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Jacobson JC, Pandya SR. A narrative review of gastroesophageal reflux in the pediatric patient. Transl Gastroenterol Hepatol 2021; 6:34. [PMID: 34423155 DOI: 10.21037/tgh-20-245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/12/2020] [Indexed: 11/06/2022] Open
Abstract
Gastroesophageal reflux (GER) is the retrograde passage of gastric contents into the esophagus. It is a physiologic condition that is common in neonates, typically resolves spontaneously, and does not result in clinically significant complications. When pathologic, gastroesophageal reflux disease (GERD) can cause numerous complications including persistent emesis, failure to thrive, aspiration, and respiratory symptoms. While a diagnosis can often be made from a thorough history and physical, some patients may require further testing. In general, many clinicians will reserve extensive investigation such as multiple intraluminal impedance and pH monitoring for patients with a confounding clinical picture or relative contraindications to medical or surgical management. Whereas most pediatric GER resolves spontaneously, medical management including lifestyle changes, changes to feeds, and the use of H2-antagonists and/or proton pump inhibitors (PPIs) can be utilized to alleviate symptoms. Surgical treatment is reserved for patients who are refractory to medical management or have suffered significant complications as a consequence of GER. In this article we seek to provide a concise but detailed review of recent updates in the understanding, work up and management of GER in the pediatric patient. A summary of new technologies used in the diagnostic and therapeutic arms of this disease are included.
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Affiliation(s)
| | - Samir R Pandya
- The University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
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2
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Ng TSC, Putta N, Kwatra NS, Drubach LA, Rosen R, Fahey FH, Flores A, Nurko S, Voss SD. Pediatric Solid Gastric Emptying Scintigraphy: Normative Value Guidelines and Nonstandard Meal Alternatives. Am J Gastroenterol 2020; 115:1830-1839. [PMID: 33156102 DOI: 10.14309/ajg.0000000000000831] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Adult standards for gastric emptying scintigraphy, including the type of meal and range of normative values for percent gastric emptying, are routinely used in pediatric practice, but to date have not been validated. The purpose of this study is to determine whether the use of adult criteria for gastric emptying scintigraphy is valid for children and whether alternative nonstandard meals can also be offered based on these criteria. METHODS This retrospective study analyzed patients (n = 1,151 total) who underwent solid-phase gastric emptying scintigraphy. Patients were stratified into normal and delayed gastric emptying cohorts based on adult criteria, i.e., with normal gastric emptying defined as ≤10% gastric retention at 4 hours. Patients were further stratified based on the type of meal, namely complete or partial adult standard meals or alternative cheese-based meals. Percent gastric retention values at 1, 2, 3, and 4 hours were compared. RESULTS The median (95% upper reference limit) percentage gastric retention values for the complete standard meal were 72% (93%) at 1 hour, 39% (65%) at 2 hours, 15% (33%) at 3 hours, and 6% (10 %) at 4 hours. By comparison, the values for cheese-based meals were 60% (87%) at 1 hour, 29% (61%) at 2 hours, 10% (30%) at 3 hours, and 5% (10%) at 4 hours. Consumption of at least 50% of the standard meal yielded similar retention percentages; 68% (89%) at 1 hour, 32% (57%) at 2 hours, 10% (29%) at 3 hours, and 5% (10%) at 4 hours. There were no significant age- or sex-specific differences using the adult criteria. DISCUSSION The adult normative standards for gastric emptying scintigraphy are applicable for use in the pediatric population. These same standards can be also be applied to nonstandard meal options, including cheese-based alternative meals and partial standard meals.
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Affiliation(s)
- Thomas S C Ng
- Joint Program in Nuclear Medicine, Department of Radiology, Brigham and Women's' Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Imaging, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Neha S Kwatra
- Joint Program in Nuclear Medicine, Department of Radiology, Brigham and Women's' Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laura A Drubach
- Joint Program in Nuclear Medicine, Department of Radiology, Brigham and Women's' Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel Rosen
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frederic H Fahey
- Joint Program in Nuclear Medicine, Department of Radiology, Brigham and Women's' Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alejandro Flores
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
- Colorectal Program, Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Nurko
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
- Colorectal Program, Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephan D Voss
- Joint Program in Nuclear Medicine, Department of Radiology, Brigham and Women's' Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Esophageal pH Capsule Retention. ACG Case Rep J 2020; 7:e00383. [PMID: 33062769 PMCID: PMC7535674 DOI: 10.14309/crj.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/04/2020] [Indexed: 11/18/2022] Open
Abstract
The wireless pH capsule is widely used to evaluate gastroesophageal reflux disease in patients. Common complications include premature capsule detachment, dysphagia, chest pain, and technical malfunctions. We present a 6-year-old boy who presented to our institution with a 2-day history of coffee-ground emesis. A pH capsule was found to be lodged in his distal esophagus 45 days after initial placement. We explore the possible reasons for capsule retention and briefly discuss the safety implications of this finding because we believe that this complication may be underreported.
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Does retching matter? Reviewing the evidence-Physiology and forces. J Pediatr Surg 2019; 54:750-759. [PMID: 30193878 DOI: 10.1016/j.jpedsurg.2018.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/08/2018] [Accepted: 07/30/2018] [Indexed: 11/23/2022]
Abstract
Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure. Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking. Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown. Retching needs to be addressed if we are to reduce the incidence of wrap failure. Level of Evidence V.
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Kim S, Koh H, Lee JS. Gastroesophageal Reflux in Neurologically Impaired Children: What Are the Risk Factors? Gut Liver 2017; 11:232-236. [PMID: 27840365 PMCID: PMC5347647 DOI: 10.5009/gnl16150] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/13/2016] [Accepted: 06/14/2016] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Neurologically impaired patients frequently suffer from gastrointestinal tract problems, such as gastroesophageal reflux disease (GERD). In this study, we aimed to define the risk factors for GERD in neurologically impaired children. Methods From May 2006 to March 2014, 101 neurologically impaired children who received 24-hour esophageal pH monitoring at Severance Children’s Hospital were enrolled in the study. The esophageal pH finding and the clinical characteristics of the patients were analyzed. Results The reflux index was higher in patients with abnormal electroencephalography (EEG) results than in those with normal EEG results (p=0.027). Mitochondrial disease was associated with a higher reflux index than were epileptic disorders or cerebral palsy (p=0.009). Patient gender, feeding method, scoliosis, tracheostomy, and baclofen use did not lead to statistical differences in reflux index. Age of onset of neurological impairment was inversely correlated with DeMeester score and reflux index. Age at the time of examination, the duration of the disease, and the number of antiepileptic drugs were not correlated with GER severity. Conclusions Early-onset neurological impairment, abnormal EEG results, and mitochondrial disease are risk factors for severe GERD.
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Affiliation(s)
- Seung Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hong Koh
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Knatten CK, Fjeld JG, Medhus AW, Pripp AH, Fyhn TJ, Aabakken L, Kjosbakken H, Edwin B, Emblem R, Bjørnland K. Preoperative liquid gastric emptying rate does not predict outcome after fundoplication. J Pediatr Surg 2017; 52:540-543. [PMID: 28277299 DOI: 10.1016/j.jpedsurg.2016.09.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/08/2016] [Accepted: 09/30/2016] [Indexed: 12/12/2022]
Abstract
AIM OF THE STUDY Preoperative gastric emptying (GE) rate in patients with gastrointestinal reflux disease (GERD) was evaluated as a predictor of outcome after antireflux surgery. METHODS AND PATIENTS GE was assessed using radionuclide scintigraphy and a standardized meal with cow's milk. GE half time (T1/2), patient demographics and GERD symptoms including vomiting (>4days/week), retching (>4days/week), prolonged feeding time (>3h/day), and discomfort after meals were recorded pre- and postoperatively. A standardized follow-up included a 24-h pH-monitoring and an upper gastrointestinal contrast study. Of 74 patients undergoing Nissen fundoplication between 2003 and 2009, 35 underwent a preoperative GE study. The remaining 39 patients were not examined owing to volume intolerance, cow's milk intolerance or allergy, inability to lie still, or parents refusing participation. MAIN RESULTS Median age at fundoplication was 4.9 [range 1.1-15.4] years, and follow-up time was median 4.3 [1.9-8.9] years. GERD recurred in 7 (20%) patients. Preoperative T1/2 in the seven patients with recurrent GERD was median 45 [21-87] min compared to 44 [16-121] min in the 28 patients without recurrent GERD (p=0.92). There was no significant difference between the one third of patients with the slowest GE [T1/2 54-121min] and the remaining patients [T1/2 16-49min] regarding GERD recurrence or postoperative vomiting, retching, prolonged feeding time, or discomfort after meals. CONCLUSION Preoperative GE rate did not predict outcome after antireflux surgery, as slow GE was not associated with recurrent GERD or postoperative troublesome symptoms such as vomiting, retching, or meal discomfort.
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Affiliation(s)
- C K Knatten
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; Department of Pediatrics, Oslo University Hospital, Norway.
| | - J G Fjeld
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway; Oslo and Akershus University College of Applied Sciences
| | - A W Medhus
- Department of Gastroenterology, Oslo University Hospital, Norway
| | - A H Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Norway
| | - T J Fyhn
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - L Aabakken
- Department of Gastroenterology, Oslo University Hospital, Rikshospitalet, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - H Kjosbakken
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway
| | - B Edwin
- Institute of Clinical Medicine, University of Oslo, Norway; Intervention Centre, Oslo University Hospital, Rikshospitalet, Norway; Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Norway
| | - R Emblem
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - K Bjørnland
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
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Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children. Pediatr Surg Int 2016; 32:277-83. [PMID: 26711122 DOI: 10.1007/s00383-015-3853-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome. AIMS To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery. METHODS We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients' Visick score assessed parents' perspective. RESULTS Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents' perspectives were excellent or good in 85 %. CONCLUSIONS A significant positive impact of redo Nissen intervention on the patient's outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.
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Horwood JF, Calvert W, Mullassery D, Bader M, Jones MO. Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children--a single centre experience. J Pediatr Surg 2015; 50:275-9. [PMID: 25638618 DOI: 10.1016/j.jpedsurg.2014.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 11/02/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Gastrooesophageal reflux disease (GERD) is a significant problem in children with neurological impairment (NI) with high failure rates for fundoplication. Fundoplication with vagotomy and pyloroplasty (FVP) can improve the outcome by altering the sensory or motor dysfunction associated with the reflux. We report our comparative outcomes for simple fundoplication (SF) and FVP in NI children. METHODS Case records of all patients having fundoplication under a single consultant at a tertiary UK paediatric surgical centre between January 1997 and December 2012 were retrospectively assessed for recurrent symptoms and redo surgery. The data were collected using a Microsoft Excel database and analysed on Graphpad prism software program. Data are median (range). P value<0.05 was considered significant. RESULTS Data were available for 244 out of 275 patients who underwent fundoplication during this period (157 SF and 87 FVP). Neurological disease or known syndromes were recorded in 158 patients. Thirty-five children had congenital anatomical abnormalities. Laparoscopic fundoplication was done in 37 cases. Revisional surgery for recurrent symptoms was performed in 22 patients. In the neurologically normal children, all of whom had SF, the revision rate was 6.5%. In the NI children the revision rates were 18.5% for SF and 3.9% for FVP, respectively (Fisher's exact, P<0.05). The median time to redo surgery was 10 (1-63) months, and the median time to follow up was 19.5 (2-177) months. CONCLUSIONS There appears to be a significantly lower need for redo surgery following FVP than SF in children with NI.
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Affiliation(s)
- J Fraser Horwood
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - William Calvert
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhanya Mullassery
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohammed Bader
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Matthew O Jones
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
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Gastric emptying in children with gastroesophageal reflux and in healthy children. J Pediatr Surg 2013; 48:1856-61. [PMID: 24074657 DOI: 10.1016/j.jpedsurg.2013.03.076] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 03/04/2013] [Accepted: 03/14/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this report is to examine whether children with gastroesophageal reflux (GER) have delayed gastric emptying compared to healthy children. METHODS All patients had GER verified by 24-hour pH monitoring. Gastric emptying of cow's milk was examined by radionuclide scintigraphy in 51 patients with GER and in 24 controls. Gastric emptying rate was expressed as exponential half time (T1/2). RESULTS Median age was 4.4 years [range 0.1-15.4] in patients and 6.1 years [range 2.5-10.0] in controls (p=.10). A wide range of gastric emptying rates was observed both in GER patients [range 16-121] and controls [range 29-94]. One GER patient (2%) had slower gastric emptying (T1/2=121 min) than the healthy child with the longest T1/2 (94 min). Mean T1/2 was 49 minutes (SD 20.1) and 46 minutes (SD 14.2) in GER patients and controls, respectively (p=.51). CONCLUSIONS Gastric emptying rate of milk was not significantly different between children with GER and healthy children. A wide range of gastric emptying rates was observed in both groups.
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Jackson HT, Kane TD. Surgical management of pediatric gastroesophageal reflux disease. Gastroenterol Res Pract 2013; 2013:863527. [PMID: 23762041 PMCID: PMC3665246 DOI: 10.1155/2013/863527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 03/11/2013] [Accepted: 03/27/2013] [Indexed: 01/15/2023] Open
Abstract
Gastroesophageal reflux (GER) is common in the pediatric population. Most cases represent physiologic GER and as the lower esophageal sphincter (LES) matures and a solid diet is introduced, many of these patients (>65%) experience spontaneous resolution of symptoms by two years of age. Those who continue to have symptoms and develop complications such as failure to thrive, secondary respiratory disease, and others are classified as having gastroesophageal reflux disease (GERD). Goals of GERD treatment include the resolution of symptoms and prevention of complications. Treatment options to achieve these goals include dietary or behavioral modifications, pharmacologic intervention, and surgical therapy. This paper will review the clinical presentation of GERD and discuss options for surgical management and outcomes in these patients.
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Affiliation(s)
- Hope T. Jackson
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Timothy D. Kane
- Division of Pediatric Surgery, Department of Surgery, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC, USA
- Surgical Residency Training Program, Children's National Medical Center, Division of Pediatric Surgery, 111 Michigan Avenue, NW Washington, DC 20010-2970, USA
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Abstract
This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.
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Rodriguez L, Rosen R, Manfredi M, Nurko S. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study. Gastrointest Endosc 2012; 75:302-9. [PMID: 22248598 PMCID: PMC3260460 DOI: 10.1016/j.gie.2011.09.042] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 09/20/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Botulinum toxin A has been used in children to treat spastic disorders and recently for GI conditions. Open-label studies in adults with gastroparesis have reported an improvement in symptoms and gastric emptying after endoscopic intrapyloric botulinum injections (IPBIs), although placebo-controlled trials have shown conflicting results. Only a single case report of IPBI is available in children. OBJECTIVE To determine the long-term clinical outcomes and predictive factors for IPBI response in children with gastroparesis refractory to medical therapy. DESIGN Retrospective review. SETTING Single tertiary care center. PATIENTS Children with refractory gastroparesis symptoms undergoing IPBIs. INTERVENTIONS IPBIs. MAIN OUTCOME MEASUREMENTS Clinical improvement and predictive factors for response. RESULTS A total of 70 injections were given to 47 patients (mean age 9.98 ± 6.5 years; 23 female patients) with follow-up in 45 patients. IPBI failed in 15 patients and was successful in 30 patients. The median duration of response to the first IPBI was 3.0 months (95% CI, 1.2-4.8). A total of 29 patients received a single IPBI, and 18 received multiple IPBIs. Older age and vomiting predicted response to initial IPBI, and male sex predicted response to repeat IPBI. Only 1 patient reported exacerbation of vomiting after IPBI resolving within a week. LIMITATIONS The open-label and retrospective nature of the study. CONCLUSION IPBI is safe and may be effective in the management of children with symptoms of gastroparesis. Subgroups identifying who responded to the first IPBI include older patients and those presenting with vomiting, whereas male patients responded better to repeat IPBIs.
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Affiliation(s)
- Leonel Rodriguez
- Corresponding Author: Center for Motility and Functional Gastrointestinal Disorders Division of Gastroenterology Department of Medicine Children’s Hospital Boston 300 Longwood Avenue Boston, MA 02115 Tel: (617) 355-6055 Fax: (617) 730-0043
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Delayed gastric emptying and typical scintigraphic gastric curves in children with gastroesophageal reflux disease: could pyloromyotomy improve this condition? J Pediatr Surg 2011; 46:863-9. [PMID: 21616242 DOI: 10.1016/j.jpedsurg.2011.02.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 02/11/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSES Delayed gastric emptying (DGE) is a cofactor in the etiopathogenesis of gastroesophageal reflux disease (GERD). Scintigraphy is the criterion standard to evaluate gastric emptying (GE). This study aims to define typical scintigraphic activity-time curves (ATCs) related to DGE and esophageal atresia (EA) and to demonstrate the effectiveness of pyloromyotomy (P) in improving GE. METHODS Since 2002, 83 children underwent Nissen fundoplication. Patients were divided into 2 groups: group I, GERD-only patients; group II, patients with GERD owing to EA. Depending on preoperative scintigraphy, each group was subdivided into 2 subgroups. Before surgery and 1 year after, endoscopy and scintigraphy were performed. In the presence of DGE, P was associated with Nissen fundoplication. Gastric emptying differences at baseline and at follow-up were estimated by the Student t test. Pre- and post-ATCs were evaluated by the χ(2) test. RESULTS During follow-up, GE completely normalized in subgroups with DGE. Scintigraphic ATC analysis documented an association between DGE and a typical rectilinear fitting, with a higher rate in EA patients. After P, the scintigraphic pattern changed in an exponential manner related to a faster GE. CONCLUSIONS Delayed gastric emptying is frequent in EA, and the scintigraphic ATCs are typical. Pyloromyotomy is a safe and effective technique to fully normalize GE.
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Abstract
PURPOSE Absence of consistent data on the outcome of gastric emptying after fundoplication raises concerns about preoperative workup and surgical management. This study assessed how gastric emptying evolves after isolated fundoplication in order to determine whether a preoperative investigation and/or a concurrent gastric drainage procedure are justified. METHODS Eleven children with GERD underwent both pre- and post-operative gastric emptying scintigraphy. No gastric drainage procedures were added to fundoplication. Scintigraphy was performed according to a standardized protocol (labeled meal, 300 ml + 500 μCi (99m)Tc/m(2) bsa). Half-emptying time (t (1/2)), emptying rate and fractions of retention are expressed as the median followed by the [range]; statistical significance level was set at 5%. RESULTS Postoperative t (1/2) (min) showed a much smaller dispersion and was significantly lower than preoperative one (76 [56;101] vs. 107 [57;186], p = 0.04) with a variation of -48 [-105;19]; there was no individual correlation between pre- and post-operative measurements (r = 0.25). The proportion of patients with delayed gastric emptying (t (1/2) > 100) was significantly lower in the postoperative scintigraphy (9 vs. 55%, p = 0.03). The postoperative emptying rate (%/h) was significantly faster (35.1 [18.9;41.7] vs. 28.5 [16.3;38.7], p = 0.05). The retentions (%) at 30 and 60 min were similar; at 90 and 120 min were significantly lower after surgery (45 [35;54] and 32 [24;46] vs. 53 [33;78] and 41 [25;66], p = 0.03 and 0.05). CONCLUSION Gastric emptying accelerates significantly after fundoplication with a shift to normal values in the vast majority of patients. Scintigraphy does not predict the postoperative outcome. Therefore, concomitant drainage procedures seem unnecessary and preoperative gastric emptying study not useful.
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Struijs MC, Lasko D, Somme S, Chiu P. Gastric emptying scans: unnecessary preoperative testing for fundoplications? J Pediatr Surg 2010; 45:350-4; discussion 354. [PMID: 20152350 DOI: 10.1016/j.jpedsurg.2009.10.077] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 10/27/2009] [Indexed: 11/18/2022]
Abstract
PURPOSE Delayed gastric emptying (DGE) as indicated by preoperative gastric emptying scan (GES) is one rationale for performing a gastric emptying procedure (GEP) at time of fundoplication for gastroesophageal reflux disease (GERD). However, the role of GES and GEP in the surgical management of GERD remains unclear. We examined the use of preoperative GES in fundoplication patients. METHODS Retrospective chart review of patients undergoing fundoplication from 2000 to 2005 in a single institution including patient demographics, operative procedure, and postoperative outcomes at 1-year follow-up was analyzed using chi(2) test. RESULTS Of 76 fundoplication patients, 39 (51%) had preoperative GES with 11 patients (28%) having DGE and 16 GEP performed. Developmentally delayed children were more likely to have GES. There were no significant differences in postoperative complications, length of hospital stay, or use of anti-GERD medications at 1 year between patients who had preoperative GES and those who did not. In the developmentally delayed group, there were no differences in outcomes between those with preoperative GES and those who did not. CONCLUSIONS There were no differences in outcomes for GERD patients with or without preoperative GES or GEP postfundoplication. The use of GES in the management of GERD requires further evaluation.
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Melro APC, Collares EF, Silva JMB. Effect of an isolated mild to moderate ischemic brain injury in the gastric emptying of liquids in rats. Acta Cir Bras 2008; 23:486-90. [PMID: 19030745 DOI: 10.1590/s0102-86502008000600003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 08/14/2008] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the effect of hypoxic-ischemic brain injury over the gastric emptying of liquids in rats. METHODS Fifty-two Wistar rats aged six weeks and weighing between 100 g and 150 g were divided in three groups. A Control group (C), a Sham group (S) undergoing sham procedure, and a Hypoxic-ischemic group (HI) consisting of 18 animals undergoing surgical ligature of the left carotid artery and exposure to hypoxic environment for three hours. Half of the animals were studied in the third day post-HI procedure (Early) and nine in the 14th day post-HI procedure (Late). Gastric emptying was evaluated by an infusion technique using fenolsulftalein as a marker. RESULTS After the HI procedure, all animals displayed left eyelid ptosis, and six animals showed minor sideway gait. Histological examination confirmed de brain injury in all animals from the HI group. There was no statistical significant difference among the mean gastric retention values of the three groups neither in the Early nor in the Late evaluation. CONCLUSION Isolated HI brain injury was not associated with delayed gastric emptying.
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Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. ACTA ACUST UNITED AC 2008; 14:128-36. [DOI: 10.1002/ddrr.18] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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18
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Abstract
Post-surgical gastroparesis (PSG) is recognized as a consequence of vagal nerve injury following upper abdominal surgery. It has been well documented following vagotomy for peptic ulcer surgery. With the increasing role of surgical treatment in the management of GERD and morbid obesity, PSG is now being diagnosed after fundoplication and bariatric surgery. PSG has also been reported after heart and lung transplantation, possibly due to opportunistic viral infection or motor-inhibitory effects of the immunosuppressive drugs, in addition to vagal nerve injury. Initial postoperative management of PSG should be conservative as many symptoms following abdominal surgery resolve with time. This occurs possibly because the enteric nervous system is able to adapt to the loss of vagal input or vagal reinnervation occurs. Persistent symptoms are difficult to manage and require a multidisciplinary team approach. Gastric electrical stimulation has shown promise in small series.
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Affiliation(s)
- Mehnaz A Shafi
- University of Texas Medical Branch, 4.106 McCullough Building, 301 University Boulevard, Galveston TX 77555-0764, USA
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19
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Goessler A, Huber-Zeyringer A, Hoellwarth ME. Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication. Acta Paediatr 2007; 96:87-93. [PMID: 17187611 DOI: 10.1111/j.1651-2227.2006.00005.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIM To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP). METHODS From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed. RESULTS Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively). CONCLUSION Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.
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Affiliation(s)
- A Goessler
- Department of Pediatric Surgery, University of Graz, Medical School, Auenbruggerplatz, Graz, Austria.
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20
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Jawaid W, Abdalwahab A, Blair G, Skarsgard E, Webber E. Outcomes of pyloroplasty and pyloric dilatation in children diagnosed with nonobstructive delayed gastric emptying. J Pediatr Surg 2006; 41:2059-61. [PMID: 17161205 DOI: 10.1016/j.jpedsurg.2006.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pyloroplasty and pyloric dilatation are methods used to ameliorate the symptoms of nonobstructive delayed gastric emptying in children. Our purpose was to review the results of these methods with respect to symptomatic improvements. METHODS We retrospectively reviewed the records of children who, exclusive of fundoplications, in the 11-year period before December 31, 2005, had undergone at our institution a Heineke-Mikulicz pyloroplasty (HMP) and/or a fluoroscopically guided balloon pyloric dilatation (FGBD). We recorded evidence of either short- or long-term subjective improvement of symptoms. RESULTS Twenty-three children underwent HMP. Five had no prior medical treatment. Of the 23, 3 had no subjective improvement in symptoms. Of the 20 who had subjective evidence of improvement recorded, 13 (56.5%) proved to be long-term and 7 short-term improvement. Eight children had FGBD. All 8 had prior medical treatment that had failed. There were 3 who displayed no subjective evidence of improvement, whereas 5 had subjective evidence of improvement-3 (37.5%) long term and 2 short term. CONCLUSIONS Heineke-Mikulicz pyloroplasty and FGBD in this study demonstrated only in limited numbers long-term improvement of symptoms. Efforts to understand more fully gastric emptying and to define those children who should undergo FGBD or HMP are needed.
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Affiliation(s)
- Wajid Jawaid
- Department of Pediatric Surgery, British Columbia Children's Hospital, and the University of British Columbia, Vancouver, BC, Canada V6H 3V4
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21
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Goessler A, Huber-Zeyringer A, Hoellwarth ME. Does epilepsy influence the outcome of antireflux procedures in neurologically impaired children? Pediatr Surg Int 2006; 22:485-90. [PMID: 16736214 DOI: 10.1007/s00383-006-1686-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
In neurologically impaired patients (NIP), surgical management of gastroesophageal reflux disease (GERD) has become a widespread standard. Several follow-up studies have shown a high incidence of complications and recurrent reflux. As one of the possible causes epilepsy is mentioned repeatedly in the literature. The aim of this study was to determine the effective impact of epilepsy on the postoperative outcome by comparing results of our patients suffering from epilepsy to those without this disorder. From 1984 to 1999, a total of 45 NIP underwent antireflux surgery, including 20 patients suffering from epilepsy (EP) and 25 patients without this disorder (nEP). The existence of epileptic disorders, incidence of epileptic seizures and administration of anticonvulsatory drugs as well as results of diagnostic procedures, postoperative complications and incidence and time of recurrence of pathologic GER were recorded and analysed retrospectively. Preoperatively all patients had pathologic results in 24 h pH-monitoring. Median RI was 15.75 (EP, range 5.2-28.6) and 17.55 (nEP; range 7.2-26.5). 12-months-postoperative 24 h pH-monitoring showed a median RI of 3.8 (EP; range 1.3-25.6) versus a median RI of 3.3 (nEP; range 0.7-26.3). During the long-term follow-up evaluation of 3.9 years, 17 EP suffered from persistent epileptic seizures despite medical treatment. 19 patients (42%) developed recurrent reflux. This included seven EP (35%) and 12 nEP (48%). The necessity of reoperation was higher in nEP (n = 5, 20%) than in EP (n = 1, 5%). This analysis did not show a significant correlation between recurrence of pathologic GER after fundoplication and the incidence of epileptic seizures. We consider our findings to strongly question the widespread opinion considering this correlation. We conclude, that cerebral seizures alone do not alter the operative outcome of antireflux surgery in NIP.
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Affiliation(s)
- A Goessler
- Department of Pediatric Surgery, University of Graz, Medical School, Auenbruggerplatz 34, 8036, Graz, Austria.
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22
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Demirbilek S, Karaman A, Gürünlüoğlu K, Akin M, Taş E, Aksoy RT, Kekilli E. Delayed gastric emptying in gastroesophageal reflux disease: the role of malrotation. Pediatr Surg Int 2005; 21:423-7. [PMID: 15912364 DOI: 10.1007/s00383-005-1460-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2005] [Indexed: 02/06/2023]
Abstract
The association between gastroesophageal reflux (GER) and intestinal malrotation (IM) has been well described. Delayed or impaired gastric emptying in IM is thought to be a contributing factor in the development of gastroesophageal reflux disease (GERD). The current study assessed the role of malrotation in delayed gastric emptying in children with GERD. We also evaluated the interactions between GERD, malrotation, gastric pH abnormalities, and gastric dysmotility. Sixty-seven patients between 1 and 5 years of age (mean 3.08+/-1.2) and with symptoms of GER, such as emesis, reactive or recurrent lung disease, and/or growth retardation, were studied in 2001-2005. Upper and lower gastrointestinal contrast studies were performed for the diagnosis of malrotation. Gastric motility was evaluated with a liquid gastric emptying protocol. GER was documented by upper gastrointestinal studies, scintigraphy, and/or 24-h pH monitoring. In our series of 44 children with GERD, there was an unexpectedly high incidence of IM: 54.5% (24/44). IM has previously been known to occur in 25% of patients with GERD. GERD was found in 24 (82.7%) of 29 patients with IM. Mean nuclear gastric emptying (MNGE) was 51.6+/-8.04 min in patients with isolated GERD and 96.6+/-20.5 min in children with IM and GERD. There was a statistically significant difference in MNGE time (p<0.05) between children with primary GERD and in those with GERD and IM. Esophageal pH monitoring showed that mean fraction time below pH 4 was 7.06+/-1.1% in patients with isolated GERD and 14.7+/-4.1% in patients with IM and GERD. GERD is common in children between 1 and 5 years old. Using gastric emptying studies and esophageal pH monitoring, we have shown that gastric dysmotility and esophageal pH abnormalities are highly prevalent, especially in children with malrotation compared with children with isolated GERD. These findings suggest that malrotation is an important factor responsible for delayed gastric emptying in GERD. Hence, we recommend that all infants and children with GERD and delayed gastric emptying undergo careful evaluation for malrotation.
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Affiliation(s)
- Savaş Demirbilek
- Department of Pediatric Surgery, Medical School of Inonu University, Inönü Universitesi, Turgut Ozal Tip Merkezi, Cocuk Cerrahisi Anabilim Dali, 44069 Malatya, Turkey.
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Abstract
Gastroesophageal reflux is common in infants and generally resolves spontaneously within the first year of life as the lower esophageal sphincter mechanism matures. The reflux is only considered a "disease" (GERD) when it becomes symptomatic or causes pathological consequences. GERD is commonly associated with esophageal atresia and there is a high incidence in neurologically impaired children; in both groups conservative treatment is notoriously ineffective. The diagnosis of GER is made on upper gastrointestinal contrast studies, endoscopy and pH monitoring. Medical management comprises antacids, reduction of gastric acid production and prokinetic agents. The indications for antireflux surgery include an established esophageal stricture, associated anatomical defect and failure of medical therapy. Apnoeic episodes secondary to documented GER in the infant, constitute an absolute indication for early surgery.
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Affiliation(s)
- L Spitz
- Department of Paediatric Surgery, Institute of Child Health, University College London and Great Ormond Street Hospital for Children, UK
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Jesus LED, Monteiro PCC, Siqueira RR, Marinho EB, Nogueira PAV. Gastrostomias e fundoplicaturas: estudo retrospectivo de 5 anos em pacientes pediátricos no Hospital Municipal Jesus/RJ. Rev Col Bras Cir 2003. [DOI: 10.1590/s0100-69912003000200002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Analisar o quadro clínico, morbi-mortalidade e resultados da fundoplicatura gastroesofágica em crianças, com ênfase em portadores de encefalopatias crônicas. MÉTODO: Foram estudados retrospectivamente os prontuários de 55 pacientes em série, submetidos a fundoplicaturas e/ou gastrostomias por 5 anos (1994-1999), analisando manifestações clínicas, características epidemiológicas e evolução pós-operatória. Análises estatísticas, quando pertinentes, utilizaram o método do qui-quadrado. RESULTADOS: Manifestações respiratórias, pacientes com menos de seis meses e encefalopatas predominaram. Opistótono esteve relacionado a formas graves. A mortalidade até 30 dias foi de 7,3%, significativamente maior em cardiopatas congênitos. Complicações imediatas da cirurgia foram basicamente atelectasias e pneumonias (14,6%), relacionadas estatisticamente à desnutrição grave, e infecções da ferida (5,5%). O índice de recorrência de Doença do Refluxo Gastro-Esofagiano foi de 14,5%. O índice de pneumonias caiu de 65,5% em pré-operatório para 16,5% em pós-operatório tardio. Em média houve melhora nutricional a longo prazo, embora com ampla variação individual. CONCLUSÃO: É essencial manter um alto índice de suspeita para Doença do Refluxo Gastro-Esofagiano em lactentes e crianças encefalopatas com manifestações respiratórias. Nestes grupos a indicação cirúrgica é mais freqüente e bastante segura, exceto em presença de desnutrição grave e cardiopatia congênita. Opistótono é marcador de doença grave. Os resultados da cirurgia a longo prazo são favoráveis em crianças encefalopatas.
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Abstract
Minimally invasive surgical approaches to various pediatric surgical disease processes are becoming the standard of care. Laparoscopic Nissen fundoplication is transitioning toward the preferred method for the surgical correction of gastroesophageal reflux (GER) disease in infants and children that do not respond to medical management or have complications from their GER. This approach offers a shorter hospitalization, reduced discomfort, and cosmetic advantages when compared with the open operation. This report discusses the pathophysiology of GER, its clinical manifestations, and the diagnostic evaluation for this disorder. Also, the laparoscopic Nissen fundoplication technique currently utilized at Children's Mercy Hospital is described.
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Affiliation(s)
- Daniel J Ostlie
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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26
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Jesus LED. Refluxo gastroesofágico no paciente encefalopata. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000400008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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27
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Sun M, Wang WL, Wang W, Wen DL, Zhang H, Han YK. Gastroesophageal manometry and 24-hour double pH monitoring in neonates with birth asphyxia. World J Gastroenterol 2001; 7:695-7. [PMID: 11819856 PMCID: PMC4695576 DOI: 10.3748/wjg.v7.i5.695] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- M Sun
- Pediatric Department, Second Clinical College, China Medical University, Shenyang 110003, China.
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Abstract
Gastrointestinal issues are a major chronic problem in 80 to 90% of children with cerebral palsy and in children with neurodevelopmental disabilities who are at special risk of developing malnutrition because of uncoordinated swallowing, gastroesophageal reflux, and constipation. In addition to poor linear growth, there is a decrease in muscle strength and coordination, impaired cerebral function leading to decreased motivation and energy. Significant neurodevelopmental progress can be achieved with improved nutritional status. A multidisciplinary approach, with input from neurologists, gastroenterologists, nurses, occupational therapists, and dieticians, can make a major contribution to the medical wellbeing and quality of life of these children. Different neurological diseases ( eg, spinal dysraphism, syringomyelia, tethered cord syndromes) can give rise to gastrointestinal dysfunction and symptoms that may need different gastrointestinal or surgical management. The introduction of new drugs, including proton pump inhibitors and innovative endoscopic and surgical techniques in the management of gastroesophageal reflux disease and constipation also may have an impact on the treatment of neurologically handicapped children in the future.
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Affiliation(s)
- S K Chong
- Queen Mary's Hospital for Children, Surrey, UK.
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29
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Affiliation(s)
- D G Johnson
- Primary Children's Medical Center, University of Utah Health Sciences Center, Salt Lake City, Utah 84113, USA
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30
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Subramaniam R, Dickson AP. Long-term outcome of Boix-Ochoa and Nissen fundoplication in normal and neurologically impaired children. J Pediatr Surg 2000; 35:1214-6. [PMID: 10945696 DOI: 10.1053/jpsu.2000.8729] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this study was to compare the results of Boix-Ochoa and Nissen fundoplication performed in the authors' department in normal and neurologically impaired children. METHODS The medical records of all children who underwent fundoplication in the span of 10 years from 1988 to 1997 were reviewed. Boix-Ochoa procedure was the preferred operation before 1993. Since 1993, the Nissen fundoplication has been used as the operation of choice for surgical antireflux treatment. RESULTS A total of 109 fundoplications were performed during that period, of which 64.2% of the children involved were neurologically impaired. The Boix-Ochoa procedure and Nissen fundoplication were the 2 types of operations performed for antireflux surgical treatment. There were 22 recurrences of gastroesophageal reflux, 14 in the neurologically impaired group and 6 in the normal group. All except 2 recurrences were after the Boix-Ochoa procedure. Neurological impairment increased the morbidity rates after these procedures and dictated the effectiveness of the operation. Nissen fundoplication fared better in comparison with the Boix-Ochoa procedure in both the neurologically impaired and the normal group. CONCLUSIONS Antireflux surgery is beneficial in children with significant gastroesophageal reflux, irrespective of their neurological status, although complications are more common in the neurologically impaired group. Nissen fundoplication is more effective and has fewer complications.
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Affiliation(s)
- R Subramaniam
- Department of Paediatric Surgery, Booth Hall Children's Hospital, Blackley, Manchester, England
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31
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Affiliation(s)
- P B Sullivan
- University of Oxford, Department of Paediatrics John Radcliffe Hospital, Oxford OX3 9DU, UK
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32
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Levy MS, Sorrels CW, Wagner CW, Jackson RJ, Barnes RW, Smith SD. Evolution of the modified Rossetti fundoplication in children: surgical technique and results. Ann Surg 1999; 229:774-9; discussion 779-80. [PMID: 10363890 PMCID: PMC1420823 DOI: 10.1097/00000658-199906000-00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the modified Rossetti fundoplication with the classic Nissen. SUMMARY BACKGROUND DATA The traditional surgical treatment of gastroesophageal reflux in children has been the classic Nissen fundoplication, defined by liver mobilization, crural repair, takedown of short gastric vessels, and floppy wrap. The authors have progressed in our technique of fundoplication and now perform a modified Rossetti fundoplication, defined by liver retraction without mobilization, no crural repair, short gastric vessels left intact, and 2-cm floppy wrap. METHODS A retrospective chart review was performed on 407 pediatric patients who had open fundoplications (Jan. 13, 1993, to Feb. 25, 1998). Two groups were analyzed: the Nissen group (171 patients) and the Rossetti group (236 patients). Groups were compared for incidence of recurrent reflux, dysphagia, hiatal hernia, need for esophageal dilation, revision of fundoplication, time to discharge, and operative time. RESULTS Incidence of dysphagia (3.7% vs. 3.3%), postoperative hiatal hernia (1.9% vs. 1.4%), need for esophageal dilation (1.2% vs. 0.5%), and need for fundoplication revision (2.5% vs. 2.3%) were similar between the groups. The mean operative time was significantly decreased in the Rossetti group (65 +/- 25 minutes) versus the Nissen group (73 +/- 33 minutes). Recurrent reflux occurred significantly more often in the Nissen group (11.2%) than in the Rossetti group (5.1 %). CONCLUSION The modified Rossetti fundoplication has a low complication rate and is the authors' preferred method for the surgical treatment of gastroesophageal reflux in children.
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Affiliation(s)
- M S Levy
- Division of Pediatric Surgery, Arkansas Children's Hospital, Little Rock 72202-3591, USA
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33
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Bustorff-Silva J, Fonkalsrud EW, Perez CA, Quintero R, Martin L, Villasenor E, Atkinson JB. Gastric emptying procedures decrease the risk of postoperative recurrent reflux in children with delayed gastric emptying. J Pediatr Surg 1999; 34:79-82; discussion 82-3. [PMID: 10022148 DOI: 10.1016/s0022-3468(99)90233-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Although several centers often perform gastric emptying procedures (GEP) together with fundoplication for gastroesophageal reflux (GER) and delayed gastric emptying (DGE), the benefit of GEP is controversial. The present study addresses the question of whether adding a GEP in children with preoperatively diagnosed GER and DGE affects the recurrence rate of GER after Nissen fundoplication (NF). METHODS A retrospective chart review was performed on all children under the age of 16 years, operated on for GER from 1980 to 1997, who had a preoperative diagnosis of DGE, and at least 6 months of follow-up. Gastric retention of more than 50% of a radiolabeled meal at 90 minutes was considered DGE. Recurrent reflux was defined as reappearance of GER symptoms, confirmed by postoperative esophagram or 24 hours of pH monitoring. RESULTS Of the 183 patients with DGE, 92 were available for long-term follow-up. Of these, 20 had no gastric emptying procedure performed (no-GEP group) and 72 had a GEP performed together with an NF (GEP group). Groups were comparable as to age at operation, mean follow-up time, male to female ratio and prevalence of associated anomalies. A higher prevalence of neurological impairment (NI) was present in the GEP group (48.6% v20.0%). Mean preoperative gastric retention was significantly higher in the GEP group (69.9 +/- 1.3%) than in the no-GEP group (61.4 +/- 2.2%). No complications resulted from the GEP. Recurrent reflux rate was 18.1% in the GEP group (13 of 72) versus 35.0% (7 of 20) in the no-GEP group. Actuarial analysis disclosed a marginally significant difference in the rate of recurrent reflux between the groups (P = .057) and estimation of the relative risk showed a 1.94 increase of recurrent reflux risk in the no-GEP (0.89<RR<4.20). CONCLUSIONS Children with DGE, who did not have GEP, had twice the frequency of recurrent reflux as those who had a GER Preoperative screening for DGE, as well as operative correction of DGE at the time of fundoplication, is therefore recommended.
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Affiliation(s)
- J Bustorff-Silva
- Division of Pediatric Surgery, UCLA School of Medicine, Los Angeles, CA 90095-1749, USA
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Bustorff-Silva J. Electrogastrography for evaluating neurologically impaired children with recurrent vomiting. J Pediatr Gastroenterol Nutr 1998; 27:373-4. [PMID: 9740220 DOI: 10.1097/00005176-199809000-00026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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35
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Abstract
Gastroesophageal reflux (GER) is a common disorder in infants and children with a high rate of spontaneous resolution. Some children, however, will continue to have problems and progress from functional GER to pathogenic GER. In children with functional GER, diagnostic testing and pharmacologic treatment is unnecessary. In more involved cases, there are a number of tests available that help to quantify and qualify the extent of disease. Treatment begins with conservative measures and progresses to acid neutralization/supression and medications to enhance motility. Should medical management fail to control the consequences of reflux disease, surgical intervention is warranted.
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Affiliation(s)
- V M Tsou
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
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Roy-Choudhury S, Ashcraft KW. Thal fundoplication for pediatric gastroesophageal reflux disease. Semin Pediatr Surg 1998; 7:115-20. [PMID: 9597704 DOI: 10.1016/s1055-8586(98)70024-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- S Roy-Choudhury
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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37
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Johnson DG, Reid BS, Meyers RL, Fry MA, Nortmann CA, Jackson WD, Marty TL. Are scintiscans accurate in the selection of reflux patients for pyloroplasty? J Pediatr Surg 1998; 33:573-9. [PMID: 9574754 DOI: 10.1016/s0022-3468(98)90319-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastric emptying scintiscans are currently used to select reflux patients for added pyloroplasty at the time of fundoplication. The accuracy of this scan selection approach has been assumed. If preoperative scintiscans do not reliably predict postfundoplication gastric emptying, however, the decision to add pyloroplasty to the fundoplication operation may be inappropriate and even harmful. METHODS The authors studied 27 children prospectively before and after gastric fundoplication. Gastric emptying at 60 minutes was measured by double isotopic labeling of liquid (111In) and solid (99mTc) phases of a test meal specifically designed for label fixation. The authors' question involved the accuracy of preoperative gastric scintiscans in predicting postfundoplication delay of gastric emptying (DGE). An evaluation of pyloroplasty as an effective treatment for DGE was not part of the study design. Pyloroplasty was performed as a secondary operation in three of the study children, however, because they persisted with unrelieved symptoms of retching, fullness, and abdominal discomfort. Scintiscan-documented postfundoplication delay in gastric emptying was present in all three patients at 18, 58, and 12 weeks, respectively. Additional scintiscans were performed in these patients after pyloroplasty. RESULTS Gastric emptying of solids at 60 minutes did not show a significant change after a gastric fundoplication operation, although the trend was in the direction of a decrease (paired t test, P= .13). Liquid emptying at 60 minutes, however, was significantly increased (paired t test, P = .01). The variation in values between patients was wide, and the correlation between pre- and postoperative study results in the same patient was poor (r2 = 0.337 for solids and r2 = 0.116 for liquids). Most unexpectedly, scintiscans after postfundoplication pyloroplasty in the three patients with persistent symptoms showed no improvement in delayed gastric emptying on repeat scintiscan 42 to 117 weeks later. CONCLUSIONS The data suggest that preoperative scintiscan evidence for postfundoplication DGE is probably accurate for solid emptying but not for liquids, at least as measured by the double isotope methodology of our study. Preoperative scintiscans that use a liquid phase label only may be highly misleading for the prediction of postfundoplication DGE. Furthermore, pyloroplasty may not be useful as treatment even when postfundoplication delay in gastric emptying can be accurately anticipated or confirmed. A fundamental motility disorder of the gastric body seems to be more important than muscular resistance at the gastric outlet as a cause for postfundoplication DGE, and the most effective treatment approach remains unclear.
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Affiliation(s)
- D G Johnson
- Division of Pediatric Surgery, Primary Children's Medical Center and University of Utah School of Medicine, Salt Lake City 84113, USA
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Dunn JC, Lai EC, Webber MM, Ament ME, Fonkalsrud EW. Long-term quantitative results following fundoplication and antroplasty for gastroesophageal reflux and delayed gastric emptying in children. Am J Surg 1998; 175:27-9. [PMID: 9445234 DOI: 10.1016/s0002-9610(97)00241-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The operative management of children with combined gastroesophageal reflux and delayed gastric emptying is controversial. This study measures the long-term follow-up of gastric emptying in children who have undergone gastroesophageal fundoplication combined with antroplasty. METHODS Fifteen randomly selected children with gastroesophageal reflux and scintigraphically demonstrated delayed gastric emptying underwent fundoplication and antroplasty. Each patient had another gastric emptying scintigraphic study performed an average of 3.6 years postoperation. RESULTS All patients reported improvement of their symptoms compared with before the operation, and none required further medical therapy for gastroesophageal reflux or experienced dumping syndrome. Eleven of the 15 patients had significant long-term improvement of their gastric emptying postoperatively. The mean percent of isotope meal remaining in the stomach at 90 minutes improved from 72% preoperatively to 40% postoperatively (P = 0.0005). CONCLUSIONS Gastric emptying in children with gastroesophageal reflux and delayed gastric emptying is significantly improved for several years in three-fourths of patients after fundoplication and antroplasty. Fundoplication and concomitant antroplasty are recommended for symptomatic children with documented gastroesophageal reflux and delayed gastric emptying.
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Affiliation(s)
- J C Dunn
- Department of Nuclear Medicine, UCLA School of Medicine, Los Angeles, California 90095, USA
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Brown RA, Wynchank S, Rode H, Millar AJ, Mann MD. Is a gastric drainage procedure necessary at the time of antireflux surgery? J Pediatr Gastroenterol Nutr 1997; 25:377-80. [PMID: 9327365 DOI: 10.1097/00005176-199710000-00002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Gastroesophageal reflux is part of a generalized foregut motility disorder, which may also include delayed gastric emptying. With persistence of gastroesophageal reflux, or the presence of complications, including recurrent aspiration syndrome and esophageal stricture formation, surgical correction may be indicated. It is uncertain whether a procedure to resolve delayed gastric emptying is indicated at this time as well. METHODS Sixty-seven children with proven gastroesophageal reflux had preoperative gastric emptying assessed using 99Technetium-Sn-colloid labelled milk. Delayed gastric emptying was defined as a gastric residual activity of more than 40% at 2 hours after feeding. The antireflux operation was a partial anterior fundoplication. Postoperative milk scans assessed the effect of surgery on gastric emptying. RESULTS Gastric emptying at 2 hours improved overall from a median of 22% before surgery to 17% after surgery. In 17 patients delayed gastric emptying was identified before surgery; in 15 of those it returned to within normal limits after surgery. In 50 children with normal gastric emptying before surgery (gastric residual activity at 2 hours 16%), 14 (28%) showed delayed gastric emptying in the postoperative scan. CONCLUSIONS Delayed gastric emptying is common in children who undergo surgery for gastroesophageal reflux disease. A partial anterior fundoplication antireflux operation improves gastric emptying to within normal limits in the majority (88%) in this group, rendering a synchronous gastric drainage procedure unnecessary.
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Affiliation(s)
- R A Brown
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Sullivan PB. Gastrointestinal problems in the neurologically impaired child. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1997; 11:529-46. [PMID: 9448914 DOI: 10.1016/s0950-3528(97)90030-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux, with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children. Early recognition of an infant with neurological impairment that is compromising the normal feeding process is crucial. Detailed assessment of the nature of the feeding difficulties will help to predict the anticipated future nutritional needs and will allow decisions to be made about the appropriateness of input from different professionals (speech therapy, dietitians, gastroenterologists). Only when such information has been carefully assembled will rational and directed medical and surgical therapy be possible. Nutritional rehabilitation of disabled children can be associated with increased mortality and morbidity secondary to gastro-oesophageal reflux, retching, dumping syndrome or aspiration. It may also entail an increased work for care givers and increase costs of care. It is therefore necessary to document the impact of such rehabilitation on growth and quality of life for both patient and care giver.
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Affiliation(s)
- P B Sullivan
- University of Oxford, Department of Paediatrics, John Radcliffe Hospital, UK
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Okuyama H, Urao M, Starr GA, Drongowski RA, Coran AG, Hirschl RB. A comparison of the efficacy of pyloromyotomy and pyloroplasty in patients with gastroesophageal reflux and delayed gastric emptying. J Pediatr Surg 1997; 32:316-9; discussion 319-20. [PMID: 9044144 DOI: 10.1016/s0022-3468(97)90201-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Delayed gastric emptying (DGE) in children with gastroesophageal reflux (GER) is often treated with a gastric emptying procedure. Although pyloroplasty is the most common gastric emptying procedure performed, pyloromyotomy is easier to perform and is associated with less morbidity. The aim of this study was to compare the efficacy of pyloromyotomy and pyloroplasty in children with DGE and GER undergoing a fundoplication. MATERIALS AND METHODS We reviewed the charts of 54 patients with DGE who underwent pyloromyotomy (n = 29), or pyloroplasty (n = 25) along with a fundoplication. A technetium 99-labeled sulfur colloid liquid-phase gastric emptying study (GES) was performed in the pre- and early postoperative period (within 6 months after operation). Normal stomach emptying was defined as greater than 40% at 1 hour. Comparisons were made with regard to postoperative complication rate, incidence of redo fundoplication, length of postoperative hospital stay, and pre- and postoperative GES. RESULTS The pyloroplasty and pyloromyotomy group were comparable in terms of age, sex, operative indications, and neurological status. There was no significant difference in the GES between the two groups preoperatively. There was a trend toward a decreased incidence of early postoperative complications including gas bloat, wound infection, pneumonia, dysphagia, bowel obstruction and dumping syndrome in the pyloromyotomy (8, 28%) when compared with the pyloroplasty group (12, 48%, P = .10). The mean postoperative hospital stay was 10.6 +/- 1.4 days for the pyloroplasty group and 7.6 +/- 1.0 days for the pyloromyotomy group (P + .08). The incidence of a redo fundoplication was 8% in the pyloroplasty and 7% in the pyloromyotomy group. Postoperative gastric emptying increased significantly in both groups (pyloroplasty group, from 18.1 +/- 3.1 to 49.5 +/- 7.9%, P = .0005; pyloromyotomy group, from 19.3 +/- 2.1 to 41.2 +/- 3.7%, P = .0001). There was no significant difference in the postoperative GES between the two groups (P = .289). CONCLUSION Both pyloroplasty and pyloromyotomy performed in conjunction with a fundoplication resulted in a significant increase in early postoperative gastric emptying. There was no advantage of pyloroplasty over pyloromyotomy during this follow-up period. These data suggest that pyloromyotomy is an effective gastric emptying procedure in children with GER and DGE.
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Affiliation(s)
- H Okuyama
- Section of Pediatric Surgery, CS Mott Children's Hospital, Ann Arbor, MI 48109-0245, USA
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Ramachandran V, Ashcraft KW, Sharp RJ, Murphy PJ, Snyder CL, Gittes GK, Bickler SW. Thal fundoplication in neurologically impaired children. J Pediatr Surg 1996; 31:819-22. [PMID: 8783112 DOI: 10.1016/s0022-3468(96)90142-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Children with neurological impairment (NI) frequently require feeding gastrostomy, and this often aggravates or produces gastroesophageal reflux (GER). From 1976 to 1994, 141 children with severe NI underwent Thal fundoplication and gastrostomy (GT). GER was evident in 80%; in the rest, fundoplication was an adjunct to GT. Ph results were positive in 38 cases, and 57 children had reflux according to the barium studies. There were no major intraoperative complications. Disruption of the repair and/or recurrent GER was noted in 14 cases (10%); 8 were redone as Thals, and 6 were converted to Nissen procedures. Pyloroplasty was done later in 9 children (6%). Bowel obstruction was seen in 4 patients (3%). Clinical follow-up (mean, 54 months) showed improvement in 96%; only 5 of the 141 (3.2%) have residual symptoms. Of the patients with an intact Thal, 67% could burp or vomit. The ability to vomit may protect the Thal fundoplication and avoid disruption of the repair.
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Affiliation(s)
- V Ramachandran
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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Abstract
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.
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