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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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Ishii S, Fukahori S, Asagiri K, Tanaka Y, Saikusa N, Hashizume N, Yoshida M, Masui D, Komatsuzaki N, Higashidate N, Sakamoto S, Kurahachi T, Tsuruhisa S, Nakahara H, Yagi M. Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in Neurologically Impaired Patients. J Neurogastroenterol Motil 2017; 23:533-540. [PMID: 28750491 PMCID: PMC5628985 DOI: 10.5056/jnm16211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/04/2017] [Accepted: 04/02/2017] [Indexed: 11/20/2022] Open
Abstract
Background/Aims The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance pH measurements (pH/MII) and 13C-acetate breath test (13C-ABT) analyses. Methods 13C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation analyses were performed to investigate the correlation between the 13C-ABT parameters and the clinical or pH/MII parameters. Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time (t1/2, 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t1/2. Results The mean t1/2 of all patients was 215.5 ± 237.2 minutes and the t1/2 of 24 (92.3%) patients were > 100 minutes. Significant moderate positive correlations were observed between both t1/2 and lag phase time and the non-acid reflux related parameters. Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups when the cutoff was t1/2 ≥ 140 minutes. Conclusion The present study demonstrated that GE with t1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD.
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Affiliation(s)
- Shinji Ishii
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Kimio Asagiri
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Yoshiaki Tanaka
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan.,Division of Medical Safety Management, Kurume University School of Medicine, Fukuoka, Japan
| | - Nobuyuki Saikusa
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Naoki Hashizume
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Motomu Yoshida
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Daisuke Masui
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Naoko Komatsuzaki
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Naruki Higashidate
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Saki Sakamoto
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Tomohiro Kurahachi
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Shiori Tsuruhisa
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Hirotomo Nakahara
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine, Fukuoka, Japan
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Jancelewicz T, Lopez ME, Downard CD, Islam S, Baird R, Rangel SJ, Williams RF, Arnold MA, Lal D, Renaud E, Grabowski J, Dasgupta R, Austin M, Shelton J, Cameron D, Goldin AB. Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review. J Pediatr Surg 2017; 52:1228-1238. [PMID: 27823773 DOI: 10.1016/j.jpedsurg.2016.09.072] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the surgical treatment of pediatric gastroesophageal reflux disease (GERD). METHODS Five questions were addressed by searching the MEDLINE, Cochrane, Embase, Central, and National Guideline Clearinghouse databases using relevant search terms. Consensus recommendations were derived for each question based on the best available evidence. RESULTS There was insufficient evidence to formulate recommendations for all questions. Fundoplication does not affect the rate of hospitalization for aspiration pneumonia, apnea, or reflux-related symptoms. Fundoplication is effective in reducing all parameters of esophageal acid exposure without altering esophageal motility. Laparoscopic fundoplication may be comparable to open fundoplication with regard to short-term clinical outcomes. Partial fundoplication and complete fundoplication are comparable in effectiveness for subjective control of GERD. Fundoplication may benefit GERD patients with asthma, but may not improve outcomes in patients with neurologic impairment or esophageal atresia. Overall GERD recurrence rates are likely below 20%. CONCLUSIONS High-quality evidence is lacking regarding the surgical management of GERD in the pediatric population. Definitive conclusions regarding the effectiveness of fundoplication are limited by patient heterogeneity and lack of a standardized outcomes reporting framework. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly level 3-4).
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Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105.
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, Program Director, Pediatric Surgery Fellowship, University of Louisville, Louisville, KY
| | | | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC
| | - Shawn J Rangel
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105
| | - Meghan A Arnold
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Dave Lal
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth Renaud
- Department of Surgery, Division of Pediatric Surgery, Albany Medical Center, Albany, NY
| | - Julia Grabowski
- Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Mary Austin
- Department of Pediatric Surgery, The University of Texas Medical School at Houston and in Surgical Oncology and Pediatrics at the UT M.D., Anderson Cancer Center, Houston, TX
| | - Julia Shelton
- Division of Pediatric Surgery, University of Iowa Children's Hospital, Iowa City, IA
| | - Danielle Cameron
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
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Loots C, van Herwaarden MY, Benninga MA, VanderZee DC, van Wijk MP, Omari TI. Gastroesophageal reflux, esophageal function, gastric emptying, and the relationship to dysphagia before and after antireflux surgery in children. J Pediatr 2013; 162:566-573.e2. [PMID: 23102795 DOI: 10.1016/j.jpeds.2012.08.045] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Revised: 07/13/2012] [Accepted: 08/28/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess gastroesophageal reflux (GER), esophageal motility, and gastric emptying in children before and after laparoscopic fundoplication and to identify functional measures associated with postoperative dysphagia. STUDY DESIGN Combined impedance-manometry, 24-hour pH-impedance, and gastric-emptying breath tests were performed before and after laparoscopic anterior partial fundoplication. Impedance-manometry studies were analyzed with the use of conventional analysis methods and a novel automated impedance manometry (AIM) analysis. RESULTS Children with therapy resistent GER disease (n = 25) were assessed before fundoplication, of whom 10 (median age 6.4 years; range, 1.1-17.1 years; 7 male; 4 with neurologic impairment) underwent fundoplication. GER episodes reduced from 97 (69-172) to 66 (18-87)/24 hours (P = .012). Peristaltic contractions were unaltered. Complete lower esophageal sphincter relaxations decreased after fundoplication (92% [76%-100%] vs 65% [29%-91%], P = .038). Four (40%) patients developed postoperative dysphagia, which was transient in 2. In those patients, preoperative gastric emptying was delayed compared with patients without postoperative dysphagia, 96 minutes (71-104 minutes) versus 48 minutes (26-68 minutes), P = .032, and AIM analysis derived dysphagia risk index was greater (56 [15-105] vs 2 [2-6] P = .016). Two patients underwent a repeat fundoplication. DISCUSSION Fundoplication in children reduced GER without altering esophageal motility. Four patients who developed dysphagia demonstrated slower gastric emptying and greater dysplasia risk index preoperatively. AIM analysis may allow detection of subtle esophageal abnormalities potentially leading to postoperative dysphagia.
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Affiliation(s)
- Clara Loots
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands.
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Caldaro T, Garganese MC, Torroni F, Ciofetta G, De Angelis P, di Abriola GF, Foschia F, Rea F, Romeo E, Dall'Oglio L. 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] [What about the content of this article? (0)] [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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Estevão-Costa J, Fragoso AC, Prata MJ, Campos M, Trindade E, Dias JA, Brazão AM. Gastric emptying and antireflux surgery. Pediatr Surg Int 2011; 27:367-71. [PMID: 20737154 DOI: 10.1007/s00383-010-2702-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2010] [Indexed: 12/29/2022]
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] [What about the content of this article? (0)] [Affiliation(s)] [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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Novotny NM, Jester AL, Ladd AP. Preoperative prediction of need for fundoplication before gastrostomy tube placement in children. J Pediatr Surg 2009; 44:173-6; discussion 176-7. [PMID: 19159739 DOI: 10.1016/j.jpedsurg.2008.10.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure performed for children with oral aspiration and failure to thrive. The concurrent presence of gastroesophageal reflux (GER) may be difficult to diagnose in these children and may dictate the need for an antireflux procedure. The purpose of this study was to review our preoperative evaluation of children undergoing PEG placement to better elucidate preoperative factors that may require eventual fundoplication. METHODS A retrospective review at a tertiary care, children's hospital between May 2002 and August 2007 was performed of patients undergoing PEG placement. Patients were identified through database search by operative procedure codes. Patient groups were defined as those undergoing PEG alone (group 1) and those requiring fundoplication after prior PEG (group 2). Comparison of patient demographics and radiologic qualitative results of GER was analyzed using chi(2) analysis, with significance determined at P < .05. RESULTS A total of 863 patients underwent PEG placement over this 64-month period. A sampled cohort of patients undergoing PEG over a year comprised group 1. Forty-four patients (5.1%) underwent Nissen fundoplication after prior PEG placement (group 2). Patient demographics were similar between the groups. Comparison of comorbid conditions and qualitative indicators of GER between the groups showed only cerebral palsy had a significantly higher associated risk of GER that required antireflux surgery. Preoperative clinical assessment had a 95% positive predictive value in identifying children who required only PEG. CONCLUSIONS Despite the high predictive value of individualized clinical assessment in the ultimate decision for gastrostomy without need of fundoplication, further studies are needed to determine whether children with conditions such as cerebral palsy may require a concurrent antireflux surgery at the time of gastrostomy.
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Affiliation(s)
- Nathan M Novotny
- Department of Surgery, Indiana University School of Medicine, Indianapolis, 46202, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
BACKGROUND Gastrointestinal sequelae have been sporadically reported in survivors of congenital diaphragmatic hernia (CDH). The aim of the present paper was to evaluate the gastrointestinal morbidity in infant, adolescent and adult patients who had undergone repair of CDH. METHODS Thirty-one of 38 survivors after left-side CDH repair were followed up. They were subdivided in two groups. Group A consisted of 12 patients (39%) with a mean age of 4.5 years and group B, 19 patients (61%) with a mean age of 21.0 years. Patients underwent physical examination, barium meal study, gastroesophageal scintigraphy, esophageal pH monitoring and manometry of the esophagus and stomach. Upper intestinal endoscopy was performed in patients with confirmed gastroesophageal reflux (GER). RESULTS All patients were within the normal range for height or weight. A total of 41.7% of group A and 15.8% of group B had typical symptoms suggesting GER. Barium meal study was pathological in 33.3% of group A and 21% of group B patients. In 58% of group A and 42% of group B, GER was documented on scintigraphy. In 41.7% of group A and 47% of group B the time taken for the stomach to empty half of its radioactive content (T(1/2)) was pathological. On 24 h pH monitoring pathological GER was documented in 54.5%, whereas in group B it was present in 33.3%. In 36.4% of group A and 46.7% of group B alteration of peristalsis of the stomach was recorded. Endoscopy showed esophageal pathology in 33%. CONCLUSIONS Foregut dysmotility and GER are major sequelae in survivors of CDH repair. Long-term follow up of patients with CDH is recommended.
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Affiliation(s)
- Francesco Arena
- Department of Medical and Surgical Pediatric Sciences, Operative Unit of Pediatric Surgery, University of Messina, Messina, Italy.
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11
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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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12
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Eradi B, Wright J, Gibbons NJ, Blackshaw PE, Perkins AC, Wakefield J, Sithole J, Singh SJ. Validity of 13C octanoic acid breath test for measurement of solid meal gastric emptying time in children. J Pediatr Surg 2006; 41:2062-5. [PMID: 17161206 DOI: 10.1016/j.jpedsurg.2006.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE It is important to establish a physiologic range of gastric emptying (GE) in children. Gastric emptying time measured with (99)Tc-labeled solid meal (GE(Tc)) is the gold standard. Large-scale studies with GE(Tc) are ideal but not feasible because of radiation exposure. The (13)C-labeled octanoic acid breath test (GE(13C)) does not involve radiation and is suitable for large studies. The aim of this study was to validate GE(13C) with GE(Tc) and to explore whether GE(13C) could be used to establish a physiologic range of GE in children. METHOD Twenty-five healthy children underwent simultaneous GE(Tc) and GE(13C) using a standardized solid test meal. The time taken for the stomach to empty half its content (T(1/2)(13C)) and solid lag phase (lag(13C)) for GE(13C) were computed from the fractional excretion of (13)C in expired air. T(1/2)(13C) and lag(13C) were compared with corresponding values obtained by GE(Tc). RESULT Correlation coefficient between T(1/2)(13C) and T(1/2)(Tc) was 0.69 (P < .01; r = 0.92 if 3 outliers were omitted). Correlation coefficient between lag(13C) and lag(Tc) was 0.39 (P < .05). There was good agreement between the methods by the Bland Altman method. CONCLUSION There is good agreement between GE(13C) and GE(Tc). GE(13C) can be safely used to establish the reference range of GE in healthy children.
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Affiliation(s)
- B Eradi
- Department of Paediatric Surgery, Leicester Royal Infirmary, LE1 5WW Leicester, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Melo-Filho AA, Vinagre AM, Collares EF, Bustorff-Silva JM. Effect of different types of fundoplication on the gastric emptying of liquids and gastric compliance in rats. J Pediatr Surg 2005; 40:1551-6. [PMID: 16226983 DOI: 10.1016/j.jpedsurg.2005.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study is to evaluate the early and late effects of partial fundoplication (PFp) and total fundoplication (TFp) on gastric emptying (GE) and on gastric compliance (GC) in rats. METHODS One hundred fifty-nine male Wistar rats, 6 to 8 weeks of age and weighing 150 to 250 g underwent sham operation, PFp or TFp. They were randomly divided into early group (group E) and late group (group L), evaluated on the 7th and 28th postoperative days, respectively. Gastric emptying studies were performed with and without short-term induction of GE delay. RESULTS Gastric emptying studies: In group E, TFp altered gastric retention when compared with sham subgroup in rats with GE delay. In group L, neither PFp nor TFp produced changes in GE. Gastric volume-gastric compliance studies: In group E, only TFp reduced significantly gastric volume, but both PFp and TFp caused a significant decrease in GC. A trend toward normalization of gastric volume and GC was perceived in group L. Partial fundoplication did not change the intragastric pressure response in either group E or group L. Total fundoplication increased the intragastric pressure significantly in group E, but this difference disappeared on the 28th postoperative day. CONCLUSIONS Partial fundoplication induces less change in gastric motor physiology than TFp. These findings provide background to explain some differences in the postoperative course after PFp and TFp.
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Affiliation(s)
- Antonio A Melo-Filho
- Division of Pediatric Surgery, Department of Surgery, State University of Campinas, Campinas-SP 13083-970, Brazil
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Abstract
BACKGROUND/PURPOSE Delayed gastric emptying (DGE) is frequent in patients with gastroesophageal reflux disease (GERD) and may require additional investigation. The current study assesses whether relative esophageal exposure, postprandial (PP) versus fasting, diagnosed by pH monitoring could predict DGE. METHODS Thirty patients with GERD underwent extended esophageal pH monitoring and were assigned as DGE or non-DGE according to scintigraphy. The PP to fasting ratio for reflux index, relative frequency of long episodes in PP, and distribution of the longest episode were used to assess the relative esophageal exposure. The effectiveness of these parameters to predict DGE was estimated; the cutoffs for continuous variables were chosen with receiver operating characteristics (ROC) curves and the probabilities were calculated using a logistic regression model. RESULTS The area under the ROC curve of PP to fasting ratio for reflux index was greater than that of relative frequency of long episodes in PP. There was a good equilibrium between sensitivity and specificity at a PP to fasting ratio of 1. A PP to fasting ratio greater than 1, ie, a reflux index in PP greater than in fasting, presented a sensitivity of 93% and a negative predictive value of 91%. The occurrence of the longest episode in PP had a specificity of 94% and a positive predictive value of 89%. A reflux index greater in PP plus a longest episode in PP presented a 94% probability of DGE; a reflux index greater in fasting plus a longest episode in fasting had a 95% probability of non-DGE. These combinations represented 60% of the series. CONCLUSIONS PP to fasting ratio for reflux index and distribution of the longest episode seem accurate to identify DGE; thus, additional investigation to assess gastric emptying may be avoided in the majority of patients.
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Affiliation(s)
- José Estevão-Costa
- Division of Pediatric Surgery, Faculty of Medicine, Hospital São João, Porto, Portugal
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17
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Abstract
The proportion of children with severe neurodevelopmental disabilities, in whom symptoms of gastroesophageal reflux develop after gastrostomy placement, has not been well studied. The medical records of children who received a gastrostomy tube (with or without a simultaneous antireflux procedure) at our institution between 1987 and 1997 were reviewed to identify neurologically related diagnoses at the time of the gastrostomy, diagnostic tests ordered to detect reflux, and dates and reasons for re-admissions within 2 years of discharge. Of 102 patients studied, 37 received a gastrostomy tube alone. Complete follow-up data were available for 30 of these patients, 7 of whom (23%) required subsequent antireflux surgery within 2 years. Patients with a seizure disorder had greater than a 4-fold risk of re-admission for this operation compared with other patients (57% [4/7] vs. 13% [3/23]; P=0.03). In a child with severe neurodevelopmental disability, the existence of a seizure disorder at the time of a gastrostomy operation increases the risk of subsequently requiring an antireflux procedure by a factor of 4.
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Affiliation(s)
- John W Harrington
- Department of Pediatrics, New York Medical College and Westchester Medical Center, 312 Munger Pavilion, Valhalla, NY 10595, USA
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18
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Abstract
Fundoplication is the standard surgical approach to gastroesophageal reflux (GER) in a child. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurologic impairment, and young infants. Fundoplication failure can take the form of persistent reflux-related symptoms, symptoms that are caused by complications of the surgery, or anatomic problems such a para-esophageal hernia or migration of the wrap into the mediastinum. The most effective strategy for treatment of the child undergoing fundoplication is to prevent failure by careful patient selection, individualization of the operation based on the patient's anatomy and physiology, and meticulous attention to the technical details of the operation. Options for the child with a failed fundoplication include medical management, jejunal feeding using a percutaneous tube or a Roux-en-Y jejunostomy, revision of the fundoplication, or esophagogastric dissociation. If the fundoplication is to be revised, the same principles of patient selection, individualization of the operation, and attention to technique must be used to optimize the chance of success. The primary goal in the treatment of GER is to improve quality of life for the patient and the family.
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Affiliation(s)
- Jacob C Langer
- University of Toronto, Department of Pediatric General Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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19
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Abstract
Gastroesophageal reflux is a physiological phenomenon, occurring with different severity and duration in different individuals. Reflux occurs when this normal event results in the occurrence of symptoms/signs or complications. The pathophysiology of gastroesophageal reflux is complex and diverse, since it is influenced by factors that are genetic, environmental (e.g., diet smoking), anatomic, hormonal, and neurogenic. However, many mechanisms remain incompletely understood. Future research should focus on a better understanding of the physiology of the upper and lower esophageal sphincters, and of gastric motility. The afferent and efferent neural pathways and neuropharmacologic mediators of transient lower esophageal sphincter relaxations and gastric dysmotility require further study. The role of anatomic malformations such as hiatal hernia in children has been underestimated. While therapeutic possibilities are greater in number and largely improved, the outcomes of some treatments are far from satisfactory in many cases. In addition to development of new forms of treatment, research should address better use of currently available medical and surgical treatments.
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Affiliation(s)
- Yvan Vandenplas
- Acacemic Children's Hospital of Brussels, Vancouber, British Columbia, Canada.
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Estevão-Costa J, Campos M, Dias JA, Trindade E, Medina AM, Carvalho JL. Delayed gastric emptying and gastroesophageal reflux: a pathophysiologic relationship. J Pediatr Gastroenterol Nutr 2001; 32:471-4. [PMID: 11396816 DOI: 10.1097/00005176-200104000-00015] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is frequent in patients with gastroesophageal reflux (GER), but its pathophysiologic role has not yet been established. To identify a relationship between DGE and GER, we assessed whether DGE increases esophageal acid exposure and the related importance of possible mechanisms. METHODS Thirty pediatric patients with pathological GER were divided according to gastric emptying scintigraphy into a DGE group (n = 14) and normal-emptying group (n = 16). The esophageal pH-monitoring parameters of the two groups were compared with respect to the individual variation between postprandial and fasting periods. RESULTS Patients with DGE had less total acid exposure than did those with normal emptying, but patients in both groups had a pathological fraction of time when pH was below 4 in both the postprandial (median: 18 vs. 27.6; P = 0.49) and fasting (8.5 vs. 23.9; P = 0.01) periods. Patients in the normal-emptying group had similar fraction of time when pH was below 4 in the postprandial and fasting periods. However, patients in the group with DGE had a fraction of time when pH was below 4 in the postprandial period that was almost double that presented in fasting period (postprandial to fasting ratio: 2.11:0.90; P = 0.002). The postprandial to fasting ratio for episodes per hour was similar in the two groups (1.81 vs. 1.79; P = 0.62). Patients with DGE had a significantly higher frequency of long episodes in the postprandial period than did those with normal emptying (62.5% vs. 38.2%; P = 0.04). The occurrence of the longest episode in the postprandial period was also significantly higher for patients with DGE (57.1% vs. 6.2%; P = 0.003). CONCLUSIONS DGE seems to accentuate postprandial reflux by increasing the volume of refluxate per episode of reflux through an underlying incompetent lower esophageal sphincter.
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Affiliation(s)
- J Estevão-Costa
- Division of Pediatric Surgery, Hospital São João, Porto, Portugal.
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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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Abstract
Gastro-oesophageal reflux (GOR) is an extremely common paediatric problem that often runs a harmless and self-limited course. Physiological GOR however can lead to marked parental anxiety, many unnecessary investigations and often unwarranted and potentially harmful therapeutic interventions. Our ability to better define GOR and gastro-oesophageal reflux disease (GORD) has improved in the past 15 years with a better understanding of the pathophysiology in infants and children due to the development and wider use of flexible endoscopy, 24-hour oesophageal pH monitoring and, more recently, the use of micromanometric methods for studying oesophageal motility. This will be further enhanced in the future with the development of non-invasive breath testing to study gastrointestinal motility and the use of electrical impedance to study fluid movement. Our therapeutic interventions have also improved particularly in the areas of acid suppression, improved surgical techniques and most recently laparoscopic fundoplication. This chapter reviews these advances in the paediatric area especially with regard to pathophysiology, diagnostic testing and therapeutic intervention.
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Affiliation(s)
- G P Davidson
- Gastroenterology Unit, Women's and Children's Hospital, 72 King William Road, North Adelaide, Adelaide, SA, 5006, Australia
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Abstract
BACKGROUND Conflicting reports exist regarding the permanence of improved gastric emptying (GE) after fundoplication for gastroesophageal reflux in children. METHODS Changes in gastric volume (GV) and GE of a radiolabeled mixed meal induced by a Nissen fundoplication (NF) were compared with those with a NF plus pyloroplasty (NF + P). GE was measured preoperatively, 15 and 30 days postoperation, in 24 Sprague-Dawley rats; 12 had NF alone, and 12 had NF + P Results were expressed as percent gastric retention at 90 minutes (GR90). GV was measured at the same time periods in 20 additional rats. RESULTS NF rats had enhanced GE with reduction of preoperative GR90 from 37.6% to 23.7% at 15 days (P < .05); however, at 30 days the GR90 increased to 34.3%. NF + P rats had enhanced GE with reduction in GR90 from 37.2% to 20.8% at 15 days (P< .05), which persisted at 30 days (20.4%). Mean GV decreased from (1.36 mL/100 g body weight) preoperation to 0.86 at 15 days (P< .05) at 15 days in the NF group, and returned to 1.29 at 30 days. Mean GV decreased from 1.36 to 0.91 at 15 days in the NF + P rats and persisted at 0.90 at 30 days. CONCLUSION In the rat model, NF enhances GE transiently, whereas NF + P produces long-term enhancement of GE.
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Affiliation(s)
- J Bustorff-Silva
- Department of Surgery, UCLA School of Medicine, Los Angeles, California 90095, USA
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24
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Abstract
Children with neurological impairment frequently have difficulties in consuming sufficient energy and other nutrients to maintain adequate nutritional status. Under-nutrition is a significant contributory factor to growth failure. Eating may be distressing and time-consuming for the child and carer. Aspiration of feeds is common and may predispose to chronic chest infections. Gastro-oesophageal reflux is also common and may contribute to significant morbidity. This paper discusses some of the issues involved in the nutritional management of neurologically impaired children.
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Affiliation(s)
- A G Thomas
- Department of Paediatric Gastroenterology, Booth Hall Children's Hospital, Manchester, UK
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Romeo C, Bonanno N, Baldari S, Centorrino A, Scalfari G, Antonuccio P, Centonze A, Gentile C. Gastric motility disorders in patients operated on for esophageal atresia and tracheoesophageal fistula: long-term evaluation. J Pediatr Surg 2000; 35:740-4. [PMID: 10813339 DOI: 10.1053/jpsu.2000.6048] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND/PURPOSE Disturbed peristalsis is reported frequently after successful repair of esophageal atresia (EA). Delayed gastric emptying could be considered a cause of symptoms of gastroesophageal reflux (GER) in patients with repaired EA. The aim of the current study was to evaluate the incidence of and to characterize gastric motility disorders in a long-term follow-up of patients operated on for EA-tracheoesophageal fistula (TEF) by studying gastric emptying with scintigraphic techniques and comparing the results with gastric manometric data. METHODS Eleven patients, between 12 and 23 years of age (median, 17) operated on for EA-TEF between 1975 and 1985, were studied. The scinthigraphic study was undertaken using a standard solid meal. The manometric study was performed using a 2.3-mm probe with 3 solid-state transducers. RESULTS Dysphagia was present in about 20% of patients. Dyspepsia was recorded in 40% of the patients. A pathological reflux was present in 2 patients. Delayed gastric emptying (T1/2 > 90') was present in 4 patients (36%). Manometric data showed alteration of gastric peristaltic activity in 5 patients (45%). CONCLUSIONS Delayed gastric emptying is frequent in long-term follow-up of patients operated on for EA-TEF. In these patients antral hypomotility also is recorded manometrically. Abnormal gastric motility can be considered as an important factor predisposing to symptoms of GER. A thorough evaluation of gastric function is recommended in symptomatic patients after EA repair.
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Affiliation(s)
- C Romeo
- Institute of Pediatric Surgery, Policlinico Viale Gazzi, Messina, Italy
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26
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Abstract
BACKGROUND/PURPOSE Nissen gastroesophageal fundoplication (GEF) increases gastric emptying (GE); however, the duration and the mechanisms for this improvement in GE remain unclear. The aim of this study was to evaluate the effects of a GEF on GE of a mixed meal, and to determine the correlation between GE and changes in intragastric pressure (IGP) and compliance. METHODS Using a radiolabeled mixed meal, GE was measured preoperatively 15 and 30 days after operation in 24 Sprague-Dawley rats divided into SHAM and GEF groups. Results were expressed as percent gastric retention at 90 minutes (GRg90), and time to evacuate 50% of the isotope meal (T1/2). Changes in IGP and compliance were determined at the same time-points using a different set of 20 rats. RESULTS Fifteen days after surgery, GR90 and T1/2 in the GEF group were reduced significantly when compared with preoperative values but returned to near preoperative values 30 days postoperation. In contrast, rats from the SHAM group showed no change in GR90 and T1/2 at 15 days and 30 days postoperation. Immediately after GEF, maximal distension of the stomach resulted in pressures 65% higher than those recorded before operation (20.2 v 11.7 mm Hg; P< .05), which persisted on the 15th postoperative day (17.7 v 10.7 mm Hg; P<.05). On the 30th postoperative day, however, there was no difference in the IGP between rats undergoing GEF compared with those undergoing a SHAM operation (11.7 v 12.0 mm Hg; P < .05). Similarly, mean gastric compliance decreased significantly immediately after and 15 days after GEF, but returned to preoperative levels 30 days after the operation. CONCLUSIONS In a rat model, GEF produces a transitory increase in GE, which is related to a simultaneous decrease in gastric volume and compliance. However, 30 days after GEF, associated with an elevated IGP, gastric volume increases and GE returns to preoperative levels.
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Affiliation(s)
- J Bustorff-Silva
- Department of Surgery, UCLA School of Medicine, Los Angeles, CA 90095, USA
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