Gastroesophageal fundoplication for reflux in infants and children

Do antireflux operations decrease the rate of reflux-related hospitalizations in children?

OBJECTIVE

Gastroesophageal reflux disease is extremely common in the pediatric population, and antireflux procedures are performed with increasing frequency. The objective of this study was to determine whether pediatric antireflux procedures are associated with a decreased rate of reflux-related hospitalizations.

METHODS

A study was conducted of pediatric patients who were undergoing antireflux procedures using data that were derived from the Washington State Comprehensive Hospital Abstract Reporting System and Vital Records. Patients were identified by a search of all records (1987-2001) for procedure codes that pertained to antireflux procedures in patients who were younger than 19 years. The number of hospitalizations for and rates of reflux-related events per patient-year before and after an antireflux procedure was calculated, and factors that were associated with higher antireflux procedure rates were examined.

RESULTS

A total of 1142 patients underwent antireflux procedures. The rate of reflux-related events declined sharply with age both before and after an antireflux procedure. The cohort was divided into 3 groups on the basis of age at first antireflux procedure (<1 year, 1-3 years, or 4-19 years), and the calculations of incidence rate ratios before to after an antireflux procedure were done within the same age strata. Results suggest an overall benefit of antireflux procedures in young children. For antireflux procedures that were performed in children who were older than 4 years, the benefit is less clear. Developmental delay was significantly associated with higher rates of reflux-related events among patients who underwent an antireflux procedure after age 4.

CONCLUSIONS

The rate of reflux-related events was lower after an antireflux operation for children who underwent an antireflux procedure before age 4. Older children, however, were hospitalized at equal rates before and after an antireflux procedure, and older children with developmental delay were hospitalized at greater rates after an antireflux procedure. These findings highlight the need to clarify the subjective and objective indications for antireflux procedures in infants and children.

Gastroesophageal reflux in childhood

Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.

Fundoplication and pediatric esophageal manometry: actuarial analysis over 7 years

Sixty-one children and infants who had significant gastroesophageal reflux and associated complications underwent 73 surgical procedures to control the reflux. In order to evaluate the procedure, several esophageal manograms were obtained from each patient, before, during, and after the operation. Delayed follow-up reports were also obtained from follow-up visits, letter and telephone contact, in order to assess how the patient had progressed. The results were evaluated by actuarial analytic methods. Ninety-four percent of the patients remained alive over the 7-year follow-up period. At the completion of the seventh year, 62% of these patients (actuarially calculated) remained event free. All events occurred within 18 months of surgery. One patient could not be traced at long-term follow-up, which was therefore 92% complete. The 7-year actuarial probability of failure of the fundoplication at this institution is 24% when performed using this technique in these patients. These findings support that manometric calibration of the antireflux procedure tends to give uniform results in pediatric patients, but, compared with other published series has not proved to be superior to procedures that employ only a rubber bougie in the esophagus as an obdurator to prevent a repair that will be too tight.

Gastric infarction secondary to small bowel obstruction: a preventable complication after Nissen fundoplication

Two infants who required a Nissen fundoplication for severe gastroesophageal reflux developed small bowel obstruction 5 and 21 months postoperatively. Their inability to belch or vomit, coupled with inappropriate airway management during resuscitation led to massive gastric dilation, and eventual infarction of their stomach, duodenum, and small intestines. These complications are preventable with appropriate management.

Follow-up examinations of conservatively and surgically treated children with hiatus hernia

Between 1966 and 1976, 65 infants and children were treated because of hiatus hernia. The diagnosis was made radiologically in all cases and in a number of patients endoscopically. 54 patients had a forme mineure (types 1 and 2), and 11 had a forme majeure (types 3 and 4). Of the 20 patients with type 1, 16 (80%) were successfully treated conservatively; two further patients needed a secondary operation. Of 34 children with type 2, 15 (44%) were treated successfully conservatively, and four needed a secondary operation. Of ten patients with type 3, four (40%) were treated primarily conservatively with success. Two children with type 1, 11 with type 2, six with type 3, and one with type 4 had to be operated on primarily because of severe esophagitis at the time of admission. From 14 mon to 10 years after discharge from hospital, follow-up examination of 33 patients showed that one child died from another cause. In 14 of the 21 conservatively treated patients and in 12 of the 18 surgically treated patients (66% in both cases), there were no symptoms or complaints. Eight had subjective complaints, but in only four (10.5%) was there a definite complaint. Three of these four patients had associated diseases (spastic tetraplegia, operated jejunal atresia). In these patients, esophagitis was present on follow-up examination and necessitated further treatment. The treatment of choice for the forme mineure without esophagitis should be conservative, and in most cases this will be sufficient. In only a few of these patients did it become necessary to carry out a secondary fundoplication. Operation is indicated primarily in cases with esophagitis and esophageal stenosis as well as in patients with a forme majeure of the hiatus hernia.

Follow-up studies on patients undergoing Nissen fundoplication utilizing intraoperative manometry

Intraoperative esophageal manometry has been developed for use in children as a guide to optimizing the surgical results of Nissen fundoplication. Eighty-two Nissen fundoplication operations were performed using intraoperative manometry. Follow-up manometry was performed within 6 wk postoperatively in 45 patients and later than 6 wk postoperatively in 33 patients. The mean preoperative lower esophageal sphincter pressure (LESP) was 13 mm Hg. The mean postoperative LESP was 42 mm Hg. LESP was found to drop in the early postoperative period nearly 40%. There was minimal further decline in LESP between the early and late follow-up determinations. Lower esophageal sphincter length (LESL) was measured both pre- and postoperatively in 56 patients with an average increase of 1.4 cm. There was a very mild decline in LESL in the late follow-up period. The clinical course of these patients was correlated with manometric findings. The routine use of gastrostomy has been found to be unnecessary.

Surgical management of reflux strictures of the esophagus in childhood

The etiology of gastroesophageal reflux (GER) in infancy is related to developmental factors, and there is a high incidence of associated conditions such as neurologic syndromes and esophageal atresia (60%). This is different from the situation in adults. Experience with 18 consecutive children with peptic esophageal strictures is reviewed to determine if conservative surgical management is effective. Eighteen children 14 months to 13 years (mean 6.3 years) of age took an average of 3.5 years from the time of onset of symptoms of GER to develop tight strictures diagnosed by esophagography and esophagoscopy. The incidence of stricture in patients with GER was approximately 15%. Preoperative dilation or direct surgical management prior to correction of reflux is ineffective. All 18 children were managed by intraoperative dilatation, Nissen fundoplication, and guided dilatation after operation. More aggressive surgical procedures were not required nor were associated operations such as pyloroplasty; they are rarely necessary. An average three-year follow-up indicates that this conservative surgical approach is effective in the management of peptic esophageal strictures in childhood with relief of symptoms and gratifying improvement in growth.

Surgical treatment of gastroesophageal reflux with esophageal stricture in infancy and childhood

During the past 5 years, 26 infants and children with gastroesophageal reflux were operated on. The results have been highly satisfactory and unattended by serious complications or mortality. Barium fluoroscopy was the most reliable diagnostic method. The indications for operation were persistent vomiting with failure to thrive, recurrent aspiration pneumonia, gastrointestinal bleeding and peptic stricture of the esophagus, not relieved by medical treatment. The high incidence of peptic stricture of the esophagus (50 percent) may reflect delay in diagnosis and medical treatment, which is successful in 60 to 87 percent of the infants with gastroesophageal reflux. Surgical treatment consisted of Nissen fundoplication combined with gastrostomy in cases of esophageal stenosis where dilatations were indicated. Complications related to the operation were minimal. In a follow-up period of 9 months to 5 years, all patients had obtained relief of symptoms of reflux and had excellent nutritional status and normal growth.

Long-term effect of Nissen fundoplication in young puppies

Nissen fundoplication effectively prevents gastroesophageal reflux in children. However, the long-term effect of this operation on the distal esophagus of infants and children is unknown, and a fear has been expressed that wrap-around operations on a small infant esophagus would constrict growth of the lower esophagus and cause late partial obstruction. In this study, the long-term effect of Nissen fundoplication was evaluated. There were 20, 1-2-wk-old puppies operated upon; 10 underwent Nissen fundoplication and 10 had only a sham operation to serve as a control group. Three puppies in each group had esophageal manometry and barium studies of the esophagus preoperatively and at various times postoperatively. The diameter of the esophagus was measured in all dogs during the operation. All fundoplications were done with a #20F dilator inside the esophagus. Two dogs in each group were sacrificed at 1, 2, and 3 yr of age, and the remainder were sacrificed at 4 yr of age. At autopsy, there was no difference in the diameter of the esophagus in the dogs with Nissen fundoplication compared with the sham-operated dogs. Barium studies in the fundoplicated group showed no dilation of the esophagus compared to the sham-operated group. Both groups grew normally and there were no differences in weight at the time of sacrifice. It seems that Nissen fundoplication does not affect growth of the distal esophagus in young puppies, and that body weight and linear growth are not altered by this operation.

Use of intraoperative esophageal manometrics in surgical treatment of gastroesophageal reflux in pediatric patients

Intraoperative lower esophageal sphincter (LES) pressures and lenghts were measured in 10 pediatric patients requiring surgery for compications of gastroesophageal reflux. LES pressure changed significantly pre- and post-Nissen fundoplication (9.8 +/- 1.51 mm Hg vs. 32.8 +/- 2.68 mm Hg, p less than 0.001). LES length also showed a significant change (1.3 +/- 0.13 cm vs. 2.8 +/- 0.26 cm, p less than 0.001). One week postoperatively LES pressures were significantly greater than preoperative values (26.4 +/- 1.74 mm Hg vs. 15.6 +/- 2.64 mm Hg, p less than 0.01). Eight of 10 patients have been evaluated 6 mo post fundoplication. None has gastroesophageal reflux by acid reflux testing or water siphon barium esophagram. None of the 10 patients has had gas bloat syndrome during the follow-up period.