Pre and post-operative evaluation of gastroesophageal reflux and esophageal motility in neurologically impaired children using combined pH–multichannel intraluminal impedance measurements

Prophylactic antireflux procedures are not necessary in neurologically impaired children undergoing gastrostomy placement

PURPOSE

Fundoplication is frequently used in children with neurologic impairment even in the absence of reflux due to concerns for future gastric feeding intolerance, but supporting data are lacking. We aimed to determine the incidence of secondary antireflux procedures (fundoplication or gastrojejunostomy (GJ)) post gastrostomy tube (GT) placement in children with and without neurologic impairment.

METHODS

Children under 18 undergoing a GT placement without fundoplication between 2010 and 2020 were identified utilizing the PearlDiver Mariner national patient claims database. Children with a diagnosis of cerebral palsy or a degenerative neurologic disease were identified and compared to children without these diagnoses. The incidence of delayed fundoplication or conversion to GJ were compared utilizing Kaplan-Meier and Cox proportional hazards regression analyses.

RESULTS

A total of 14,965 children underwent GT placement, of which 3712 (24.8%) had a diagnosis of neurologic impairment. The rate of concomitant fundoplication was significantly higher among children with a diagnosis of neurologic impairment as compared to those without (9.3% vs 6.4%, p < 0.001). While children with neurologic impairment had a significantly higher rate of fundoplication or GJ conversion at 5 years compared to children without (12.6% [95% confidence interval (CI): 11.4%-13.8%] vs 8.6% [95% CI 8.0%-9.2%], p < 0.001), the overall incidence remained low.

CONCLUSION

Although children with neurologic impairment have a higher rate of requiring an antireflux procedure or GJ conversion than other children, the overall rate remains less than 15%. Fundoplication should not be utilized in children without clinical reflux on the basis of neurologic impairment alone.

Simultaneous Evaluation of Laryngopharyngeal Reflux and Swallowing Function Using Hypopharyngeal Multichannel Intraluminal Impedance Measurements in Neurologically Impaired Patients

Background/Aims

This study aims to evaluate the presence of laryngopharyngeal reflux (LPR) and to investigate the use of hypopharyngeal baseline impedance (BI) for assessing swallowing dysfunction and gastroesophageal reflux disease (GERD) using hypopharyngeal multichannel intraluminal impedance and pH (HMII-pH) monitoring in neurologically impaired patients (NIPs).

Methods

The study population in this retrospective study comprised 20 NIPs (mean age, 36.1 ± 15.0 years; age range, 13-64 years) who underwent multichannel intraluminal impedance and pH (MII-pH), HMII-pH, and laryngoscopy using the Hyodo scoring method from December 2016 to April 2019. The MII-pH and HMM-pH parameters were compared in the NIPs, whereas hypopharyngeal BI values were compared between NIPs with ≥ 5 and < 5 in Hyodo scores. Correlations between the hypopharyngeal BI values and the Hyodo score were analyzed using Spearman’s correlation coefficient. A receiver operator characteristic curve was created to determine the optimum cut-off of hypopharyngeal BI value to discriminate SD.

Results

Three NIPs were diagnosed with pathological LPR and GERD by the HMII-pH monitoring. No significant differences in parameters were observed between MII-pH and HMII-pH monitoring. The correlation analysis demonstrated a significant negative correlation between the hypopharyngeal BI values and Hyodo scores. The optimal cutoff value for hypopharyngeal BI was 1552 Ω.

Conclusions

This study demonstrated the usefulness of HMII-pH monitoring in identifying NIP with pathological LPR. Considering the difficulties in performing examinations in NIPs, HMII-pH monitoring may be a potentially useful technique for the simultaneous evaluation of swallowing dysfunction, LPR, and GERD in NIP.

Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group

Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.

Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in Neurologically Impaired Patients

Background/Aims

The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance pH measurements (pH/MII) and ¹³C-acetate breath test (¹³C-ABT) analyses.

Methods

¹³C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation analyses were performed to investigate the correlation between the ¹³C-ABT parameters and the clinical or pH/MII parameters. Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time (t_1/2, 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t_1/2.

Results

The mean t_1/2 of all patients was 215.5 ± 237.2 minutes and the t_1/2 of 24 (92.3%) patients were > 100 minutes. Significant moderate positive correlations were observed between both t_1/2 and lag phase time and the non-acid reflux related parameters. Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups when the cutoff was t_1/2 ≥ 140 minutes.

Conclusion

The present study demonstrated that GE with t_1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD.

Characteristics of gastroesophageal reflux in pediatric patients with neurological impairment

PURPOSE

To clarify the characteristics of gastroesophageal reflux (GER) in pediatric patients with neurological impairment (NI).

METHODS

Twenty-six patients with NI, 1-17-year-old, fed via a nasogastric tube were categorized based on the absence (group I) or presence (group II) of abnormal GER, defined with multichannel intraluminal impedance-pH monitoring as %time with an esophageal pH <4.0 being ≥5.0% or number of liquid/mixed bolus reflux events(RE) >70 in 24 h.

RESULTS

%Time and number of distal and proximal bolus REs were not significantly different between acid and nonacid REs. %Time of acid bolus RE and that of acid and total number of distal and proximal bolus REs were significantly higher in group II than in group I. Mean acid clearance time was significantly longer in group II. Median bolus clearance time was similar between the groups. No bolus RE parameters were significantly different between acid and nonacid REs in group I. Acid bolus RE was significantly higher than nonacid RE in terms of %time and number of proximal bolus RE in group II.

CONCLUSION

Acid REs significantly increased in pediatric patients with NI with abnormal GER. The number of acid and nonacid REs was comparable in patients without abnormal GER.

The characteristics of salivary pepsin in patients with severe motor and intellectual disabilities

PURPOSE

The aim of the present study was to determine the utility of measuring the salivary pepsin level (SPL) as an objective assessment of gastroesophageal reflux disease (GERD) in severe motor and intellectual disabilities (SMID) patients.

SUBJECTS AND METHODS

This prospective study included 26 SMID patients who underwent simultaneous 24-h multichannel intraluminal impedance pH measurement (pH/MII) and SPL evaluation. The enrolled patients were divided into GERD (+) or GERD (-) groups according to the pH/MII findings. The age, gender and pH/MII parameters were compared between the two groups. A correlation analysis was also conducted for the SPL following early-morning fasting and post-enteral feeding and the age, gender, presence of gastrostomy and tracheostomy and pH/MII parameters. The SPL was compared between the two sampling groups.

RESULTS

Fifteen patients were classified as GERD (+), and 11 patients were classified as GERD (-). The mean SPL following early-morning fasting and post-enteral feeding among all patients were 104.3 (median: 38, 25th and 75th percentile: 12, 361) ng/ml and 222.2 (median: 152:0, 500) ng/ml, respectively. Regarding positivity, 76.9% and 73.1% of SPL values in early-morning fasting and post-enteral feeding SMID patients, respectively, were positive (≧16ng/ml). The SPL following early-morning fasting demonstrated a weak but significant positive correlation with age. In contrast, we noted no correlation between the pH/MII parameters and the SPL for either the early-morning fasting or post-enteral feeding patients, and no significant difference in the SPL was observed between the GERD (+) and (-) patients.

CONCLUSIONS

The present study showed that a high proportion of SMID patients had a relatively high SPL, regardless of the presence of GERD. The SPL in SMID patients might be affected by several distinctive factors in addition to gastroesophageal reflux.

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).

A baseline impedance analysis in neurologically impaired children: A potent parameter for estimating the condition of the esophageal mucosa

BACKGROUND

The aim of the present study was to investigate whether the baseline impedance (BI) value is a useful parameter to evaluate the condition of the esophageal mucosa in neurologically impaired (NI) children undergoing multichannel intraluminal impedance pH measurements (pH/MII).

METHODS

The retrospective study included 55 NI patients ≤15 years. The patients were divided into acid gastroesophageal reflux disease (GERD), non-acid GERD and GERD (-) groups. Furthermore, the patients in the acid GERD group were subdivided into erosive reflux disease (ERD) and non-erosive reflux disease (NERD) groups. pH/MII parameters and BI values (Z1-6) were compared among three groups or between two groups, respectively. A Spearman's correlation analysis was used for the correlation analysis of pH/MII parameters and BI values. A receiver operator characteristic curve analysis was used to evaluate the optimum cut-off values of BI to discriminate ERD patients.

KEY RESULTS

The BI values of the proximal and the distal channels in ERD group were significantly lower than those in NERD group. The BI values of the distal channels demonstrated significant negative correlations with acid exposure related pH/MII parameters. The optimal cut off value of BI in the most distal channel was determined to be 1500 Ω.

CONCLUSIONS & INFERENCES

The present study suggested that NI children with reflux esophagitis were likely to suffer mucosal damage up to the proximal esophagus and cut-off BI values may help estimate the presence of reflux esophagitis. Baseline impedance is a potent parameter, reflecting the esophageal mucosal damage in NI children who have difficulty in undergoing endoscopic examinations.

Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study

INTRODUCTION

Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS.

METHODS

Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a ¹³C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS.

RESULTS

After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001).

CONCLUSIONS

In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.

Post-surgical gastrointestinal reflux disease: Status quo and treatment

Reflux is a common and tricky morbidity after gastrointestinal surgery which is caused by the destruction of physiological anti-reflux barriers, greatly affecting patients' postoperative quality of life. Gastroenterologists are now actively trying very hard to explore feasible, effective, and safe anti-reflux approaches. Conservative medical treatment, typically with proton pump inhibitors, is easily accepted by patients, however, its long-term adverse events are noteworthy. In the surgical aspect, laparoscopic anti-reflux surgery is gaining more and more popularity, after the first case of fundoplication. Besides, other operations, such as bariatric surgery, pediatric surgery, and pulmonary transplantation, are also frequently complicated by post-operative digestive reflux. Herein we systematically review the status quo and treatment modalities for post-surgical reflux disease, with the hope to facilitate surgeons to cope with this challenging issue appropriately.

Evaluation of antireflux surgery using multichannel intraluminal impedance-pH measurement in neurologically impaired patients

PURPOSE

This study aimed to evaluate esophageal function before and after antireflux surgery (ARS) in neurologically impaired (NI) patients using 24 h multichannel intraluminal impedance (MII)-pH measurement.

METHODS

Seven NI patients (age, 0-33 years; median, 13 years) were assessed before and after ARS using 24 h MII-pH. We described reflux parameters such as pH reflux index, bolus exposure index, number of acidic and nonacidic reflux episodes, mean acid clearance time and median bolus clearance time, and esophageal motility parameters in dry swallows such as bolus presence time (BPT), total bolus transit time (TBTT), and total propagation velocity (TPV).

RESULTS

The postoperative reflux parameters such as pH reflux index, acid clearance time, bolus exposure index, and the number of acidic reflux episodes significantly decreased (P < 0.05) compared with the preoperative ones. The esophageal motility parameters including all sites of BPTs, TBTT, and TPV did not change in the MII-pH measurement after ARS (P = non-significant).

CONCLUSION

ARS effectively reduced gastro-esophageal reflux (GER) in NI patients without the impairment of esophageal motility by MII-pH measurement. MII-pH was useful to detect the subtype of GER before and after ARS and appeared to be appropriate for evaluating esophageal motility.