Complications and reoperation after Nissen fundoplication in childhood

Gastrojejunal (GJ) tube feeding: developing a service and evaluating associated complications in a paediatric surgical centre

INTRODUCTION

Gastrojejunal (GJ) tubes are becoming an established alternative method of delivering nutrition to children who do not tolerate gastric feeding. However, there is limited literature surrounding patient outcomes, the longevity of tubes or complications. We aim to highlight the development and evaluation of a service to provide children with GJ tube feeding.

MATERIALS AND METHODS

A retrospective case-note review of children either undergoing an initial gastrostomy to gastrojejunal tube conversion or gastrojejunal tube replacement in our tertiary paediatric surgical centre between January 2015 and June 2018.

RESULTS

134 GJ feeding tubes were placed in 33 neurologically impaired children with a median age of 4.9 years (8 months-17 years) having a median 4 tube placements per child (1-11) within the study period. All tubes were 14 or 16 Fr 'AMT G-JET' tubes with a median replacement time of 174.9 days (13-504 days). The most common indication was foregut dysmotility in children with global developmental delay. The complication rate was 34.3% (46 tubes). In the study period, 2 patients (6.1%) reverted to oral feeding, 6 patients (18.2%) to gastric feeding and 25 children (75.7%) continued with jejunal feeding. No child required fundoplication. There were no procedure-related mortalities or mortality.

CONCLUSIONS

GJ tube feeding is an effective and safe method of managing children with foregut dysmotility. Many patients do not require permanent jejunal feeding, and thus the reversibility of this method is an asset. A dedicated team is needed to co-ordinate tube replacements and provide efficient long-term jejunal feeding.

LEVEL OF EVIDENCE

IV.

Risk factors for recurrent gastroesophageal reflux disease after Thal fundoplication

PURPOSE

The recurrence rate of gastroesophageal reflux disease (GERD) after fundoplication has been reported to be 7-25%. We investigated the risk factors for recurrence of GERD after Thal fundoplication (TF) in our department with the aim of further reducing the recurrence rate of GERD.

METHODS

We retrospectively analyzed 276 patients who underwent TF for GERD at our hospital between 2000 and 2019. Retrospectively considered variables were obtained from the medical records of patients. The variables included patient characteristics, GERD severity, surgery-related factors and postoperative course.

RESULTS

The postoperative GERD recurrence rate was 5.8%. In the univariate analysis, the presence of convulsive seizures (12/4 vs. 110/150, p = 0.046) and the absence of a tracheostomy (0/16 vs. 53/207, p = 0.048) at the time of TF were significantly associated with recurrence. In the multivariate analysis, the presence of convulsive seizures at the time of TF was the only factor significantly associated with recurrence.

CONCLUSION

The presence of convulsive seizures and the absence of a tracheostomy at the time of TF were significantly associated with GERD recurrence after TF. Active control of seizures and consideration of surgical indications, including assessment of respiratory status, are important in preventing the recurrence of GERD after TF.

Optimal management of gastrojejunal tube in the ENFit era - Interventions that changed practice

BACKGROUND

We experienced a high incidence of jejunal tube (JEJ) displacement in children who underwent percutaneous endoscopic transgastric jejunostomy (PEGJ), ever since the introduction of ENFit connector (2017).

METHODS

Two interventions were introduced in 2018 - fixative suture to PEGJ ENFit connector, and conversion to balloon transgastric-jejunal feeding device (Balloon GJ) whenever possible. Children receiving PEGJ and Balloon GJ in 2.8 years were categorized into 3 eras: 2016 (pre-ENFit), 2017 (ENFit) and 2018 (interventional), for comparison of complications and sequelae. Kaplan-Meier survival curves with log-rank test (P < 0.05) were applied.

RESULTS

100 children underwent 323 JEJ insertions - PEGJ (n = 237), Balloon GJ (n = 86). Complications occurred in 188 JEJs (58%), more frequently with PEGJ than Balloon GJ (69% vs. 29%, P < 0.0005). PEGJ had higher complication/1000-tube-days (6 vs. 0, P < 0.0005). In 2018, complication rate reduced from 76% to 30% (P < 0.0005) owing to effectiveness of PEGJ connector suture application (P = 0.019), and increased utilization of Balloon GJ (16% to 44%, P = 0.005). Balloon GJ showed better JEJ survival (P = 0.019), less morbidity (emergency attendance, X-ray) and greater cost-effectiveness than PEGJ.

CONCLUSIONS

Balloon GJ had better overall outcomes than PEGJ. Suture application to connector successfully reduced JEJ internal displacement in PEGJ; however, conversion to Balloon GJ should be strongly considered.

LEVEL OF EVIDENCE

II.

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.

Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis

Neurologically impaired children (NIC) suffer severe gastroesophageal reflux (GER) with poor fundoplication outcome. Aims of the study were: (1) to determine the recurrence of GER after fundoplication in NIC; (2) to compare fundoplication versus gastro-jejunal tube feeding insertion (GJ) and fundoplication versus total esophagogastric dissociation (TEGD) in primarily treating GER in NIC. Using defined search strategy, two investigators identified all comparative studies reporting the mentioned procedures to primarily treat GER in NIC. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 3840 titles/abstracts screened, 14 studies on fundoplication (2716 pts.) reported a recurrence/persistence of GER higher in NIC (14.2 ± 8.3%) than in neurologically normal (9.4 ± 5.2%; p = 0.0001), with an increased incidence of re-do fundoplication (12.6 ± 7.0% versus 9.1 ± 4.5%; p < 0.01). Three studies revealed a similar risk of undergoing subsequent fundoplication after GJ (4.9 ± 2.1%) or initial fundoplication (12.0 ± 0.6%; p = ns). Four studies showed a lower recurrence of GER following TEGD (1.4 ± 1.1%) than fundoplication (24.8 ± 1.4%; p = 0.002). NIC are at risk of recurrence/persistence of GER after fundoplication or GJ. TEGD seems more effective to primarily treat GER in NIC. Prospective randomized controlled trials are necessary to establish which is the ideal treatment of GER in NIC.

Impact of Esophageal Atresia on the Success of Fundoplication for Gastroesophageal Reflux

OBJECTIVES

Fundoplication is commonly performed in patients with a history of esophageal atresia (EA), however, the success of this surgery is reduced, as reflected by an increased rate of redo fundoplication. We aimed to determine whether EA impacts the prevalence of fundoplication, its timing, and performance of a redo operation.

STUDY DESIGN

A single-center, retrospective review of all patients undergoing fundoplication over a 20-year period (1994-2013) was performed. Redo fundoplication was used as a surrogate for surgical failure.

RESULTS

A total of 767 patients (patients with EA 85, those who did not have EA 682) underwent fundoplication during the study period. Median age (months) at primary fundoplication was lower in patients with EA (7.2 vs those who did not have EA 23.3; P < .001). Redo fundoplication rates between groups were not significantly different (EA 11/85 vs 53/682; P = .14). Median time (months) between primary and redo fundoplication was greater in patients with EA (36.2 vs 11.7; P = .03).

CONCLUSIONS

Contrary to popular belief, the incidence of redo fundoplication was not significantly increased in patients with a history of EA. However, patients with EA underwent fundoplication at younger ages, which may be related to early life-threatening events in these patients. These results inform perioperative counseling, and highlight the importance of sustained surgical follow-up in patients with EA.

Esophagogastric dissociation reduces the re-operation rate for persistent gastroesophageal reflux in severely neurologically impaired children

PURPOSE

In this study we want to demonstrate the effectiveness of the esophagogastric dissociation as a first level operation in treatment of the gastroesophageal reflux in severe neurologically impaired children, in term of a reduction of reoperation rate.

METHODS

We divided patients operated from 1998 to 2005 in a group A, composed by children treated with fundoplication, and in a group AR, composed by the patients of group A who had a recurrence of reflux and that was treated with esophagogastric dissociation. Patients operated from 2005 to 2013 were selected on the basis of the severity of the neurological impairment and were divided in a group B, treated with fundoplication, and in a group C of more severe impaired children, treated with esophagogastric dissociation. Data regarding the complications of the A and C groups were analyzed with Fisher's test.

RESULTS

We evaluated 63 patients: 34 (54%) in group A, 11 in group AR, 15 (23.6%) in group B, 14 (22.4%) in group C. The Fisher's test showed a non significant difference with a p value of 0.2.

CONCLUSION

Despite of statistic result we believe that TOGD is a useful procedure as the first choice of surgical management in severe neurological impaired children affected by gastroesophageal reflux.

Short- and long-term antireflux and asthma medication use in children after nissen fundoplication

PURPOSE

We sought to determine antireflux and asthma medication use after Nissen fundoplication (NF).

METHODS

We performed a retrospective study using hospital discharge and pharmacy data from 1996 through 2005. A total of 342 pediatric patients had ≥1 NF; 336 of those had complete medication data. Use of antireflux medications and asthma medications were reviewed before and after NF.

RESULTS

Short-term (one year after NF) use of antireflux medications decreased (odds ratio [OR] = 0.35; 95% confidence interval [CI], 0.26-0.45). During the entire study period, the decrease in antireflux medication use after NF remained in place (233 to 197 patients; OR = 0.63; 95% CI, 0.47-0.84). Use of antireflux medications decreased in neurologically healthy patients (n = 186) after NF but remained the same in neurologically impaired patients. Short-term use of inhaled and systemic asthma medications did not change (OR = 1.16 [95% CI, 0.89-1.51] and 0.90 [95% CI, 0.69-1.18]), respectively. During the entire study period, inhaled and systemic asthma medication use increased after NF (OR = 2.11 [95% CI, 1.63-2.74] and 1.85 [95% CI, 1.43-2.41]), respectively. Inhaled and systemic asthma medication use increased in both neurologically healthy and impaired children. In older children (age >5 years), short-term use of inhaled and systemic asthma medications decreased after NF (OR = 0.39 [95% CI, 0.25-0.60] and 0.31 [95% CI, 0.19-0.53]), respectively. However, during the entire study period, inhaled and systemic asthma medication use in older children remained the same.

CONCLUSION

NF decreased antireflux medication use in the short and long term, particularly in neurologically healthy children. Inhaled and systemic asthma medication use increased after NF in neurologically healthy and impaired children. NF provided a short-term decrease in inhaled and systemic asthma medication use in older children but showed no change in the long term.

Gastric emptying scans: unnecessary preoperative testing for fundoplications?

PURPOSE

Delayed gastric emptying (DGE) as indicated by preoperative gastric emptying scan (GES) is one rationale for performing a gastric emptying procedure (GEP) at time of fundoplication for gastroesophageal reflux disease (GERD). However, the role of GES and GEP in the surgical management of GERD remains unclear. We examined the use of preoperative GES in fundoplication patients.

METHODS

Retrospective chart review of patients undergoing fundoplication from 2000 to 2005 in a single institution including patient demographics, operative procedure, and postoperative outcomes at 1-year follow-up was analyzed using chi(2) test.

RESULTS

Of 76 fundoplication patients, 39 (51%) had preoperative GES with 11 patients (28%) having DGE and 16 GEP performed. Developmentally delayed children were more likely to have GES. There were no significant differences in postoperative complications, length of hospital stay, or use of anti-GERD medications at 1 year between patients who had preoperative GES and those who did not. In the developmentally delayed group, there were no differences in outcomes between those with preoperative GES and those who did not.

CONCLUSIONS

There were no differences in outcomes for GERD patients with or without preoperative GES or GEP postfundoplication. The use of GES in the management of GERD requires further evaluation.

Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study

OBJECTIVE

To examine the impact of fundoplication on reflux related hospital admissions for children with neurological impairment.

DESIGN

Retrospective, observational cohort study. Setting 42 children's hospitals in the United States.

PARTICIPANTS

3721 children with neurological impairment born between 2000 and 2005 who had at least one hospital admission at a study hospital before their fundoplication.

INTERVENTION

Fundoplication.

MAIN OUTCOME MEASURES

Incident rate ratio for reflux related hospital admissions, defined as the post-fundoplication admission rate divided by the pre-fundoplication admission rate.

RESULTS

Of the 955 285 children born during the study period, 144,749 (15%) had neurological impairment. Of these, 27,720 (19%) were diagnosed as having gastro-oesophageal reflux disease, of whom 6716 (24%) had a fundoplication. Of these, 3721 (55%) had at least one previous hospital admission and were included in the study cohort. After fundoplication, hospital admissions decreased for any reflux related cause (incident rate ratio 0.69, 95% confidence interval 0.67 to 0.72; P<0.01), aspiration pneumonia (0.71, 0.62 to 0.81; P<0.01), gastro-oesophageal reflux disease (0.60, 0.57 to 0.63; P<0.01), and mechanical ventilation (0.40, 0.37 to 0.43; P<0.01), after adjustment for other patient and hospital related factors that may influence reflux related hospital admissions. Hospital admissions increased for asthma (incident rate ratio 1.52, 1.38 to 1.67; P<0.01) and remained constant for pneumonia (1.07, 0.98 to 1.17; P=0.16). Conclusions Children with neurological impairment who have fundoplication had reduced short term reflux related hospital admissions for aspiration pneumonia, gastro-oesophageal reflux disease, and mechanical ventilation. However, admissions for pneumonia remained constant and those for asthma increased after fundoplication. Comparative effectiveness data for other treatments (such as gastrojejunal feeding tubes) are unknown.

[Clinical and endoscopic outcome after Nissen fundoplication for gastroesophageal reflux disease]

CONTEXT

The surgical treatment of gastroesophageal reflux disease is indicated in patients with a chronic condition when proton pump inhibitors therapy is ineffective or when symptoms are persistently recurrent. Fundoplication failure occurrence has been detected in some patients and highlights a needing of monitoring esophageal post-surgical condition since that clinical symptoms are not sensitive enough for indicating fundoplication failure.

AIMS

To identify the frequency of a disrupted wrap in the postoperative period and to evaluate esophageal complications related with gastroesophageal reflux recurrence in children and adolescents.

METHODS

The study was cross-sectional, prospective and descriptive, including 45 patients (16 months-16.9 years) who had undergone Nissen fundoplication in a school hospital. Twenty six patients (57.8%) were neurologically impaired. Upper gastrointestinal endoscopy was performed in order to determine fundoplication integrity, endoscopic and histopathological esophageal condition. Upper gastrointestinal endoscopies were performed from 12 up to 30 months after surgery.

RESULTS

Patent wrap was identified in 41 patients (91.1%). Recurrent peptic esophagitis was found in 6 of 45 patients, 2 of which required a second fundoplication and other two had Barrett esophagus. Endoscopic peptic esophagitis was associated with a defective wrap (P = 0.005). Conclusions - Fundoplication was effective for treating esophagitis, even in patients with previous esophageal stenosis. Endoscopic follow up may detect surgery failure in children undergone anti-reflux surgery even in asymptomatic patients.

Effect of an isolated mild to moderate ischemic brain injury in the gastric emptying of liquids in rats

PURPOSE

To evaluate the effect of hypoxic-ischemic brain injury over the gastric emptying of liquids in rats.

METHODS

Fifty-two Wistar rats aged six weeks and weighing between 100 g and 150 g were divided in three groups. A Control group (C), a Sham group (S) undergoing sham procedure, and a Hypoxic-ischemic group (HI) consisting of 18 animals undergoing surgical ligature of the left carotid artery and exposure to hypoxic environment for three hours. Half of the animals were studied in the third day post-HI procedure (Early) and nine in the 14th day post-HI procedure (Late). Gastric emptying was evaluated by an infusion technique using fenolsulftalein as a marker.

RESULTS

After the HI procedure, all animals displayed left eyelid ptosis, and six animals showed minor sideway gait. Histological examination confirmed de brain injury in all animals from the HI group. There was no statistical significant difference among the mean gastric retention values of the three groups neither in the Early nor in the Late evaluation.

CONCLUSION

Isolated HI brain injury was not associated with delayed gastric emptying.

Laparoscopic redo fundoplication in children: failure causes and feasibility

PURPOSE

This retrospective study reports our experience in laparoscopic approach after failure of antireflux surgery. It evaluates the results and circumstances of failure of the initial procedure to understand indications of refundoplication.

METHODS

Four hundred seventeen patients were operated on for a gastroesophageal reflux disease (GERD) by laparoscopy in our unit from August 1993 to February 2005. Thirty redo procedures (7.19%) were performed. The indications were 24 (80%) recurrent reflux resistant to the medical treatment and 6 (20%) severe dysphagia resistant to iterative dilatations. The average age was 57.6 months. Nineteen patients (63%) were males and 11 patients (37%) were females. The time between the first and the redo procedure was an average of 16 months. Ten (33%) of them were neurologically impaired (NI); in 7 patients, a percutaneus gastrostomy was also associated. The techniques previously used were 13 Nissen, 7 Nissen-Rossetti, and 10 Toupet.

RESULTS

The redo procedure was performed by laparoscopy in 27 cases. A conversion was necessary in 3 children because of a difficult dissection. In the 24 cases of recurrent reflux, we realized a valve disassembly, reconstruction of hiatus and Nissen refundoplication. In 3 cases of dysphagia, the release of the hiatus needed a complete valve redo. The mean operative time was 140 minutes (110 to 240 minutes). The sole complication was a pleural perforation. All patients were fed on the first day. The mean duration of hospitalization was 3.1 days. The follow-up was from 48 months to 12 years. A new recurrent reflux occurred in 6 patients; 5 of them were NI.

CONCLUSION

The failure rate of the antireflux laparoscopic surgery is similar to the conventional surgery. The redo procedure is possible by laparoscopic with a success rate similar to the open redo surgery. The rate and morbidity of complications are acceptable and decrease with experienced surgeons. The indications of redo procedures should be similar to conventional surgery.

Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication

PURPOSE

The purpose of this study is to determine whether Nissen fundoplication decreases hospital admissions for respiratory symptoms and failure to thrive (FTT).

METHODS

A retrospective study using discharge abstract data from Southern California Kaiser Permanente hospitals during the last decade was done. Three hundred forty-two pediatric patients had at least one Nissen fundoplication. Hospital admissions for aspiration and other pneumonia, respiratory distress/apnea, and FTT were determined before and after Nissen fundoplication. Age and associated neurologic disorders were also studied. Statistical analysis was determined by chi(2) analysis, Poisson regression analysis, and relative risk.

RESULTS

The number of patients requiring hospital admission for aspiration and other pneumonia, respiratory distress/apnea, and FTT was similar before and after Nissen fundoplication. The proportion of readmission within 1 year after Nissen fundoplication for aspiration pneumonia was 0.1250 (95% confidence interval [CI], 0.0266-0.3236); other pneumonia, 0.5465 (95% CI, 0.4355-0.6542); respiratory distress/apnea, 0.5039 (95% CI, 0.4145-0.5931); and FTT, 0.5669 (95% CI, 0.4761-0.6545). Associated neurologic disorders independently increased hospital admissions for aspiration and other pneumonia, respiratory distress/apnea, and FTT. Age was inversely related to hospital admissions for respiratory distress and FTT.

CONCLUSION

Nissen fundoplication did not improve hospital admissions for pneumonia, respiratory distress/apnea, and FTT. Associated neurologic disorders increased readmissions for pneumonia, respiratory distress/apnea, and FTT, whereas increasing age decreased readmission for respiratory distress and FTT.

Estudo comparativo entre as técnicas de nissen e Boix-Ochoa em ratos

OBJETIVO: Comparar, em ratos, a eficiência das técnicas de Nissen e Boix-Ochoa no tratamento do refluxo gastroesofagiano (RGE) induzido pela operação de Heller. MÉTODO: Foram usados 30 ratos Wistar, com idades entre 40 e 60 dias de vida e peso corporal entre 210 g e 342 g. Os animais foram distribuídos em três Grupos (A, B, C) de 10 ratos. Em todos os animais realizou-se a operação de Heller. No Grupo B ela foi seguida de uma operação de Nissen e, no Grupo C, de uma operação de Boix-Ochoa. A pressão intra-gástrica necessária para produzir RGE foi medida em todos os animais: antes de qualquer procedimento; imediatamente após as operações de Heller, Nissen e Boix-Ochoa; e seis semanas depois, quando os animais foram mortos. RESULTADOS: Verificou-se que tanto a recuperação da perda de peso, que caracteriza o quadro de RGE, como a reconstituição mais fisiológica dos gradientes pressóricos gastroesofagianos são obtidos de forma mais eficiente pela técnica de Boix- Ochoa. CONCLUSÃO: As operações de Nissen e Boix- Ochoa são eficientes no tratamento do RGE induzido pela técnica de Heller, em ratos. A segunda, no entanto, restaurou, de forma mais adequada, os valores fisiológicos dos parâmetros estudados neste trabalho: o peso corporal e os gradientes pressóricos gastroesofagianos.

Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study

BACKGROUND/PURPOSE

Recurrent gastroesophageal reflux disease (rGERD) is a common problem after fundoplication. Previous studies attempting to identify risk factors for rGERD have failed to control for confounding variables. The purpose of this study was to identify significant risk factors for rGERD after controlling for potential confounding variables.

METHODS

A retrospective, matched case-control study was conducted at a tertiary children's hospital. Cases (n = 116) met 1 of these criteria: reoperation for rGERD, symptomatic rGERD (confirmed by upper gastrointestinal series, esophagogastroduodenoscopy, or pH monitoring), or postoperative reinstitution of antireflux medication for more than 8 weeks. Controls (n = 209) were matched for surgeon, approach (laparoscopic/open), technique (partial/complete), and approximate operative date. Univariate and multivariable associations were analyzed by conditional logistic regression.

RESULTS

Significant risk factors for rGERD were age of less than 6 years (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-7.5), preoperative hiatal hernia (OR, 3.2; 95% CI, 1.4-7.3), postoperative retching (OR, 5.1; 95% CI, 2.6-10.0), and postoperative esophageal dilatation (OR, 10.8; 95% CI, 1.8-65.4). Interestingly, significant association was not found between neurologic impairment and rGERD after controlling for potential confounding variables.

CONCLUSION

Age of less than 6 years, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilatation are independently associated with increased risk of rGERD. Neurologic impairment alone does not increase the risk of developing rGERD.

Watson fundoplication in children: a comparative study with Nissen fundoplication

BACKGROUND

Nissen fundoplication is the gold standard antireflux procedure in children. In 1996, one pediatric surgeon adopted the anterior fundoplication described by Watson in 1991. This procedure is reported to achieve good reflux control while permitting burping, active vomiting, and reducing gas bloat. An audit project was undertaken to compare the clinical outcome of children undergoing Nissen and Watson fundoplication.

METHODS

The case notes of 144 children undergoing open fundoplication between February 1995 and February 2002 were reviewed retrospectively.

RESULTS

Results of 72 boys and 59 girls comprising 76 Nissen and 55 Watson fundoplications were assessed. In each group, one death occurred within 1 month of operation. Chest infections occurred in 6.6% (Nissen) and 1.8% (Watson), and wound infections in 2.6% and 1.8%, respectively. Dysphagia was recorded in 7.9% of Nissen and 1.8% of Watson fundoplications. Follow-up data were analyzed in 70 children with Nissen and 48 children with Watson fundoplication. When overall clinical outcome was assessed for those patients with a minimum follow-up of 1 year, 85.1% Nissen and 88.2% Watson were judged good/excellent; 14.9% Nissen and 11.8% Watson were judged poor/bad.

CONCLUSION

Watson fundoplication can safely be performed in children with comparable clinical outcome to Nissen fundoplication.

Factors predicting failure of redo Nissen fundoplication in children

Recurrence of gastro-oesophageal reflux (GOR) following redo Nissen fundoplication represents a significant clinical problem. The aim of this study was to identify factors predicting failure of redo Nissen fundoplication. The notes of children who underwent redo Nissen fundoplication for recurrent GOR in a single institution between June 1994 and May 2005 were reviewed. Data are reported as median (range), or as numbers of cases. Multiple logistic regression analysis, using type of first fundoplication, neurological status, presence of gastrostomy, age-weight, retching-gas bloat after first fundoplication, associated anomalies, oesophageal atresia and length of follow-up as factors, was used to generate a model to identify factors predicting recurrent vomiting (failure) after redo. Eighty-one children underwent redo Nissen fundoplication 15.9 months (0.2-176) after the initial Nissen fundoplication. In 29, the first Nissen was laparoscopic. Age at redo Nissen fundoplication was 3.3 years (0.3-15.9) and weight 12.8 kg (5-60). Thirty-four children (42%) presented with recurrent vomiting (failure). Overall, the model successfully predicted vomiting (failure) after redo fundoplication (P = 0.009). Open surgery at first fundoplication (P = 0.011) and neurological impairment (P = 0.046) were both significant predictors of redo failure in the model, whereas presence of gastrostomy (P = 0.035) and older-heavier age-weight (P = 0.028) were associated with significantly better results. Retching-gas bloat, associated anomalies and oesophageal atresia were not significant predictors of failure. Redo Nissen fundoplication has a high failure rate. Risk factors are open fundoplication at first operation and neurological impairment. Redo fundoplication after primary laparoscopic Nissen has a lower risk of failure.

Quality of life of children with neurological impairment who receive a fundoplication for gastroesophageal reflux disease

BACKGROUND

Children with neurological impairment (NI) commonly have gastroesophageal reflux disease (GERD) treated with a fundoplication. The impact of this procedure on quality of life is poorly understood.

OBJECTIVES

To examine the quality of life of children with NI who have received a fundoplication for GERD and of their caregivers.

METHODS

The study was a prospective cohort study of children with NI and GERD who underwent a fundoplication at a children's hospital between January 1, 2005, and July 7, 2006. Quality of life of the children was assessed with the Child Health Questionnaire (CHQ) and of the caregivers with the Short-Form Health Survey Status (SF-36) and Parenting Stress Index (PSI), both at baseline and 1 month after fundoplication. Functional status was assessed using the WeeFIM. Repeated-measures analyses were performed.

RESULTS

Forty-four of the 63 parents (70%) were enrolled. The median WeeFIM score was 31.2 versus the age-normal score of 83 (P = .001). Compared with the baseline scores, mean CHQ scores improved over 1 month in the domains of bodily pain (32.8 vs. 47.5, P = .01), role limitations-physical (30.6 vs. 56.6, P = .01), mental health (62.7 vs. 70.6, P = .01), family limitation of activities (43.3 vs. 55.1, P = .03), and parental time (43.0 vs. 55.3, P = .03). The parental SF-36 domain of vitality improved from baseline over 1 month (41.3 vs. 48.2, P = .001), but there were no changes from baseline in Parenting Stress scores.

CONCLUSIONS

Parents reported that the quality of life of children with NI who receive a fundoplication for GERD was improved from baseline in several domains 1 month after surgery. The quality of life and stress of caregivers did not improve in nearly all domains, at least in the short term.

Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication

AIM

To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP).

METHODS

From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed.

RESULTS

Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively).

CONCLUSION

Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.

Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Undernutrition, growth failure, overweight, micronutrient deficiencies, and osteopenia are nutritional comorbidities that affect the neurologically impaired child. Monitoring neurologically impaired children for nutritional comorbidities is an integral part of their care. Early involvement by a multidisciplinary team of physicians, nurses, dieticians, occupational and speech therapists, psychologists, and social workers is essential to prevent the adverse outcomes associated with feeding difficulties and poor nutritional status. Careful evaluation and monitoring of severely disabled children for nutritional problems are warranted because of the increased risk of nutrition-related morbidity and mortality.

Antireflux surgery outcomes in pediatric gastroesophageal reflux disease

OBJECTIVES

Antireflux surgery is performed frequently in children with gastroesophageal reflux disease (GERD). Few comparative studies exist which assess the indications for and short- or long-term outcome of open Nissen fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric GERD. We investigated the frequency of reoperation and factors that might influence its occurrence.

METHODS

We performed a retrospective, follow up cohort study of all children </=5 years, who underwent LNF or ONF at our institution from January 1, 1997 to December 31, 2002, where five pediatric surgeons perform fundoplication. Mean follow up time was 36.2 months. The following information was obtained: surgical indications, hospital course data, and long-term surgical outcomes. Data were analyzed using univariate and multiple logistic regressions.

RESULTS

Overall, 456 (150 [32.9%] ONF vs. 306 [67.1%] LNF) cases were analyzed. Reoperation was performed in 55 (12.06%), LNF 43 (14.05%), and ONF 12 (8%). The mean interim to reoperation for LNF was 11 months compared to 17 months for ONF (p= 0.007). The reoperation rate at 12 and 24 months were 10.5%, 13.4% and 4%, 6.7% respectively, when LNF was compared to ONF (p= 0.01). The multivariate analysis showed that initial LNF and prematurity were the main predictors for reoperation.

CONCLUSIONS

The majority of reoperations for both LNF and ONF occurred in the first year after initial operation; LNF had a significantly higher reoperation rate than ONF. The probability of reoperation for LNF and ONF increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions.

The surgical treatment of gastro-esophageal reflux in neonates and infants

Gastro-esophageal reflux (GER) is a physiological process characterized by the involuntary passage of gastric contents into the lower esophagus not induced by noxious stimuli. It represents a common condition in preterm infants and may occur in healthy neonates. The phenomenon is only considered as GER disease when it causes the patient to be symptomatic or results in pathological complications. Fundoplication is recommended in symptomatic neonates and infants with GER that does not respond to medical treatment. The presence of respiratory symptoms related to GER is the primary indication for fundoplication in this selected population. The Nissen fundoplication is the antireflux procedure of choice and the experience concerning other procedures, including laparoscopic techniques, is limited in this age group. The best results are achieved in newborn infants with isolated GER, as the recurrence rate of GER in infants with associated anomalies is high. Further studies are necessary to evaluate the benefit of laparoscopic fundoplication in this age group.

Use of radiofrequency ablation of the lower esophageal sphincter to treat recurrent gastroesophageal reflux disease

PURPOSE

Recurrent gastroesophageal reflux disease (GERD) after gastroesophageal surgery is a troublesome problem. Reoperative surgery often is complicated by adhesions and recurrence. Radiofrequency ablation or energy delivery (RF or the Stretta procedure) is a new method for treating GERD. This study is the first report describing the use of the Stretta procedure in pediatric patients.

METHODS

Six patients who underwent previous gastroesophageal surgery presented with recurrent GERD. Medical records were reviewed and the severity of reflux graded using a modified scoring system. All underwent RF and were graded for GERD at 6 months postprocedure.

RESULTS

Mean operating time was 80 +/- 12 minutes. Mean age at initial operation was 12 +/- 4 years and for the RF, 18.0 +/- 3.4 years. All patients were discharged as outpatients. Early complications occurred in one child with self-resolving acute gastric distension. Five of 6 patients were completely asymptomatic at 3 months after the procedure, and 3 stopped anti secretory agents. One patient was improved but still symptomatic and needed a redo fundoplication. Another required a repeat application of RF 10 months after the initial one. Mean GERD score pre-Stretta was 5.2 +/- 1.0, which improved to 1.6 +/- 1.9 at 6 months postprocedure (P <.05; paired t test).

CONCLUSIONS

Use of RF treatment of the lower esophageal sphincter is a potentially successful modality to treat recurrent GERD in children. Long-term follow-up is required.

Esophagogastric separation for failed fundoplication in neurologically impaired children

PURPOSE

Recurrent gastroesophageal reflux (GER) after a fundoplication in severely neurologically impaired children is a frustrating problem without an effective solution: redo fundoplications carry a significant recurrence rate and gastrojejunostomy (GJ) tube feedings are associated with frequent tube dislodgment. The authors report a series of esophagogastric separation (EGS) procedures aimed at the management of failed fundoplication in neurologically impaired children.

METHODS

Medical records of 10 patients who underwent EGS for recurrent GER were reviewed retrospectively. Variables examined included diagnosis, preoperative problems, operative and perioperative data, and outcomes.

RESULTS

None of the patients were feeding orally and all were dependent on tube feedings. A median of 1.5 (range, 1 to 3) fundoplications had been performed previously and failed. All had preoperative emesis and feeding intolerance. Eight had failure to thrive and 5 recurrent pneumonias. Median age at the time of the procedure was 7.5 years (range, 2 to 22). Median postoperative length of stay was 9 days (range, 5 to 17), and there were no leaks from the anastomosis. Salivary secretion intolerance was the most common postoperative problem (5 of 10 patients). Repeat exploration was required for perforation of the colon in one and paraesophageal hernia in another. Recurrent GER was not noted. All 9 currently surviving children are tolerating bolus gastrostomy feedings, which was an advantage to the parents.

CONCLUSIONS

EGS is an attractive alternative for failed fundoplication in severely neurologically impaired children.

Use of electrogastrography in children

Electrogastrography (EGG), the measurement of gastric pacemeaker activity by means of surface electrodes, provides a noninvasive technique to detect and quantify the characteristics of the gastric slow wave. With a predominant frequency of three cycles per minute, the activity of the specialized cells responsible for this pacing, the interstitial cells of Cajal, is crucial in providing the underlying electrophysiologic changes that enable coordinated smooth muscle contraction and synchronized peristalsis. Advances in electronics and software to define frequency distribution, stability of the signal, postprandial changes, and other parameters have contributed to more widespread interest in EGG and its application to the investigation of functional gastrointestinal disturbances. Definition of pediatric norms and postnatal changes in the EGG of premature infants has provided the foundation for further studies investigating correlative changes with such important functions as gastric emptying and motility. The EGG remains a promising diagnostic tool. Future studies will help define its usefulness in identifying abnormal functions of the interstitial cells of Cajal.

Is endoscopic follow-up needed in pediatric patients who undergo surgery for GERD?

BACKGROUND

This study evaluated the role of endoscopy in the postoperative management of pediatric patients who undergo fundoplication for GERD.

METHODS

Medical records of 109 otherwise healthy children who underwent operation for GERD from 1979 to 1996 were reviewed. Patients with respiratory symptoms or esophageal stenosis were excluded. All patients underwent endoscopic surveillance with endoscopy being performed in the early (within 1 year) and late (between 1 and 2 years) postoperative periods. Specifically evaluated were the appearance of the wrap and evidence of esophagitis. The risk of a recurrence of esophagitis based on wrap appearance and the presence of clinical symptoms in patients with endoscopic evidence of esophagitis were also evaluated.

RESULTS

At early endoscopy 3 patients with an intact wrap and 8 with a defective wrap had esophagitis (not significant). At late endoscopy, 5 patients with an intact wrap and 17 with a defective wrap had esophagitis (p < 0.05).

CONCLUSIONS

An intact wrap does not prevent recurrence of GERD. Such an occurrence is even more likely when endoscopy demonstrates a defective wrap. For all patients who have undergone fundoplication, endoscopic evaluation at 1 to 2 years is recommended to detect esophagitis in the absence of symptoms so treatment can be initiated before symptoms occur.

Esophagogastric dissociation versus fundoplication: Which is best for severely neurologically impaired children?

PURPOSE

Neurologically impaired children (NIC) often have swallowing difficulties, severe gastroesophageal reflux, recurrent respiratory infections, and malnutrition. Bianchi proposed esophagogastric dissociation (EGD) as an alternative to fundoplication and gastrostomy. The authors compared these 2 approaches.

METHODS

Twenty-nine consecutive symptomatic NIC refractory to medical therapy were enrolled in a prospective study and divided into 2 groups: A (n = 12), NIC who underwent fundoplication and gastrostomy; B (n = 14), NIC who underwent EGD. Three were excluded because of previous fundoplication. Anthropometric (percentage of the 50th percentile/age of healthy children) and biochemical parameters, respiratory infections per year, hospitalization (days per year), feeding time (minutes), and "quality of life" (parental psychological questionnaire, range 0 to 60), were analyzed (t test and Mann-Whitney test) preoperatively and 1 year postoperatively. Complications were recorded.

RESULTS

Compared with group A, group B presented a statistically significant increase of all anthropometric and nearly all biochemical parameters with a statistical difference in terms of respiratory infections, hospital stay, feeding time, and psychological questionnaire. In group A, 2 bowel obstructions, 1 tight fundoplication, 1 dumping syndrome, and 3 failures of fundoplication occurred. Group B presented 1 anastomotic stricture, 1 paraesophageal hernia, and 1 bowel obstruction.

CONCLUSIONS

Compared with fundoplication and gastrostomy, EGD offered better nutritional rehabilitation, reduction in respiratory infections, and improved quality of life. EGD can be rightfully chosen as a primary procedure.

Is epidural analgesia associated with an improved outcome following open Nissen fundoplication?

Postoperative epidural analgesia is increasingly popular in paediatric practice, although evidence of its benefit is scarce. We performed a retrospective analysis of a series of 104 consecutive open Nissen fundoplications, to determine whether mode of analgesia, epidural (n=65) or opioid infusion (n=39), influenced certain outcome measures, including intensive care utilization, duration of hospital stay, morbidity and mortality. The two groups were similar in terms of demographic characteristics and associated pathologies. Overall, morbidity and mortality (2%) rates were low. Mean duration of hospital stay was significantly greater for the opioid group, compared to those receiving epidural analgesia (13 vs. 8 days, P < 0.05). The number of patients who remained in hospital for more than 7 days was also significantly greater in the opioid group. Accepting the limitations of a retrospective study, these data suggest that epidural analgesia might be associated with an improved outcome following Nissen fundoplication and this merits a prospective study.

Technical aspects of feeding the disabled child

Children with neurological impairment frequently have difficulties in consuming sufficient energy and other nutrients to maintain adequate nutritional status. Under-nutrition is a significant contributory factor to growth failure. Eating may be distressing and time-consuming for the child and carer. Aspiration of feeds is common and may predispose to chronic chest infections. Gastro-oesophageal reflux is also common and may contribute to significant morbidity. This paper discusses some of the issues involved in the nutritional management of neurologically impaired children.

Management of supraesophageal complications of gastroesophageal reflux disease in infants and children

Therapy of supraesophageal manifestations of gastroesophageal reflux disease (GERD) in infants and children nearly always includes "lifestyle modifications" (conservative or nonpharmacologic therapy). Depending on the severity of the GERD manifestation, pharmacotherapy is often added. Although data to support the practice are not abundant, it is rational to begin with prokinetic pharmacotherapy and to add acid suppression if pathologic effects of acid contact with the esophagus or airway are suspected. Pathologic effects of acid produce most forms of supraesophageal GERD; the exception is infantile regurgitation, the most common example of supraesophageal GERD, which is often unaccompanied by either esophagitis or evidence of acid entry into the airway. Currently, fundoplication is rarely required for pediatric GERD, but the supraesophageal complications of GERD are more common indications for this surgery than the esophageal complications in children. Other management options for supraesophageal symptoms in children include delivery of nutrients by tube feeding slowly and continuously into the stomach or, better, small intestine. Short-term or trial tube feeding uses a transnasal tube, for example, for nasojejunal feeding; longer-term tube feeding is simplified by a gastrostomy, which can be placed relatively noninvasively using endoscopy or fluoroscopy.

Characterization and management of paraesophageal hernias in children after antireflux operation

PURPOSE

The aim of this study was to determine the important factors in the development and subsequent treatment of postoperative paraesophageal hernia (PPEH).

METHODS

A retrospective analysis was performed in 464 consecutive children (ages 3 days to 18 years) for PPEH after a primary antireflux operation performed at a Children's Hospital and University Hospital between 1985 and 1997. All operations included a crural repair, but the Nissen fundoplication was performed with (n = 162) and without (n = 70) plication of the esophagus to the crus at 3 points. Patients with and without PPEH were compared with respect to the type of antireflux operation, the patient's age at operation, and the preoperative and postoperative clinical courses. A preoperative corrected gastric emptying value was obtained from a radionuclide gastric emptying study in 289 patients. The treatment of PPEH also was examined.

RESULTS

The incidence of PPEH in our patients was 4.5% (21 of 464). Although there was a lower incidence of PPEH in patients with crural plication compared with patients without crural plication during Nissen fundoplication (5 of 162, 3% v 7 of 70, 10%; P = .035), 2 patients with crural plication had a postoperative esophageal leak. Patients with PPEH had a significantly increased prevalence of gagging before the initial antireflux operation compared with patients without PPEH (3 of 21, 14.3% v 7 of 443, 1.6%; P = .007). A higher prevalence of slow corrected gastric emptying preoperatively also was seen in patients with PPEH compared with patients without PPEH (8 of 15, 53% v 79 of 274, 29%; P = .046). The prevalences of central nervous system disease, young age (<6 months) at initial operation, and a particular type of antireflux operation were not higher in patients with PPEH. Nine patients with a small PPEH treated by simple observation alone subsequently had resolution of symptoms.

CONCLUSIONS

Patients who have gagging or slow corrected gastric emptying before an antireflux operation are at higher risk for a postoperative paraesophageal hernia. Patients with a small postoperative paraesophageal hernia can be treated nonoperatively. Crural plication of the esophagus during Nissen fundoplication reduces the occurrence of postoperative paraesophageal hernia, but also may result in significant morbidity.

Interposition of a jejunal segment between esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux

Here the authors report the clinical experience with placement of an isolated jejunal segment between the esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux (GER) in a child. A 6-year-old neurologically normal girl experienced severe symptomatic GER after 3 previous well-constructed Nissen fundoplications that failed over a 4-year period. The gastric cardia was closed, and a 16-cm isolated segment of proximal jejunum was placed in an isoperistaltic direction between the distal esophagus and an incision through the pylorus, extending onto both the antrum and duodenum. A gastrostomy was used for 3 months. The patient recovered from the operation without complications and has been completely relieved of reflux symptoms during the 15 months postoperation. She has gained over 6.5 kg in weight and 3.2 cm in height during this period and has not experienced difficulty swallowing solid foods. Esophagogastric dissociation with placement of an isolated jejunal segment between the esophagus and pylorus may have a useful role in the surgical management of multirecurrent symptomatic GER as a "rescue procedure" with low risk compared with other options.

Antireflux surgery in children suffering from reflux-associated respiratory diseases

The aim of our study was to evaluate the success, complications, and morbidity following a modified Thal fundoplication in children with reflux-associated respiratory disease (RARD). We used a procedure consisting of retroesophageal hiatal plasty, wrapping the gastric fundus around the gastroesophageal junction 180 degrees, and fixation of the lesser curvature at the abdominal wall. Follow-up by questionnaire of 128 (77 male, 51 females) out of 196 antireflux procedures between 1992 and 1995 was achieved. Surgical therapy was considered justified whenever there was gastroesophageal reflux resulting in severe recurrent respiratory symptoms. Eleven percent of the children suffered from bronchiectasis. The diagnosis of RARD was based on a high index of suspicion, barium swallow with fluoroscopy, 24-hr two-level pH-monitoring, bronchoscopy, bronchoalveolar lavage and detection of lipid-laden alveolar macrophages, esophago-gastroscopy, and esophageal biopsy. Patients with bronchopulmonary diseases such as allergy, immunodeficiency, cystic fibrosis, primary ciliary dyskinesia, and malformation of the bronchial tree or vessels had been excluded. "Evident improvement" as a result of surgery was reported in 88%, "no change" in 10%, and a "change for the worse" in 2% of patients. Persistent mild difficulties in swallowing were observed in 11%. Paraesophageal hernia, gas-bloat syndrome, and dumping syndrome were not observed. Two children needed a second operation because of relapse. The use of emergency steroidal medication for acute respiratory distress decreased impressively (219 single doses/year before surgery vs. 30 single doses/year after surgery). The need for more than 4 times/year of antibiotic therapy before surgery was reduced from 52. 3% before to 14% after surgery. Most (90.6%) of the parents stated they would agree to have surgery done again if medically indicated. In conclusion, Thal fundoplication is sufficient, safe, and effective in the management of RARD. Complications of the procedure were minor and of little consequence to the patient.

Lipid-laden alveolar macrophages (LLAM): a useful marker of silent aspiration in children

At present there is no test available which identifies children suffering from silent aspiration due to gastroesophageal reflux (GER). The purpose of this study was to determine whether lipid-laden alveolar macrophage (LLAM) scoring is a useful method to arrive at the diagnosis. We evaluated bronchoalveolar lavage fluid (BALF) from 68 children aged 6 months to 14 years (median 3.75 years) for the presence of lipid-laden alveolar macrophages. We compared children with chronic chest disease (CCD) and GER to healthy surgical controls without known lung disease, and to children with recurrent pneumonia without GER. By grading the amount of intracellular Sudan Red-positive material, we determined a semiquantitative lipid-laden macrophage (LLAM) score for each patient. Patients with chronic chest disease suspected to be caused by silent aspiration secondary to GER had a significantly higher LLAM score (median, 117; range, 10-956) than children with recurrent pneumonia due to other reasons (median, 29; range, 5-127; P < 0.01) and healthy controls (median, 37; range, 5-188; P < 0.01). We believe that simply observing lipid-laden macrophages is nonspecific, but quantitation of these cells is a useful method for diagnosing silent aspiration in children, especially when the score exceeds 200.

Feeding problems in merosin deficient congenital muscular dystrophy

Feeding difficulties were assessed in 14 children (age range 2-14 years) with merosin deficient congenital muscular dystrophy, a disease characterised by severe muscle weakness and inability to achieve independent ambulation. Twelve of the 14 children were below the 3rd centile for weight. On questioning, all parents thought their child had difficulty chewing, 12 families modified the diet, and 13 children took at least 30 minutes to complete a meal. On examination the mouth architecture was abnormal in 13 children. On videofluoroscopy only the youngest child (2 years old), had a normal study. The others all had an abnormal oral phase (breakdown and manipulation of food and transfer to oropharynx). Nine had an abnormal pharyngeal phase, with a delayed swallow reflex. Three of these also showed pooling of food in the larynx and three showed frank aspiration. These six cases all had a history of recurrent chest infections. Six of eight children who had pH monitoring also had gastro-oesophageal reflux. As a result of the study five children had a gastrostomy, which stopped the chest infections and improved weight gain. This study shows that children with merosin deficient congenital muscular dystrophy have difficulties at all stages of feeding that progress with age. Appropriate intervention can improve weight gain and reduce chest infections. The severity of the problem has not been previously appreciated in this disease, and the study shows the importance of considering the nutritional status in any child with a primary muscle disorder.

Effectiveness of fundoplication in early infancy

PURPOSE

The aim of this study was to evaluate the results of fundoplication performed in the first 4 months of life.

METHODS

Case-notes of 66 patients less than 4 months old who underwent fundoplication between January 1986 and July 1997 were reviewed. The mean length of follow-up was 24 months (range, 3 to 115 months). Diagnosis of gastrooesophageal reflux (GOR) was based on a barium meal in 55 patients or 24-hour pH monitoring in 23 patients.

RESULTS

Fundoplication was performed at a median age of 9 weeks (range, 3 to 15 weeks). Associated anomalies were identified in 56 infants and included oesophageal atresia or tracheooesophageal fistula (n = 19), lung abnormalities (n = 7), congenital diaphragmatic hernia (n = 4), and various other complex syndromes including neurological disorders (n = 26). Isolated GOR occurred in 10. Ninety percent of infants with isolated GOR improved clinically after the fundoplication compared with 64% of those with associated anomalies. Only 58% of infants in whom GOR developed after oesophageal atresia repair improved after fundoplication. Vomiting was reduced after fundoplication in 76% of infants, apnoea and/or respiratory symptoms improved in 66%, whereas failure to thrive incidence improved in only 38% of infants. Revision of the fundoplication was required in 16 (24%) patients. There were eight deaths, all of which occurred at least 6 months after the fundoplication.

CONCLUSIONS

Fundoplication in early infancy is unsuccessful in a high proportion of patients. The highest incidence of failure and redo fundoplication occurred in infants with associated anomalies. The best results were achieved in infants with emesis and respiratory symptoms.

Esophagogastric disconnection for gastroesophageal reflux in children with severe neurological impairment

PURPOSE

Fundoplication has been used successfully to treat gastroesophageal reflux in the pediatric population; however, the results are poorer in those children with neurological impairment. We propose an alternative approach to the needs of these special patients and report the use of esophagogastric disconnection to control reflux in children with profound neurological impairment.

METHODS

Between 1991 and 1997, 27 esohagogastric disconnections were performed. All patients were severely neurologically impaired with symptomatic gastroesophageal reflux confirmed by an upper gastrointestinal radiographic study. There were 16 boys and 11 girls with ages ranging from 6 months to 40 years. Three had undergone previous fundoplications that failed, whereas the remaining underwent esophagogastric disconnection as a primary antireflux procedure. Follow-up ranged from 1 month to 6.3 years (average, 2.8 years). The operative approach used a midline incision. The gastroesophageal junction was divided, and the gastric side was closed. A 30- to 40-cm jejunal limb was prepared for Roux-en-Y reconstruction and brought up to the esophagus in a retrocolic manner. Esophagojejunal and jejunojejunal anastomoses were then performed. A Stamm tube gastrostomy was placed, and the appendix was removed. A pyloroplasty and tube jejunostomy were performed when felt to be clinically indicated.

RESULTS

Gastroesophageal reflux symptoms resolved, and bolus feedings were tolerated by all patients. Oral feedings were tolerated except in those children limited by their swallowing abilities. Early postoperative complications occurred in eight patients (30%) with two (7%) requiring reoperation (esophageal leak and enterocolitis). Late reoperation was necessary in four patients (15%) for small bowel obstruction, paraesophagcal hernia, gastrostomy revision, and enterocolitis. There were no perioperative deaths, but three patients (11%) died of late surgical complications (two of small bowel obstructions, and one of improper reinsertion of a gastrostomy tube). Three other children died of unrelated causes.

CONCLUSIONS

Esophagogastric disconnection effectively eliminates gastroesophageal reflux while allowing both bolus tube feedings and oral supplementation. This operation provides an alternative method of controlling gastroesophageal reflux in children with profound neurological impairment.

Outcome of Nissen fundoplication using intraoperative manometry in children

BACKGROUND

Intraoperative manometry is useful in performing Nissen fundoplication (NF) in children. Long-term clinical outcome information after use of this method is lacking.

METHODS

A retrospective review of the outcomes of 62 consecutive NFs using intraoperative manometry was performed. The follow-up period was 3.4 years. Approximately half of the patients were neurologically normal (NN) and half were neurologically impaired (NI). All patients with gastroesophageal reflux disease (GERD) did not respond to an adequate trial of medical treatment.

RESULTS

The NF was tailored to result in a twofold increase in the lower esophageal sphincter pressure (LESP) and a 75% increase in the LES length (LESL). An accelerated growth rate in 40% of "failure to thrive" (FTT) patients was demonstrated. Eighty-four percent of caregivers reported improved quality of life after NF. There was a twofold reduction in the number of hospital admissions and a sixfold reduction in total inpatient days for both NI and NN children. The early and late mortality rate was 13%, and the complication rate was similar to other series reported in the literature, with more complications occurring in NI patients. There was a 2% incidence of wrap herniation. An improvement in long-term outcomes after NF was seen in 89% of NN children and over half of NI patients.

CONCLUSIONS

Intraoperative manometry is useful in standardizing the tightness of the wrap in NF. There was a low incidence of complications, dysphagia, recurrent emesis, and GERD in this series. Long-term outcomes using this technique were deemed very good based on caregivers' responses.

Feeding the disabled child

Feeding difficulty and malnutrition are common in disabled children. Intake may be reduced because of anorexia, chewing and swallowing difficulties, or vomiting. Feeding is often time consuming, unpleasant, and may result in aspiration. Malnutrition may result in impaired growth and neurodevelopment, and impaired cardiorespiratory, gastrointestinal, and immune functions. Multidisciplinary assessment is recommended and should include a feeding history, oral-motor examination, and nutritional assessment. The energy requirements of most disabled children are less than those for a normal child of the same age but may be increased by spasticity, athetosis, convulsions, and recurrent infections. Micronutrient deficiencies may occur even in children receiving nutritionally complete feeds if the volume is reduced because of low energy requirements. Oral intake may be improved by a change of posture, special seating, feeding equipment, oral desensitization, mashing or pureeing of lumpy food, thickening of liquids, use of calorie supplements, and treatment of reflux/esophagitis. Non-oral feeding should be considered when oral feeding is unsafe, not enjoyable, inadequate, or very time consuming. Long-term support requires a gastrostomy. This is less obtrusive than a nasogastric tube, less likely to become displaced, less traumatic, and is associated with improved quality of life, but is also associated with significant morbidity. If there is symptomatic reflux a fundoplication may be required, but this is associated with significant mortality and substantial morbidity.

Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopic gastrostomy in children

BACKGROUND

Abnormal gastroesophageal reflux after percutaneous endoscopic gastrostomy is a serious problem in neurologically impaired children. Protective fundoplication has been advocated. Whether esophageal pH monitoring before percutaneous endoscopic gastrostomy will predict later problems with gastroesophageal reflux is unclear.

METHODS

Eighty-five mostly neurologically impaired pediatric patients who underwent percutaneous endoscopic gastrostomy were studied retrospectively regarding complications, success of nutritional rehabilitation, and the incidence of pathologic gastroesophageal reflux. Follow-up period was 1 to 4 years. Twenty-four-hour esophageal pH monitoring was performed in 46 patients before percutaneous endoscopic gastrostomy.

RESULTS

There were no deaths. Two major complications occurred that required surgical intervention, and 14 minor complications occurred related to the procedure. Z-scores for weight increased significantly after percutaneous endoscopic gastrostomy. pH probe results were normal in 22 patients (group 1). Five required medical treatment for gastroesophageal reflux after percutaneous endoscopic gastrostomy, but only 1 (5%) later required Nissen fundoplication. pH probe results were abnormal in 24 patients (group 2). Nineteen required medical therapy for gastroesophageal reflux, and 7 (29%) later needed fundoplication (p < 0.05, incidence of fundoplication group 1 vs. group 2). Improvement in Z-scores was similar in patients requiring and not requiring fundoplication.

CONCLUSIONS

Percutaneous endoscopic gastrostomy is a safe and effective technique for long-term nutritional support in children. Abnormal gastroesophageal reflux is common. Normal findings in an esophageal pH study before percutaneous endoscopic gastrostomy may be predictive of a favorable outcome with respect to gastroesophageal reflux. This is in contrast to patients with abnormal results in pH studies before percutaneous endoscopic gastrostomy of whom a relatively large percentage may later require fundoplication. Improved nutritional status after percutaneous endoscopic gastrostomy does not appear to have an impact on the severity of gastroesophageal reflux.

Laparoscopic gastric antroplasty in children with delayed gastric emptying and gastroesophageal reflux

BACKGROUND/PURPOSE

A significant number of children (50%) with gastroesophageal reflux (GER) have delayed gastric emptying (DGE). Although controversial, many pediatric surgeons use a gastric outlet procedure in conjunction with fundoplication for gastroesophageal reflux in these patients. This paper describes the technique and clinical outcome of 61 patients undergoing a laparoscopic gastric antroplasty at the time of the laparoscopic fundoplication.

METHODS

The charts of 61 patients who underwent laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication between May 26, 1992 and October 17, 1996 were reviewed retrospectively. All patients had a documented DGE confirmed by a liquid isotope meal being retained in the stomach. After completion of the fundoplication, a laparoscopic antroplasty was performed by incising a 2 to 3.5-cm linear incision in the pylorus and distal gastric antrum. The seromuscular wall was divided to the level of the mucosa allowing the mucosa to bulge through the defect. The wound was closed transversely using interrupted 2-0 silk sutures.

RESULTS

Four of the 61 patients underwent conversion to open antroplasty for technical reasons. The remaining 57 patients recovered uneventfully from the laparoscopic antroplasty with clinical resolution of both GER and DGE. Two of 57 patients had intermittent episodes of retching and were unable to tolerate large bolus feedings because of dumping. They were treated by dividing the feedings into two smaller portions. These symptoms cleared within 6 months. The remaining 55 patients have tolerated feedings well. Evaluation of the gastric emptying was performed randomly in selected patients with documented improvement of the emptying after antroplasty. An evisceration of omentum through the umbilical incision developed in one patient on the third postoperative day.

CONCLUSIONS

Patients with delayed gastric emptying who need fundoplication can be treated with laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication. Laparoscopic antroplasty appears to be clinically efficacious in improving delayed gastric emptying.

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.