the included learning curve for LNF. One factor that possibly could affect our results is that four different surgeons performed the operations. Consequently, the surgeons\u0026rsquo; individual skills and rapidity could cause the variation in time. On the other hand, two of the four surgeons performed both the ONFs and the LNFs, hence the individual factor should not be the only cause for the difference in operating time and overall operating room duration. Furthermore, different surgeons have also performed the fundoplications in the three previous studies. This additionally confirms the theory that the individual skill of the surgeon should not affect the results to a great extent.\u003c/p\u003e \u003cp\u003eMoreover, another important factor to consider is that our study was retrospective. This caused difficulty in identifying the correct operating times and overall operating room durations, especially for the patients who underwent simultaneous operations or procedures in connection with the Nissen fundoplication. This was particularly difficult for the operations executed before the autumn of 2016, since a new electronic system for registration of surgery was introduced at our hospital. Consequently, this would mainly affect the operating times and overall operating room durations for the ONF group since these operations were all executed before 2016 and 71% of the patients in the ONF group underwent simultaneous operations or procedures, in comparison with 44% in the LNF group. Thus, this could contribute to the difference in operating time and overall operating room duration between the ONF and LNF group in our study.\u003c/p\u003e \u003cp\u003eIt is well-recognized among surgeons that laparoscopic surgery in general is associated with shorter postoperative hospital stay \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this study, LNF shortened the hospital stay of 4.3 days compared to ONF. In the previous publications, the median hospital stay was 5.0, 7.0, and 6.0 days respectively for the LNF group and 4.5, 7.5, and 4.0 days for the ONF group \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Accordingly, our study is from what we know the only study demonstrating a dramatically shorter hospital stay for LNF, due to a more rapid patient recovery.\u003c/p\u003e \u003cp\u003eOur study also demonstrates decreased costs for the laparoscopy group. Previous studies \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e did not analyze the costs for GERD surgery. One study found higher operating room costs for LNF, but no difference in total hospital charges between the groups \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe main reason for the distinct difference in mean total hospital charges between the two groups in our study, is due to the shorter hospital stay for LNF group. It was also a slightly higher proportion of patients who needed intensive care after ONF, which also increased the costs for that group. Even though the surgical material and equipment was more expensive for LNF, this difference was negligible in the full cost summation.\u003c/p\u003e \u003cp\u003eIn contrast to the previous randomized trials \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, LNF significantly decreased the mean morphine requirements in our study. Hence, our study seems to be the first study published during the last decade that has registered less use of morphine after LNF. It is well-recognized among surgeons that laparoscopy in general is associated with less postoperative pain \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of complications after the operation, the previously published studies have presented ambiguous results. Retching was significant more common after ONF \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, and the difference still remained after four years in the follow-up study \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. No difference was seen in early complications between the groups \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, whereas a follow-up study \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e registered both a higher recurrence rate of GERD and a higher rate of reoperation after LNF. As to our study, no significant difference was seen between the groups in incidence of both postoperative and post-discharge complications. Postoperative investigation was only performed if the patient showed symptoms of recurrence of GERD or was part of a follow-up program for another medical condition (for example long gap esophageal atresia). Only one patient in the LNF group suffered from symptoms of GERD and this patient was also diagnosed with recurrence and re-operated six months after the initial Nissen fundoplication. Of the patients suffering from symptoms of GERD in the ONF group, only one patient was diagnosed with recurrence of GERD by pH-monitoring.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study clearly indicates advantages with LNF over ONF: shorter operating time, shorter total hospital stay and faster recovery, less morphine requirements and lower overall cost, at equal postoperative outcomes. Our results clearly indicates that laparoscopy should be the preferred technique for Nissen fundoplication in children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors declared no conflicts of interest with respect to the research, authorship or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors did not receive any financial support for the research, authorship or \u0026nbsp; publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNH wrote and finalised the main manuscript.AW did the first manuscript draft.JD did the statistics and figures.EG reviewed the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNissen R. [A simple operation for control of reflux esophagitis]. \u003cem\u003eSchweiz Med Wochenschr\u003c/em\u003e 1956; 86: 590-592. 1956/05/18.\u003c/li\u003e\n\u003cli\u003eDallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. \u003cem\u003eSurg Laparosc Endosc\u003c/em\u003e 1991; 1: 138-143. 1991/09/01.\u003c/li\u003e\n\u003cli\u003eLobe TE, Schropp KP and Lunsford K. Laparoscopic Nissen fundoplication in childhood. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e 1993; 28: 358-360; discussion 360-351. 1993/03/01.\u003c/li\u003e\n\u003cli\u003eFyhn TJ, Knatten CK, Edwin B, et al. Randomized Controlled Trial of Laparoscopic and Open Nissen Fundoplication in Children. \u003cem\u003eAnn Surg\u003c/em\u003e 2015; 261: 1061-1067. 2015/08/21. DOI: 10.1097/SLA.0000000000001045.\u003c/li\u003e\n\u003cli\u003eKellokumpu I, Voutilainen M, Haglund C, et al. Quality of life following laparoscopic Nissen fundoplication: assessing short-term and long-term outcomes. \u003cem\u003eWorld J Gastroenterol\u003c/em\u003e 2013; 19: 3810-3818. 2013/07/11. DOI: 10.3748/wjg.v19.i24.3810.\u003c/li\u003e\n\u003cli\u003eKnatten CK, Fyhn TJ, Edwin B, et al. Thirty-day outcome in children randomized to open and laparoscopic Nissen fundoplication. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e 2012; 47: 1990-1996. 2012/11/21. DOI: 10.1016/j.jpedsurg.2012.05.038.\u003c/li\u003e\n\u003cli\u003eMcHoney M, Wade AM, Eaton S, et al. Clinical outcome of a randomized controlled blinded trial of open versus laparoscopic Nissen fundoplication in infants and children. \u003cem\u003eAnn Surg\u003c/em\u003e 2011; 254: 209-216. 2011/07/05. DOI: 10.1097/SLA.0b013e318226727f.\u003c/li\u003e\n\u003cli\u003eRu W, Wu P, Feng S, et al. Laparoscopic versus open Nissen fundoplication in children: A systematic review and meta-analysis. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e 2016; 51: 1731-1736. 2016/08/16. DOI: 10.1016/j.jpedsurg.2016.07.012.\u003c/li\u003e\n\u003cli\u003eZhang P, Tian J, Jing L, et al. Laparoscopic vs. open Nissen\u0026apos;s fundoplication for gastro-oesophageal reflux disease in children: A meta-analysis. \u003cem\u003eInt J Surg\u003c/em\u003e 2016; 34: 10-16. 2016/10/21. DOI: 10.1016/j.ijsu.2016.08.017.\u003c/li\u003e\n\u003cli\u003ePapandria D, Goldstein SD, Salazar JH, et al. A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e 2015; 50: 267-271. 2015/02/02. DOI: 10.1016/j.jpedsurg.2014.11.014.\u003c/li\u003e\n\u003cli\u003eBillingham MJ and Basterfield SJ. Pediatric surgical technique: laparoscopic or open approach? A systematic review and meta-analysis. \u003cem\u003eEur J Pediatr Surg\u003c/em\u003e 2010; 20: 73-77. 2009/11/03. DOI: 10.1055/s-0029-1241871.\u003c/li\u003e\n\u003cli\u003eDarzi SA and Munz Y. The impact of minimally invasive surgical techniques. \u003cem\u003eAnnual review of medicine\u003c/em\u003e 2004; 55: 223-237. 2004/01/30. DOI: 10.1146/annurev.med.55.091902.105248.\u003c/li\u003e\n\u003cli\u003ePacilli M, Eaton S, McHoney M, et al. Four year follow-up of a randomised controlled trial comparing open and laparoscopic Nissen fundoplication in children. \u003cem\u003eArch Dis Child\u003c/em\u003e 2014; 99: 516-521. 2014/02/18. DOI: 10.1136/archdischild-2013-304279.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cem\u003eTable 1. Indications for GERD-surgery.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eLNF (n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eONF (n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eRecurrent vomiting; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e16 (89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e11 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eAspiration pneumonia; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e7 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e5 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eEsophagitis; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e9 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e9 (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eFailure to thrive; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e6 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e6 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eApnea; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e2 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e2 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cem\u003eTable 2. Performed preoperative investigations\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eLNF (n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eONF (n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eEndoscopy (+/- biopsies); n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e17 (94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e11 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eEsophageal pH monitoring; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e17 (94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e11 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eUpper GI series; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e11 (61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e10 (71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eGastric emptying scintigraphy; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e6 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e3 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cem\u003eTable 3.\u0026nbsp;\u003c/em\u003e\u003cem\u003ePathological findings in the preoperative investigations.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eLNF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eONF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eEndoscopy (+/- biopsies); n/total (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e9/17 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e9/11 (82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eEsophageal pH monitoring; n/total (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e16/17 (94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e6/11 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eUpper GI series; n/total (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0/11 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e0/10 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e2/6 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e1/3 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eTable 4.\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNo difference was seen between groups regarding postoperative complications, except GERD symtoms that was reported more frequently in ONF group.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eLNF (n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eONF (n=13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eRetching; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e4 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e3 (23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eDysphagia; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e6 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e5 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eGERD symptoms; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e5 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eDiagnosed GERD; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e2 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eReoperation; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 310px;\"\u003e\n \u003cp\u003eDilation; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003e1 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"gastroesophageal reflux, GERD, laparoscopic, open, Nissen, fundoplication, cost","lastPublishedDoi":"10.21203/rs.3.rs-5231314/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5231314/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNissen fundoplication is one of the most common surgical procedures for gastroesophageal reflux. Current and previous research comparing laparoscopic Nissen fundoplication (LNF) versus open Nissen fundoplication (ONF) in children suggest ambiguous conclusions. The purpose of this retrospective study was to compare the outcome for children operated with LNF or ONF at our institution, and to evaluate the economic aspects.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e32 consecutive patients (LNF: n\u0026thinsp;=\u0026thinsp;18, ONF: n\u0026thinsp;=\u0026thinsp;14) operated with Nissen fundoplication between the years 2011\u0026ndash;2017 were included in the study. Data was collected by examination of the patient journals and preoperative, operative, postoperative, and post-discharge parameters were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCompared to ONF, the LNF group had shorter operating time (165.2 vs 216.6 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), shorter overall operating room duration (315.0 vs 334.9 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and shorter postoperative hospital stay (3.8 vs 8.1 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The LNF group also required less morphine (1.2 vs 1.7 mg/kg, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the total cost per case was 39% lower (261.1 vs 427.4 kSEK, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No difference was seen in postoperative complications and results.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLaparoscopic Nissen fundoplication is more beneficial for patients compared to open surgery, and at a lower cost.\u003c/p\u003e","manuscriptTitle":"Health benefits and economical aspects on laparoscopic vs open Nissen fundoplication in children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 06:14:24","doi":"10.21203/rs.3.rs-5231314/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-29T20:10:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-29T20:01:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-28T18:25:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152903841162089280035924020219190968859","date":"2024-10-21T05:48:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103637970549465210565755598956173617425","date":"2024-10-20T17:27:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-20T16:11:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-15T19:35:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-15T18:49:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2024-10-09T09:26:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"af4694a4-e691-45dd-bba6-22d2422a5cb8","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:04:54+00:00","versionOfRecord":{"articleIdentity":"rs-5231314","link":"https://doi.org/10.1007/s00383-025-05968-1","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2025-01-16 15:57:03","publishedOnDateReadable":"January 16th, 2025"},"versionCreatedAt":"2024-12-18 06:14:24","video":"","vorDoi":"10.1007/s00383-025-05968-1","vorDoiUrl":"https://doi.org/10.1007/s00383-025-05968-1","workflowStages":[]},"version":"v1","identity":"rs-5231314","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5231314","identity":"rs-5231314","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}