Efficacy of anterior gastric fundoplication in the treatment of gastroesophageal reflux in infants and children

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastric emptying procedures decrease the risk of postoperative recurrent reflux in children with delayed gastric emptying

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.

Laparoscopic Nissen fundoplication in disabled infants and children

During a 16-month period, 15 neurologically impaired infants and children for whom medical treatment failed underwent laparoscopic fundoplication. The indications for surgery included feeding difficulties, vomiting, and recurrent chest aspiration. The patients' weight range was 3.9 and 42 kg (6 weighed less than 12 kg). Access was modified according to each patient's size and shape. The average operating time was 2.2 hours (range, 1.4 to 3) for fundoplication and 3.1 hours (range, 2.3 to 4.1) for fundoplication with gastrostomy. Two patients had conversion to open surgery because of hypercarbia or perforated oesophagus. Use of postoperative analgesia was limited to the first 24 hours, and fluid intake and feeding were begun on days 1 and 2, respectively. Gas bloating was common postoperatively, and diarrhoea developed in three children. Twelve patients had clinical improvement, and a recurrent hiatus hernia developed in one. Laparoscopic fundoplication can be successful; however, awareness of the differences in technique for paediatric (disabled children in particular) and adult patients is essential. The technique deserves further investigation.

Gastroesophageal reflux in childhood

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

Gastroesophageal reflux. Diagnostic and therapeutic approaches

The clinical challenge of determining the medical conditions that are associated with obvious symptoms of gastroesophageal reflux and what diagnostic tests are appropriate to define this relationship is substantial. To determine which infants may be suffering from pathologic conditions associated with subtle signs of gastroesophageal reflux is even more challenging. This determination is essential to avoid subjecting many healthy infants to costly and potentially invasive testing. This article focuses on the physiology, clinical presentations, diagnosis and evaluation, and therapy of gastroesophageal reflux.