Laparoscopic fundoplication in children--an audit of fifty cases

Critical evaluation of new laparoscopic procedures in childhood are essential. The aim of this study was to audit fifty laparoscopic fundoplications in children.

METHOD

Evaluation of the financial implications, hospital stay, analgesia requirements, operative morbidity and symptom control was undertaken.

RESULTS

50 laparoscopic fundoplications were performed on children (6 months to 13 years) with a median follow-up period of 31.8 months. The conversion rate to an open procedure was 8%. The median length of opiate requirement for opiate analgesia was 1 day (range 1-5), post-operative stay 2 days (range 2-15). The operative morbidity was 8% (respiratory infection, pneumothorax, two patients, oesophageal perforation one patient). The recurrences rate was 6%. Whilst a prospective randomised trial is essential to satisfy the requirements of evidence-based medicine, the results of our review of laparoscopic fundoplication are encouraging.

Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication

Laparoscopic Nissen fundoplication has been applied with increasing frequency in the treatment of gastroesophageal reflux disease. The aim of this study was to determine the variables that predict outcome of laparoscopic Nissen fundoplication. A multivariate analysis was performed on data from 199 consecutive patients undergoing laparoscopic Nissen fundoplication. Variables included age, sex, body mass index, primary symptoms, clinical response to acid suppression therapy, erosive esophagitis, 24-hour esophageal pH score, and the percentage of time the esophageal pH was less than 4 on 24-hour pH monitoring, lower esophageal sphincter competence, status of the esophageal body motility, hiatal hernia, carditis, intestinal metaplasia of cardiac epithelium limited to the gastroesophageal junction, and Barrett's esophagus of any length. Clinical outcome was obtained from all patients at a median follow-up of 15 months (range 6 to 74 months) after surgery. One hundred seventy-three patients had an excellent or good outcome (87%) and 26 had a fair or poor outcome. Three factors were significantly predictive of a successful outcome: an abnormal 24-hour pH score (odds ratio = 5.4; 95% confidence interval [CI] = 1. 9-15.3), a typical primary symptom (odds ratio = 5.1; 95% CI = 1. 9-13.6), and a clinical response to acid suppression therapy (odds ratio = 3.3; 95% CI = 1.3-8.7). We conclude that 24-hour pH monitoring provides the strongest outcome predictor of laparoscopic Nissen fundoplication and that outcome is based more on the correct identification of the disease than on its severity.

[Laparoscopic anti-reflux surgery--report of experiences in Austria]

In Austria neither the open nor the laparoscopic fundoplication can be described as a routine operation. The number of laparoscopic operations is increasing year by year, the indication for surgery is more determined by radiological than by functional diagnostic tools. In our own patients the complication rate in 196 laparoscopic operations is 6%, regarding symptoms of reflux and dysphagia. Dysphagia was found only in cases with 360 degrees fundoplication, whereas recurrent reflux occurred in 270 degrees hemifundoplications (Toupet). The mortality rate following laparoscopic fundoplications was zero, morbidity below 10%.

[Laparoscopic anti-reflux surgery--report of experiences from Germany]

This is a report on a questionnaire in Germany reflecting the activity in antireflux surgery, both in open and laparoscopic modifications in the time period of 1990 through 1995. It serves as an overview of the acceptance of diagnostic workup, indication, applied techniques, and different antireflux procedures. In a total of 104 representative hospitals, 2,036 patients were operated during this time. Almost 80% of the hospitals provide antireflux surgery in the open technique and only 1/3 of the hospitals have experience in the laparoscopic technique. There is a total rise in antireflux surgery during the last 5 years, since the number of laparoscopic antireflux operations rises constantly with a total amount of open operations of about 250 cases per year. In open surgery the most favourite technique is the Nissen-Rossetti procedure, while in laparoscopic technique the choice for the original Nissen, the Nissen-Rossetti, or the floppy Nissen technique is divided in almost equal parts.

[Surgical treatment of gastroesophageal reflux disease]

Antireflux surgery is successful in 85-90% of eligible patients, with relief of symptoms, cure of oesophagitis and possibly prevention of progression of the dysplasia in a Barrett's oesophagus. The mortality in the latest publications is given as 0.05%. The morbidity, apart from recurrences, is not yet sufficiently known. Some 250 antireflux operations are performed annually in the Netherlands, fewer than 20% of the estimated requirement of 10 operations per 100,000 of the population per year, and also fewer than in Scandinavia. Nissen fundoplication (folding the fundus of the stomach around the entire circumference (360 degrees) of the oesophagus) is generally accepted as the standard primary operation. Nissen fundoplication during laparoscopy seems to be just as good. Results of randomized clinical trials will have to be awaited to prove this assumption. Belsey's operation (folding the fundus around 270 degrees of the circumference of the oesophagus via thoracotomy) is nowadays performed almost exclusively in recurrent reflux disease and in persistent dysphagia after a primary operation.

Comparison of outcomes of open versus laparoscopic Nissen fundoplication performed in a single practice

BACKGROUND

We reviewed Nissen fundoplications performed in a single practice from January 1989 to March 1997, encompassing our transition from open to laparoscopic procedures. Because all operations were done by two surgeons in the same two hospitals, the study is well controlled for comparisons.

METHODS

Records of 271 consecutive patients were reviewed.

RESULTS

From 1989 to 1992 all patients underwent open fundoplication (n = 78). Thereafter, with increasing frequency, laparoscopic fundoplication was performed. The laparoscopic group was slightly younger (48 +/- 14 years) than the open group (54 +/- 13 years), but gender distribution and body mass index (BMI) did not differ. Mean operating time for laparoscopic cases was 163 +/- 58 minutes compared with 148 +/- 59 minutes for open cases (NS). Intraoperative complication rate was 8% for both groups. Length of hospitalization was shorter for patients undergoing laparoscopic surgery (2.4 days versus 7.2 for open procedures, P <0.05). In follow-up, 82% of the open Nissen group were asymptomatic compared with 84% of the laparoscopic Nissen group. The same proportion of patients required reoperation for dysphagia (3% for each group). Of patients who had the open procedure, 21% had wound complications. None of those treated laparoscopically had long-term morbidity from trocar insertion sites.

CONCLUSION

Equal effectiveness in treating reflux combined with shorter hospitalization and absence of wound complications makes the laparoscopic approach the preferred method for performing fundoplication.

Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients

OBJECTIVE

To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States.

DESIGN

During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients.

RESULTS

Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used.

CONCLUSION

The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

The failure rate of surgery for gastro-oesophageal reflux

PURPOSE

The aim of this study was to document the presenting symptomatology and radiological findings of failed fundoplication, to determine the risk factors involved in recurrent gastro-oesophageal reflux, and to assess the results of revisional surgery.

METHODS

Sixty-six patients requiring redo fundoplication during the past 15 years were studied. Sixty children had their initial fundoplication performed at our institution.

RESULTS

The median time from initial fundoplication to the diagnosis of failure was 1.5 years. The main presenting symptoms were severe retching (n = 33), recurrent vomiting and aspiration (n = 26) and intolerable gas bloat (n = 7). Severe dysphagia occurred in two children with tight Nissen fundoplications. Contrast radiographic studies demonstrated fundoplication failure and correlated with the operative findings in 85% of cases. Risk factors for failure comprised hypertonic cerebral palsy, severe learning difficulties, oesophageal atresia, CHARGE syndrome, and tracheomalacia. The cause for the fundoplication failure included herniation of the fundoplication into the posterior mediastinum (failed crural repair, n = 30), disruption of the wrap (n = 10), combination of herniation and disruption (n = 22), and a tight wrap (n = 4). After revisional surgery, 13 children had persisting symptoms, five of whom underwent a third antireflux procedure.

CONCLUSIONS

The predominant cause of fundoplication failure is herniation into the posterior mediastinum, which occurred most frequently in children with hypertonic cerebral palsy. This may be prevented by meticulous attention to accurate apposition of the crura at initial procedure. Redo fundoplication failed to resolve the preoperative symptoms in 20%, with five children requiring a third fundoplication.

Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study

BACKGROUND

Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study.

METHODS

Some 110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups.

RESULTS

Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result.

CONCLUSIONS

Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Gastroesophageal reflux and severe combined immunodeficiency

BACKGROUND

Gastrointestinal and respiratory symptoms and failure to thrive not associated with infections or medications were noted in patients with severe combined immunodeficiency.

OBJECTIVE

The aim of our study was to determine the frequency of gastroesophageal reflux in patients with severe combined immunodeficiency.

METHODS

We studied the case histories of 73 pediatric patients who had been treated at Duke University Medical Center for severe combined immunodeficiency between 1982 and 1995. Charts were reviewed for documentation of gastroesophageal reflux on the basis of clinical course and results of barium swallow, esophageal pH probe monitoring, or endoscopy. To compare the incidence of gastroesophageal reflux in patients with severe combined immunodeficiency to known high-risk populations, we additionally tabulated the underlying diagnoses in an age-matched group of patients who underwent Nissen fundoplication from 1990 to 1995.

RESULTS

We found clinically significant gastroesophageal reflux in 15 of the 73 patients (20.5%), much higher than has been reported in the normal population (0.1% to 0.3%, p < 0.001). Of patients treated between 1990 and the present, 10 of 36 (27.7%) had significant gastroesophageal reflux compared with five of 37 patients (13.5%) in the previous years. Thus with greater recognition and improved methods for diagnosis, the observed incidence of gastroesophageal reflux has increased greatly. The clinical presentations were not different from those of patients with other well-documented underlying diagnoses. Seven of the 15 patients (46.6%) did not respond to medical treatment with antacids, H2-blockers, and prokinetic agents and underwent surgical treatment. Indications for surgery included persistent esophagitis, vomiting, pneumonia, and growth failure.

CONCLUSIONS

The reason for the high incidence of gastroesophageal reflux in patients with severe T-cell disorders remains unclear. Considering the frequency of this association, early recognition and treatment is important to enable adequate nutrition and prevent damage to the esophagus and lungs.

Illness behavior influences the outcome of laparoscopic antireflux surgery

BACKGROUND

While gastroesophageal reflux is amenable to medical and surgical treatment, the severity of pathophysiologic changes of the disease correlates poorly with the symptomatology. Similarly, the overall successful outcome of surgical therapy can be lessened by the poor outcome in a small number of patients despite the technical success of the operation. We conducted a study to determine the influence of illness behavior on the outcome and efficacy of laparoscopic Nissen fundoplication.

STUDY DESIGN

From a larger group of patients undergoing a laparoscopic Nissen fundoplication, 77 patients (57 male, 20 female) completed an illness behavior questionnaire before and after surgery. This previously validated questionnaire assessed 10 scales of illness behavior. The results were compared with visual analog scales of outcome for overall satisfaction, heartburn, and solid food dysphagia, which were elicited independently from a standardized clinical follow-up questionnaire.

RESULTS

Patients completed the questionnaire on average 2 months before and 25 months after surgery. High preoperative and postoperative scores for the "affective" and "hypochondriacal" scales were associated with poorer satisfaction with the surgical outcome. Although successful relief of reflux symptoms was unrelated to any preoperative illness behavior scale, postoperative scores for "disease conviction" and "disease affirmation" were predictors of further symptomatic heartburn in a small group of patients. Dysphagia did not correlate with illness behavior. When preoperative and postoperative scores were compared, no change in illness behavior was demonstrated, with the exception of lower scores for disease conviction and disease affirmation.

CONCLUSIONS

These results suggest that while patient perception of disease is improved by laparoscopic fundoplication, patient satisfaction with the surgical outcome is in part determined by preoperative illness behavior.

Dysphagia after laparoscopic antireflux surgery. The impact of operative technique

BACKGROUND

Concerns about laparoscopic antireflux surgery include the frequent appearance of troublesome postoperative dysphagia. This study reviews the frequency of early (less than 6 weeks) and persistent (greater than 6 weeks) solid food dysphagia in patients undergoing Toupet, Rosetti-Nissen, or Nissen fundoplications.

METHODS

One hundred eighty-four consecutive patients with normal esophageal peristalsis undergoing laparoscopic antireflux surgery were prospectively studied. Before operation, all patients had endoscopy, 24-hour pH study, and an esophageal motility study. The choice of operation was dependent on anatomy and surgeon preference. Before discharge, all patients were given instructions on a soft diet. Postoperative symptoms were scored by the patients as absent, mild, moderate, or severe 4 weeks and 12 weeks after operation. The option of esophageal dilation was offered to patients with moderate to severe persistent solid food dysphagia.

RESULTS

New onset moderate to severe dysphagia to solid foods was present in 30 (54%), 8 (17%), and 13 (16%) patients undergoing Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively, in the first month after operation (p < 0.001). Moderate to severe dysphagia persisted at 3 months in six (11%), one (2%), and two (2%) patients undergoing laparoscopic Rosetti-Hell, Nissen, and Toupet fundoplications, respectively (p < 0.05). Esophageal dilatation was performed in five (4%), zero, and one (1%) patients undergoing laparoscopic Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively (p < 0.05). There was no additional morbidity related to division of short gastric vessels in patients undergoing Nissen fundoplication.

CONCLUSIONS

Laparoscopic Rosetti-Nissen fundoplication is associated with a higher rate of early and persistent postoperative dysphagia than either laparoscopic Nissen fundoplication or Toupet fundoplication. Consideration of complete fundus mobilization should be a part of all laparoscopic antireflux procedures.

Thal fundoplication in neurologically impaired children

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.

Laparoscopic fundoplication: a natural extension for the thoracic surgeon

BACKGROUND

Thoracic surgeons have historically played a significant role in surgical treatment of benign esophageal disorders. With the advent of video-assisted thoracic surgical techniques, chest surgeons have also become adept at minimally invasive procedures. Thus, it seems appropriate that thoracic surgeons participate in minimally invasive antireflux operations, such as laparoscopic Nissen fundoplication.

METHODS

From February 1993 to May 1995, 66 patients (32 male, 34 female) with a mean age of 45.5 years (range, 15 to 82 years) underwent a laparoscopic fundoplication. Gastroesophageal reflux disease was diagnosed on the basis of history and endoscopically documented esophagitis or abnormal esophageal pH testing or both. There were 45 type I, 3 type II, and 7 type III hiatal hernias. Eleven patients had gastroesophageal reflux disease with no hernia.

RESULTS

Conversion to laparotomy occurred in 6 patients (9%) due to bleeding in 2 patients, inability to expose the gastroesophageal junction in 3, and gastric laceration in 1 patient. All but 1 patient underwent a Nissen fundoplication performed over a 50F to 60F dilator. The remaining patient (type II hernia without gastroesophageal reflux disease) underwent a reduction, closure, and anterior gastropexy. There was no operative mortality. Immediate postoperative morbidity included moderate dysphagia in 7 patients (11%), ileus in 2 patients (3%), and deep venous thrombosis and atrial arrhythmia in 1 each (1.5%). Excluding 1 patient hospitalized for 42 days due to severe psychosis, the mean postoperative stay was 4.0 +/- 2.5 days (median, 3 days). Three patients (5%) required dilation for dysphagia, and 1 (1.5%) has noted recurrent reflux during follow-up (mean, 14.4 months; range, 6 to 30 months). A single patient has undergone reoperation for persistent dysphagia (1.5%).

CONCLUSIONS

A laparoscopic Nissen procedure is safe, effective treatment for refractory gastroesophageal reflux disease when performed by thoracic surgeons experienced in minimally invasive surgical procedures.

Objective assessment of gastroesophageal reflux after short esophagomyotomy for achalasia with the use of manometry and pH monitoring

The role of an antireflux procedure as an adjunct to esophagomyotomy for achalasia remains a subject of controversy. Little objective documentation exists of this operation's effect on sphincteric competence and the degree of postoperative gastroesophageal reflux. This report of esophageal manometry and 24-hour pH monitoring on 14 patients with esophageal achalasia whom we had previously treated by a short esophagomyotomy without an antireflux procedure provides such documentation. Esophagomyotomy reduced lower esophageal sphincter pressure by 12% to 71% (mean 41%) from a preoperative mean of 26.7 mm Hg to a postoperative mean of 14.6 mm Hg. The number of postoperative episodes of acid reflux per patient in 24 hours was fewer than 29 (normal < 49) in 13 patients, with a median of 12 episodes for the entire group. Esophageal acid exposure, measured as percentage of total time with pH less than 4.0 (normal < 4.5%), was below 4.5% in 10 patients, six of whom had values less than 1%. Among the four patients with values greater than 4.5%, only one had a temporal correlation of symptoms with an episode of acid reflux. Multivariate analysis showed that esophageal acid exposure time correlated only with the level of residual lower esophageal sphincter pressure during the relaxation phase of deglutition. A pressure less than 8 mm Hg was predictive of normal acid contact time (p < 0.001). Mean lower esophageal sphincter pressure, percent reduction in lower esophageal sphincter amplitude, postoperative vector volume, and length of the lower esophageal sphincter did not significantly correlate with amount of esophageal acid exposure. We conclude that a short esophagomyotomy without an antireflux procedure results in a competent lower esophageal sphincter in most patients. Increased esophageal acid exposure, when it occurs, is due to slow clearance of esophageal acid from relatively few reflux episodes and is more likely to occur when there is a high residual pressure during deglutition after myotomy. These findings suggest that the addition of an antireflux procedure to a short esophagomyotomy would not be expected to improve clinical results.

Laparoscopic fundoplication: the alternative to long-term medical therapy for severe gastroesophageal reflux disease

Gastroesophageal reflux disease is common. Fundoplication is very effective for those patients who fail medical therapy, particularly those with an incompetent lower esophageal sphincter. Open surgery is reported to achieve cure rates in excess of 90 percent. Laparoscopic fundoplication has been performed since 1991. The early experience with this procedure is reviewed.

RESULTS

1992 cases were reported in the literature. The mortality rate was 0.1 percent. Operative complications occurred as follows: 0.9 percent esophagogastric perforation rate; 0.6 percent bleeding rate (requiring transfusion); and 0.6 percent pneumothorax rate. No splenectomies were reported. 4.8 percent of patients required conversion to the open procedure. As experience with the procedure is gained this conversion rate decreases. Recurrent reflux postoperatively is 3.4 percent, but follow-up is short (range: 0 to 36 months; mean: two years). Dysphagia requiring dilatation occurs in 3.5 percent of patients. Gas bloat occurs in 0 to 24 percent of patients. These results compare favorably with the published results of medical therapy and the open fundoplication.

CONCLUSIONS

The early experience with laparoscopic fundoplication appears promising and provides an attractive alternative to long-term medical therapy and to open surgery in appropriate patients. Long-term follow-up is awaited.

Laparoscopic control of short gastric vessels

BACKGROUND

The Nissen fundoplication is currently the most commonly performed antireflux surgery whether performed as an open procedure or through the laparoscope. Extensive experience with open Nissen fundoplication has shown that dividing the short gastric vessels to mobilize the fundus ensures that the wrap will be loose and without tension. The standard laparoscopic technique for fundal mobilization is dissecting out the short gastric vessels, applying hemoclips, and then dividing them. For surgeons new to laparoscopic surgery, this can be an intimidating task. Introduction of the ultrasonic coagulating shears, a new energy source technology, offered the possibility of making this process quicker and easier.

STUDY DESIGN

We present a randomized prospective study comparing two methods of ligating the short gastric vessels during laparoscopic fundoplication. Thirty-one patients were enrolled and randomized into two groups: those who underwent short gastric ligation by dissection, clipping, and dividing, and those in whom the ultrasonic laparoscopic coagulating shears were used. The results were tabulated and subjected to statistical analysis.

RESULTS

Fifteen patients had laparoscopic fundoplication with ligation of the short gastric vessels by using clips and 16 by using the ultrasonic coagulating shears. There was no demographic difference between the two groups and the number of short gastric vessels ligated was the same in both groups. Significance was seen for the median operating time for short gastric control (22 minutes for clipping versus 12 minutes for coagulating shears), median blood loss (70 mL for clipping versus 2.5 mL for the ultrasonic coagulating shears), and technical difficulty (93 percent with clipping versus 19 percent with the coagulating shears).

CONCLUSIONS

Based on the results from this randomized prospective study, the ultrasonic coagulating shears are easier to use and less prone to intraoperative "complications" and postoperative morbidity. We believe that this new technology will make it easier and more desirable for surgeons to mobilize the gastric fundus during laparoscopic fundoplication.

Wrap session: is the Nissen slipping? Can medical treatment replace surgery for severe gastroesophageal reflux disease in children?

For over 20 yr, antireflux surgery has been the treatment of choice for severe gastroesophageal (GE) reflux disease in children, and antireflux operations are said to be the commonest major surgical procedures performed by pediatric surgeons in North America. Yet, only recently have the results of surgery been more closely examined; both the surgical morbidity and operative failure rates have been found to be particularly high in children with neurological impairment, repaired esophageal atresia, and chronic lung disease. Of interest, these groups of children are among those most at risk for developing severe GE reflux disease in the first place. Close examination of surgical reports also raises some questions about the indications for surgery in some children, specifically whether the presence of severe GE reflux disease had been established before surgery and whether a trial of appropriate medical management had been given. Failure of medical management has always been an accepted indication for surgery. However, in the past the medical management that was available for children was ineffective because drug dosages were not optimized (H2-receptor antagonists), the drugs had side effects precluding their use long term or in high doses (bethanechol, metoclopramide), or they were simply insufficiently potent to treat severe GE reflux disease (all the above drugs plus cisapride). Thus, in the past, failure of medical management did not mean failure of very much. In contrast, the proton pump inhibitor omeprazole has recently been shown to be effective and safe for the treatment of severe childhood GE reflux disease refractory to other medical treatments and where antireflux surgery has failed. The issues of why certain groups of children are at highest risk for severe GE reflux disease are discussed as are the outcomes and roles of surgical and medical treatment for all groups of children with severe GE reflux disease. The options of antireflux surgery or omeprazole should be reserved for those children with severe GE reflux disease, e.g., GE reflux accompanied by a complication.

Trends in the use of fundoplication in children with gastro-oesophageal reflux

OBJECTIVE

To document changing trends in the indications for fundoplication in children with gastro-oesophageal reflux and to identify the main shortcomings and complications of the procedure.

METHODOLOGY

Retrospective review of 405 consecutive children undergoing fundoplication between 1978 and 1992 inclusive.

RESULTS

Trends in the indications for fundoplication related to broadening of its use in those with severe neurological impairment and uncontrolled reflux, and to changes in the management of patients in the neonatal period. Complications included unwrapping with recurrence of reflux, hiatal hernia, adhesive small bowel obstruction, dumping syndrome, post-operative persistence of oesophageal stricture, excessively tight wrap and poor oesophageal clearance (mostly in oesophageal atresia patients).

CONCLUSIONS

This study identified those patients most likely to develop complications following fundoplication. This may assist in the pre-operative assessment of the likely benefit of fundoplication in children who often have other complex problems.