Motor function of the esophagus and the lower esophageal sphincter in children who undergo laparoscopic nissen fundoplication

New insights in gastroesophageal reflux, esophageal function and gastric emptying in relation to dysphagia before and after anti-reflux surgery in children

In children with gastroesophageal reflux (GER) disease refractory to pharmacological therapies, anti-reflux surgery (fundoplication) may be a treatment of last resort. The applicability of fundoplication has been hampered by the inability to predict which patient may benefit from surgery and which patient is likely to develop post-operative dysphagia. pH impedance measurement and conventional manometry are unable to predict dysphagia, while the role of gastric emptying remains poorly understood. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis (AIM) analysis, which relates bolus movement and pressure generation within the esophageal lumen.

Gastroesophageal reflux, esophageal function, gastric emptying, and the relationship to dysphagia before and after antireflux surgery in children

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.

The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review

BACKGROUND

Antireflux surgery (ARS) for gastroesophageal reflux disease (GERD) is one of the most frequently performed major operations in children. Many studies have described the results of ARS in children, however, with a wide difference in outcome. This study aims to systematically review the efficacy of pediatric ARS and its effects on gastroesophageal function, as measured by gastroesophageal function tests. This is the first systematic review comprising only prospective, longitudinal studies, minimizing the risk of bias.

METHODS

Three electronic databases (Medline, Embase, and the Cochrane Library) were searched for prospective studies reporting on ARS in children with GERD.

RESULTS

In total, 17 eligible studies were identified, reporting on a total of 1,280 children. The median success rate after ARS was 86% (57-100%). The success rate in neurologically impaired children was worse in one study, but similar in another study compared to normally developed children. Different surgical techniques (total versus partial fundoplication, or laparoscopic versus open approach) showed similar reflux recurrence rates. However, less postoperative dysphagia was observed after partial fundoplication and laparoscopic ARS was associated with less pain medication and a shorter hospital stay. Complications of ARS varied from minimal postoperative complications to severe dysphagia and gas bloating. The reflux index (RI), obtained by 24-h pH monitoring (n = 8) decreased after ARS. Manometry, as done in three studies, showed no increase in lower esophageal sphincter pressure after ARS. Gastric emptying (n = 3) was reported either unchanged or accelerated after ARS. No studies reported on barium swallow x-ray, endoscopy, or multichannel intraluminal impedance monitoring before and after ARS.

CONCLUSION

ARS in children shows a good overall success rate (median 86%) in terms of complete relief of symptoms. Efficacy of ARS in neurologically impaired children may be similar to normally developed children. The outcome of ARS does not seem to be influenced by different surgical techniques, although postoperative dysphagia may occur less after partial fundoplication. However, these conclusions are bound by the lack of high-quality prospective studies on pediatric ARS. Similar studies on the effects of pediatric ARS on gastroesophageal function are also very limited. We recommend consistent use of standardized assessment tests to clarify the effects of ARS on gastroesophageal function and to identify possible risk factors for failure of ARS in children.

Laparoscopic fundoplication for gastroesophageal reflux disease in infants and children

The number and types of minimally invasive surgical procedures being performed in children have increased exponentially in the last 15 years. Laparoscopic fundoplication is commonly performed for gastroesophageal reflux disease (GERD), although the population of patients who undergo this procedure is different in adults and children. In Japan, laparoscopic fundoplication has become a standard procedure, even for children with neurological impairment; however, its indications remain controversial. In this article we review the status of laparoscopic antireflux surgery for infants and children, looking at its indications, the procedures available, the complications, and the training required to perform the procedure safely and effectively.

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

BACKGROUND

The laparoscopic Nissen fundoplication has become a frequently performed procedure in infants and children who suffer from gastroesophageal reflux disease (GERD). In this study we describe our 8-year experience with 106 consecutive laparoscopic Nissen fundoplications.

METHODS

From January 1994 to May 2002, we included 106 consecutive patients (57 neurologically normal (NN) and 49 neurologically impaired (NI)). The indications were symptomatic GERD, pulmonary symptoms or a combination of both. Patient's outcome was assessed by symptom evaluation, technical examinations and a questionnaire.

RESULTS

Mortality was 0% and conversion rate was 2.8%. Major postoperative complications occurred in 12 patients, mostly neurologically impairment. Dysphagia occurred in 23 patients of which 4 required dilatations and 2 a redo Nissen. Gas bloating occurred in 15 children, with spontaneous regression in all. Recurrent pneumopathies were seen in four children. Documented recurrence of reflux occurred in three symptomatic patients. Redo laparoscopic surgery was performed in six patients. A questionnaire was sent to each patient's parents. This showed that most patients had a normal or clearly improved quality of life (93.1% NN, 90.5% NI). Most patients were satisfied with the result and up to 39.5% gave a maximum satisfaction score.

CONCLUSION

The laparoscopic Nissen fundoplication can safely be performed with a low conversion rate and no surgical mortality in neurologically normal and neurologically impaired children. Neurologically impaired children are more susceptible to per- and postoperative complications. A good quality of life and a high index of satisfaction could be achieved in most patients.

Effectiveness of esophageal manometry in predicting the outcome of children with primary GER after floppy Nissen-Rossetti wrap

BACKGROUND

Surgical treatment of gastroesophageal reflux (GER) can result in many postoperative problems because of an incorrect indication or an unsuitable fundoplication. Many preoperative tests have been suggested to perform a "tailored fundoplication," but there is no clear evidence as to which is the best. The aim of our study was to define the effectiveness of esophageal manometry in predicting the outcome of children who need fundoplication because of refractory primary gastroesophageal reflux.

METHODS

Thirty-two children were included in the study. Patients with gastroenterologic and respiratory symptoms numbered 10 (31%) and 22 (69%), respectively. The preoperative motility pattern was (1) inappropriate relaxations alone in nine patients (28%) and associated with esophageal body dysmotility in one patients (3%); (2) low-pressure lower esophageal sphincter (LES), alone in 13 patients (41%) and associated with body dysmotility in eight (25%). Motility pattern of the esophageal body was abnormal in nine children. Manometric anomalies were absent only in one case.

RESULTS

Low pressure of the LES associated with atypical esophageal motility disorders was significantly higher in the gastroenterological group and in the older patients. Low pressure of the LES associated with good esophageal activity was significantly higher in the respiratory group and in the patients younger than 24 months. There was no correlation between motility pattern and outcome, and no statistically significant differences were found between pressure values at the different levels and symptoms, outcome, and age groups.

CONCLUSIONS

Esophageal manometry is not mandatory to predict the outcome of patients undergoing laparoscopic Nissen-Rossetti fundoplication for refractory primary GER treatment.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Laparoscopic fundoplication and gastrostomy

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.