Survival of children following Nissen fundoplication

Jejunal Feeding by Gastrojejunal Tube in Pediatric Refractory Gastroesophageal Reflux Disease

OBJECTIVES

The objective of this study is to determine whether jejunal nutrition by gastrojejunal tube (GJT) could be a therapeutic option for refractory gastroesophageal reflux disease (GERD), avoiding further antireflux surgery.

METHODS

A monocentric retrospective study was conducted for all children <18 years who underwent GJT placement to treat GERD. We collected data at the first GJT placement, 5 months after last GJT withdrawal, and at the end of the follow-up (June 2021).

RESULTS

Among 46 GERD patients with 86 GJT, 32 (69.6%) and 30 (65.2%) avoided antireflux surgery 5 and 28 months, respectively, after the definitive GJT removal. Five months after GJT removal, discharge from hospital, transition to gastric nutrition, GERD complications, and treatment were significantly improved. Median age and weight at the first GJT placement were 7 months and 6.8 kg. Patients had digestive comorbidities or complicated GERD in 69.6% and 76.1% patients, respectively. The median duration of jejunal nutrition using GJT was 64.5 days. GJT had to be removed in 63 (75.9%) cases for technical problems.

CONCLUSIONS

Jejunal nutrition by GJT could be an alternative to antireflux surgery avoiding sustainably antireflux surgery in most of complicated GERD patients. The high frequency of mechanical complications raises that these devices should be technically improved.

10 Year Follow-Up of Randomized Trial of Laparoscopic Nissen Versus Thal Fundoplication in Children

Introduction: The aim of this study was to compare the long-term outcomes of laparoscopic complete (Nissen) fundoplication (LNF) with laparoscopic partial (Thal) fundoplication (LTF) in children. This is the only prospective, randomized study to follow patients up for more than 10 years. Interim results published in 2011 at median 2.5 year follow-up showed that LNF had a significantly lower failure rate compared with LTF. Materials and Methods: A randomized, controlled trial of LNF versus LTF in children (<16 years) was performed. The primary outcome measure was "absolute" failure of the fundoplication-recurrence of symptoms that merited either reoperation or insertion of transgastric jejunostomy (GJ). Secondary outcomes were "relative" failure (need for postop antireflux medication), complications (e.g., dysphagia), and death. Results: One hundred seventy-five patients were recruited; 89 underwent LNF, and 86 underwent LTF. Eight patients had no follow-up recorded. At long-term follow-up, 59 patients had died (35%); LNF 37/85 (43.5%) and LTF 22/82 (26.8%), P = .02. Median length of follow-up in survivors was 132 months. There was no statistically significant difference in "absolute" failure rate between LNF 8/85(9.4%) and LTF 15/82 (18%), P = .14. There was no difference in "relative" failure between LNF 7/85 (8.2%) and LTF 12/82 (14%), P = .23. Long-term dysphagia affected 5 out of 108 (4.6%) patients; 3/48 (6.2%) of LNF and 2/60 (3.3%) of LTF (P = .65). Conclusions: There was no statistically significant difference in 'absolute' failure between LNF and LTF at long-term follow-up. Neurologically impaired children have a high mortality rate following fundoplication due to comorbidities. This trial commenced in 1998 and was approved by the Oxfordshire Research Ethics Committee (No. 04.OXA.18-1998).

Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review

BACKGROUND

Antireflux surgery is commonly performed in children, yet evidence for its efficacy is limited. The aim of this review was to determine the effect of antireflux surgery with regard to objective measures of quality of life (QoL) and value of upper gastrointestinal investigations in neurologically normal (NN) and neurologically impaired (NI) children.

METHODS

A systematic review was conducted of articles reporting children undergoing antireflux surgery in whom preoperative and postoperative objective testing was performed. Primarily, Embase, CINAHL, MEDLINE and PubMed were searched from inception to April 2019. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess article quality.

RESULTS

Of 789 articles, 14 met the eligibility criteria, 12 prospective observational and 2 retrospective studies. The median MINORS score was 59·4 (i.q.r. 39 to 62·5) per cent. Seven studies reported assessment of validated QoL measures before and after antireflux surgery in 148 children. Follow-up ranged from 1 to 180 months. All studies confirmed significant improvements in QoL measures among NN and NI children at all follow-up points. Eleven studies reported on preoperative and postoperative investigations in between 416 and 440 children children. Follow-up ranged from 0·5 to 180 months. Nine studies confirmed improvements in gastro-oesophageal reflux using 24-h oesophageal pH monitoring with or without manometry, but conflicting results were identified for four studies reporting gastric emptying. No studies reported fluoroscopy or endoscopy adequately.

CONCLUSION

Based on the results of studies of low-to-moderate quality, antireflux surgery improved QoL and reduced oesophageal acid exposure in NN and NI children in the short and medium term. Although antireflux surgery is a common elective operation, the lack of rigorous preoperative and postoperative evaluation(s) in the majority of patient-reported studies is striking.

Total esophagogastric dissociation (TEGD): Lessons from two decades of experience

BACKGROUND

Total esophagogastric dissociation (TEGD) has been performed in our institution since 1994, predating its published description by Bianchi in 1997. Originally it was considered a rescue procedure when conventional antireflux surgery failed. Recently TEGD has been considered a viable primary option for the treatment of gastroesophageal reflux disease (GERD) in severely neurological impaired (NI) patients. We describe our institution's experience of TEGD in this selected cohort of patients.

METHODS

An institutional retrospective review was performed detailing our total experience of open TEGD between 1994 and 2015 in severely neurologically impaired (NI) patients. Demographic, complications, and outcome were analyzed.

RESULTS

Sixty-six NI patients underwent TEGD between 1994 and 2015 (39 female). Primary TEGD was performed in forty-nine patients (74.2%), while the remainder were rescue procedures following the failure of previous antireflux surgery. In 98% of cases no recurrence of clinically significant reflux was reported. The mean hospital length of stay was 10.2 days. There were sixteen reported complications in twelve patients representing 18.2% of the cohort. One death was attributable to the procedure (1.5%). Median follow-up was 31.6 months (range, 1.3-137.9 months).

CONCLUSION

TEGD appears to be a valid surgical option to treat severe GERD in severely neurologically impaired children, both as a primary procedure and as a rescue procedure following failure of anti-reflux surgery. Further studies comparing TEGD versus laparoscopic fundoplication are desirable to understand which of these procedures can be the most effective in this compromised group of patients.

TYPE OF STUDY

Retrospective study Level of evidence: IV.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

Oesophageal replacement with stomach: A personal series and review of published experience

AIM

To describe the outcomes of oesophageal replacement using stomach in children.

METHODS

All children undergoing oesophageal replacement in a regional centre were prospectively recorded in a customised database and subjected to continual follow up. Complications within 30 days were classified as early, and all other complications were classified as late. Outcomes were related to a comprehensive analysis of published experience where studies were classified as having long-term follow up if the median duration exceeded 5 years.

RESULTS

Ten children underwent oesophageal replacement using the stomach between 1998 and 2016. Indications were oesophageal atresia (6), caustic ingestion (2), foreign body ingestion (1) and oesophageal hamartoma (1). Two children died at 2 and 7 months after gastric transposition. All survivors are under review, with a median follow up of 8.5 years (range 3-14 years). Complications occurred in every case. Among survivors, three had early complications and eight had late complications. Early complications included anastomotic leak (2) and lung compression by stomach (1). Late complications were anaemia (8), anastomotic stricture (7), oesophagitis (5), dumping syndrome (2), perforation of a jejunostomy (1), para-gastric hiatal hernia (1), gastric outlet obstruction (1), Barrett's oesophagus (1), prolonged inability to swallow (1) and recurrent lower respiratory tract infections (1). Among 57 publications, only three achieved complete long-term follow up. The incidence of reported complications was higher when follow up was complete.

CONCLUSIONS

Oesophageal replacement by gastric transposition in children leads to serious chronic morbidity. Published experience masks this because of incomplete and short follow up.

Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review

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).

Total esophagogastric dissociation: single center experience

AIM

Fundoplication fails in approximately 20% of children with severe neurodisability. We aimed to evaluate total esophagogastric dissociation (TOGD) as a primary procedure and as a ‘rescue’ procedure for severely neurologically impaired children with significant swallowing discoordination and gastroesophageal reflux disease.

METHODS

Casenotes of 40 children with severe neurodisability who underwent TOGD between 2005 and 2015 were retrospectively reviewed. Of these, 33 were primary procedures and 7 were ‘rescue’ procedures following failed fundoplication.

RESULTS

Median age at surgery was 3 years 7 months (range 1 month to 13 years 11 months). Preoperatively, all children had symptoms of regurgitation, retching or vomiting and 70% of children had an unsafe swallow. There were 5 early complications related to surgery in 4 children requiring surgical intervention. One child died following relaparotomy for esophagojejunal anastomotic breakdown because of multiorgan failure. Gastrostomy feeding was established by a median of 6 days (range 2 to 25 days) and median hospital stay was 10 days (range 4 to 280 days). There were 5 late complications. Median follow-up was 13 months (range 1 month to 8 years 4 months). All children have had resolution of gastroesophageal reflux. Thirteen percent of children experience bloating or pain on feeding and 26% of children experience retching unrelated to gastroesophageal reflux. There were 8 late deaths unrelated to surgery.

CONCLUSION

TOGD should be considered as a primary and definitive procedure in selected severely neurodisabled children who are at higher risk of failure of fundoplication, recurrent aspiration and a reduced quality of life.

Laparoscopic vs. open Nissen's fundoplication for gastro-oesophageal reflux disease in children: A meta-analysis

BACKGROUND AND OBJECTIVE

Available evidence showed inconsistent results between laparoscopic Nissen's fundoplication (LNF) and open Nissen's fundoplication (ONF) for children with gastro-oesophageal reflux disease (GERD), so this study aimed to evaluate the efficacy and safety between LNF and ONF.

METHODS

Systematic, comprehensive literature searches were conducted to include randomized controlled trials (RCTs) that compared LNF and ONF for GERD. Two reviewers independently selected studies, abstracted data and assessed the methodological quality and evidence level. Data was analyzed by Review Manager Version 5.0. Risk ratio (RR) was used for dichotomous outcomes, and mean difference (MD) was used for continuous scales. Heterogeneity was estimated with the I² statistic, fixed-effect model was used if I² <50%, and otherwise random-effects model was used.

RESULTS

Three RCTs (171 children) were included. There was not a statistical difference in mortality (RR 1.12, 95%CI 0.50 2.48), or postoperative complications (RR 0.87, 95%CI 0.61 1.25), readmission (RR 1.53, 95%CI 0.67 3.51), or hospital stay (MD 0.85, 95%CI -0.06 1.75) between LNF and ONF. But LNF was associated with more incidence of recurrence (RR 3.32, 95%CI 1.40 7.84), longer surgery duration (MD 76.33, 95%CI 69.37 83.28), but fewer retching (RR 0.11, 95%CI 0.02 0.58) than ONF.

CONCLUSIONS

LNF might be as effective and safe as ONF in the short and long term, but both were associated with high risk of recurrence and mortality, especially for those children with neurological impairment, before the age of 18 months and female gender. This required a comprehensive evaluation of children before surgery.

Extrapolating published survival curves to obtain evidence-based estimates of life expectancy in cerebral palsy

Studies reporting long-term survival probabilities for cohorts of persons with cerebral palsy provide evidence-based information on the life expectancy of those cohorts. Some studies have provided estimates of life expectancy based on extrapolation of such evidence, whereas many others have opted not to do so. Here we review the basic methods of life table analysis necessary for performing such extrapolations, and apply these methods to obtain evidence-based estimates of life expectancy from several studies that do not report such estimates themselves.

Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children--a single centre experience

BACKGROUND AND AIMS

Gastrooesophageal reflux disease (GERD) is a significant problem in children with neurological impairment (NI) with high failure rates for fundoplication. Fundoplication with vagotomy and pyloroplasty (FVP) can improve the outcome by altering the sensory or motor dysfunction associated with the reflux. We report our comparative outcomes for simple fundoplication (SF) and FVP in NI children.

METHODS

Case records of all patients having fundoplication under a single consultant at a tertiary UK paediatric surgical centre between January 1997 and December 2012 were retrospectively assessed for recurrent symptoms and redo surgery. The data were collected using a Microsoft Excel database and analysed on Graphpad prism software program. Data are median (range). P value<0.05 was considered significant.

RESULTS

Data were available for 244 out of 275 patients who underwent fundoplication during this period (157 SF and 87 FVP). Neurological disease or known syndromes were recorded in 158 patients. Thirty-five children had congenital anatomical abnormalities. Laparoscopic fundoplication was done in 37 cases. Revisional surgery for recurrent symptoms was performed in 22 patients. In the neurologically normal children, all of whom had SF, the revision rate was 6.5%. In the NI children the revision rates were 18.5% for SF and 3.9% for FVP, respectively (Fisher's exact, P<0.05). The median time to redo surgery was 10 (1-63) months, and the median time to follow up was 19.5 (2-177) months.

CONCLUSIONS

There appears to be a significantly lower need for redo surgery following FVP than SF in children with NI.

Surgical intervention for feeding and nutrition difficulties in cerebral palsy: a systematic review

AIM

The aim of the study was to systematically review surgical intervention for feeding difficulties in cerebral palsy.

METHOD

We searched databases including MEDLINE from 1980 to July 2012. Two reviewers independently assessed studies and rated the overall quality and strength of the evidence.

RESULTS

Thirteen publications (11 unique studies) met the inclusion criteria and addressed gastrostomy outcomes or treatment of reflux via fundoplication. In nine studies, gastrostomy-fed children gained weight. Relative to typically developing populations, baseline weight z-scores ranged from -3.56 to -0.39 and follow-up z-scores ranged from -2.63 to -0.33. Other growth measures were mixed. Two studies assessed fundoplication: in one, both Nissen fundoplication and vertical gastric plication reduced reflux (by 57% and 43% respectively), while in one case series, reflux recurred within 12 months in 30% of children. The highest rates of adverse events across studies were site infection (59%), granulation tissue (42%), and recurrent reflux (30%). Death rates ranged from 7 to 29%; however, the underlying cause was probably not surgery.

INTERPRETATION

Evidence for the effectiveness of surgical interventions is insufficient to low. Studies of gastrostomy typically demonstrated significant weight gain. Results for other measures were mixed. Many children remained underweight, although, given a lack of appropriate reference standards, these results should be interpreted cautiously.

Gastroesophageal reflux in the 21st century

PURPOSE OF REVIEW

Gastroesophageal reflux (GER) remains a common, challenging problem for clinicians, with differentiation of normal development from disease a particular issue. This review updates clinicians on advances in diagnosis of GER, relationship to other problems, and current practice in management.

RECENT FINDINGS

Development and understanding of multichannel intraluminal impedance-pH monitoring has given insights into the relationship of GER to symptoms. Medical treatment has changed little. Avoidance of overmedicalizing normal development is the major issue for clinicians. Laparoscopic fundoplication is established as equivalent to open fundoplication. Newer endoscopic techniques have only limited use in children to date.

SUMMARY

Major changes in pediatric GER relate to understanding of physiology and relationship of GER to symptoms. The major challenge for clinicians involve differentiation of normal from abnormal GER, and applying the most relevant management.

Morbidity and mortality in total esophagogastric dissociation: a systematic review

BACKGROUND/PURPOSE

Total esophagogastric dissociation has been described as both a primary and a rescue procedure for patients with severe gastroesophageal reflux. Although most commonly used in the neurologically impaired, it has also been used in those with no neurological impairment. The main objective of this study was to determine morbidity and mortality for this procedure.

METHODS

All published cases of esophagogastric dissociation in children were identified. Series were updated where possible by personal communication with the author. Patient characteristics, indications, morbidity, and mortality were analyzed.

RESULTS

One hundred eighty-one cases were identified. One hundred seventeen were primary operations and 64 were rescue procedures. There were 29 (16.0%) early complications and 28 (15.5%) late complications with 6 (3.3%) deaths related to the procedure of a total of 35 deaths. Twenty-one patients (11.6%) required re-operation in the study periods.

CONCLUSIONS

Esophagogastric dissociation has an acceptable morbidity and mortality. It is useful as both a primary and a rescue procedure.

Reflux aspiration in children with neurodisability--a significant problem, but can we measure it?

Recurrent respiratory problems are common in children with severe neurodisability, and respiratory deterioration is a leading cause of premature death in this group. Although the etiology is multifactorial, recurrent pulmonary aspiration is thought to play a significant role. Gastroesophageal reflux is known to be common, as is oral-motor discoordination. Differentiating direct aspiration of food and saliva and gastric reflux aspiration is difficult and presents a challenge in managing patients and assessing their suitability for surgical antireflux procedures. This is particularly the case when children present with predominantly respiratory symptoms, where there may be direct aspiration, reflux aspiration, neither, or both. A clinical biomarker to identify and quantify reflux aspiration would therefore be useful in surgical assessment and may also be applicable as an outcome measure for clinical trials of antireflux surgery. In this review, we discuss the evidence base behind existing and potentially novel biomarkers of aspiration in bronchoalveolar lavage fluid. We highlight the limitations of the lipid-laden macrophage index, particularly with regard to its specificity and interrater/intrarater reliability. We discuss the laboratory methods available to measure promising new biomarkers (pepsin and bile acids) and highlight their potential advantages and disadvantages. Finally, to understand how aspiration causes clinical signs and symptoms in our patients, we need to study the effect of aspirated substances on the lung, and here we review the available in vivo and in vitro literature.