Surgical management of pediatric gastroesophageal reflux disease

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children

BACKGROUND

Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies.

METHODS

The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated.

RESULTS

Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563.

CONCLUSION

Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Gastroesophageal reflux disease in children: What's new right now?

Gastroesophageal reflux (GER) in children is very common and refers to the involuntary passage of gastric contents into the esophagus. This is often physiological and managed conservatively. In contrast, GER disease (GERD) is a less common pathologic process causing troublesome symptoms, which may need medical management. Apart from abnormal transient relaxations of the lower esophageal sphincter, other factors that play a role in the pathogenesis of GERD include defects in esophageal mucosal defense, impaired esophageal and gastric motility and clearance, as well as anatomical defects of the lower esophageal reflux barrier such as hiatal hernia. The clinical manifestations of GERD in young children are varied and nonspecific prompting the necessity for careful diagnostic evaluation. Management should be targeted to the underlying aetiopathogenesis and to limit complications of GERD. The following review focuses on up-to-date information regarding of the pathogenesis, diagnostic evaluation and management of GERD in children.

[Robot-Assisted Repeated Fundoplication in Children and Adolescents]

BACKGROUND

Recurrent gastroesophageal reflux symptoms in adolescents and young adults who underwent fundoplication in childhood present a technical challenge for the surgeon. The distal oesophagus and hiatus are difficult to access by laparotomy, the anatomy is modified by the primary procedure, and there are often dense adhesions between important structures. Robot-assisted surgery may be advantageous, because of the three dimensional (3D) view and the multiaxial freedom of movement afforded by the system.

PURPOSE

To describe our experience with robot-assisted Nissen re-fundoplication in adolescents who underwent primary fundoplication in childhood.

METHODS

The video shows the individual steps in robotic repeated fundoplication using the robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Three patients were operated with fundoplication at the age of 15 ± 2 years due to gastroesophageal reflux disease. After an average of 11,8 years after the primary procedure, they showed pathological reflux symptoms, which indicated repeated Nissen fundoplication.

RESULTS AND DISCUSSION

The 3D vision of the robotic system provided the surgeon with a good overview of the operative field. In addition, it allowed accurate dissection of the predictable adhesions around the hiatus. Mean operating time from incision to closure in the robot-assisted re-fundoplication was 174 min. Neither intra- nor postoperative complications occurred. As in conventional laparoscopic technique, there is a learning curve for the robotic surgery that can be appreciated from our data. Shorter dissection times and simplified dissection are potential benefits that need to be balanced with the higher cost of the robotic technique.

CONCLUSION

Robot-assisted re-fundoplication is an excellent alternative to the conventional laparoscopic procedure in young adults with recurrent gastroesophageal symptoms, who had a fundoplication in early childhood. The 3D-vision and the multi-axial free mobility of the instruments facilitate precise dissection that consider anatomic structures and adhesions.

Optimizing the Use of Medications and Other Therapies in Infant Gastroesophageal Reflux

Gastroesophageal reflux (GER) is the retrograde movement of gastric (and sometimes duodenal) contents into the esophagus. While the majority of GER is physiologic, for patients, it can be associated with symptoms. While some symptoms are merely bothersome (crying), others can be life threatening (cough, gagging, choking). The main driver of GER in infants is the frequent feedings that produce increased intra-abdominal pressure, which is known to trigger transient relaxations of the lower esophageal sphincter. The recent 2018 clinical practice guidelines reported by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN/ESPGHAN) have recommended non-pharmacologic management initially with subsequent consideration of brief trials with acid suppressants. The main target for these acid suppressants is the gastric parietal cells. Our review of the literature has revealed a paucity of data regarding the use of histamine-2 receptor antagonists and proton pump inhibitors in infants. Despite the absence of well-controlled clinical studies, the prescription rate of these medications has increased internationally. Risks to patients of all ages have become increasingly recognized, with new associations being reported all too often. Here we report our review of all pharmacologic modalities as well as some non-surgical options.

Current status of surgical management of gastroesophageal reflux in children

PURPOSE OF REVIEW

Surgical therapy for gastroesophageal reflux disease (GERD) is controversial with considerable debate ranging from the indications for antireflux surgery to surgical technique. This article will attempt to clarify these issues with the most up-to-date information available on the prevalence, pathophysiology, diagnosis, and surgical treatment of GERD in children. Although laparoscopic Nissen fundoplication (LNF) has become the most popular operation performed for pathologic reflux, its superiority over both open surgery and other types of fundoplication is not well established.

RECENT FINDINGS

Large retrospective studies suggest LNF has a lower complication rate than open surgery. However, three prospective randomized controlled trials have been published recently which cast doubt on the superiority of LNF and suggest that LNF may have a higher failure rate compared to open fundoplication. Antireflux surgery has higher morbidity and failure rates in infants and in children with neurologic impairment.

SUMMARY

Based on the best available evidence, LNF may be less morbid, but have a higher rate of failure than open surgery. Pediatric surgeons should be mindful of the risks and benefits of both approaches to best counsel their patients. Larger prospective randomized controlled trials are needed to determine the best treatments for pediatric GERD.