Laparoscopic Nissen fundoplication in infants and children: analysis of 106 consecutive patients with special emphasis in neurologically impaired vs. neurologically normal patients.

BACKGROUND: The laparoscopic Nissen fundoplication has become a frequently performed procedure in infants and children who suffer from gastroesophageal reflux disease (GERD). In this study we describe our 8-year experience with 106 consecutive laparoscopic Nissen fundoplications. METHODS: From January 1994 to May 2002, we included 106 consecutive patients (57 neurologically normal (NN) and 49 neurologically impaired (NI)). The indications were symptomatic GERD, pulmonary symptoms or a combination of both. Patient's outcome was assessed by symptom evaluation, technical examinations and a questionnaire. RESULTS: Mortality was 0% and conversion rate was 2.8%. Major postoperative complications occurred in 12 patients, mostly neurologically impairment. Dysphagia occurred in 23 patients of which 4 required dilatations and 2 a redo Nissen. Gas bloating occurred in 15 children, with spontaneous regression in all. Recurrent pneumopathies were seen in four children. Documented recurrence of reflux occurred in three symptomatic patients. Redo laparoscopic surgery was performed in six patients. A questionnaire was sent to each patient's parents. This showed that most patients had a normal or clearly improved quality of life (93.1% NN, 90.5% NI). Most patients were satisfied with the result and up to 39.5% gave a maximum satisfaction score. CONCLUSION: The laparoscopic Nissen fundoplication can safely be performed with a low conversion rate and no surgical mortality in neurologically normal and neurologically impaired children. Neurologically impaired children are more susceptible to per- and postoperative complications. A good quality of life and a high index of satisfaction could be achieved in most patients.

Modulus of Natural Rubber Cross-Linked by Dicumyl Peroxide. I. Experimental Observations.

Natural rubber mixed with varying amounts of dicumyl peroxide was cross-linked by heating 120 min at 149 °C. The quantitative measure of cross-linking was taken as the amount fp of decomposed dicumyl peroxide, the product of p, the number of parts added per hundred of rubber and f the fraction decomposed during the time of cure. The shear creep modulus G was calculated from measurements of the indentation of a flat rubber sheet by a rigid sphere. The glass transition temperature T g , was raised about 1.2 °C for each part of decomposed dicumyl peroxide. Above (T g + 12) the modulus-temperature relations were linear with a slope that increased with increasing cross-linking. The creep rate was negligible except near the glass transition and at low values of fp. Values of G, read from these plots at seven temperatures, were plotted as a function of fp. The linearity of the two plots permits the derivation of the general relation: G = S(fp + B)T + H(fp + B) + A where A, B, H, and S are constants. The lines representing G as a function of fp at each temperature all intersected near the point, fp = 0.45 phr, G = 2.70 Mdyn cm-2 (0.270 MN m-2). The constants were evaluated as A = 2.70 Mdyn cm-2, B = -0.45 phr, S = 5.925 × 10-3 Mdyn cm-2(phr)-1K-1 and H = 0.0684 (Mdyn cm-2) (phr)-1. This equation represented satisfactorily all the data obtained at temperatures from -50 to +100 °C for values of fp from about 1 to 24 phr.