Redo fundoplication in infants and children with recurrent gastroesophageal reflux

Surgical jejunostomy and radiological gastro-jejunostomy tube feeding in children: risks, benefits and nutritional outcomes

PURPOSE

Radiologically inserted gastrojejunal tubes (RGJ) and surgical jejunostomy (SJ) are established modes of jejunal feeding. The aim of the study is to review nutritional outcomes, complications and the practical consideration to enable patients and carers to make informed choice.

METHODS

Retrospective review of patient notes with a RGJ or SJ in 2010, with detailed follow-up and review of the literature.

RESULTS

Both RGJ and SJ are reliable modes to provide stable enteral nutrition. Both have complications and their own associated limitations.

CONCLUSIONS

The choice has to be tailored to the individual patient, the social care available, the inherent medical disease and risk/benefit of repeated anaesthetic and radiation exposure. RGJ and SJ are important tools for nutritional management that achieve and maintain growth in a complex group of children. The risk and benefits should be reviewed for each individual patient.

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.

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

BACKGROUND

Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

AIMS

To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

METHODS

We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients' Visick score assessed parents' perspective.

RESULTS

Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents' perspectives were excellent or good in 85 %.

CONCLUSIONS

A significant positive impact of redo Nissen intervention on the patient's outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

The "omega" jejunostomy tube: A preferred alternative for postpyloric feeding access

AIM

We present our technique for construction of the "Omega Jejunostomy" (OJ), a novel method of postpyloric feeding using a pouched-jejunal loop capable of accommodating a balloon gastrostomy button. We describe potential indications for the procedure and outcomes in a complex patient population.

MATERIALS AND METHODS

We retrospectively reviewed records of patients who underwent an OJ at our institution between 2005 and 2014. Primary outcomes include operating time, length of hospital stay, time to feeding goals, and postoperative complications.

RESULTS

We identified 12 children (6 males) with multiple comorbidities who underwent OJ procedures. The median age at surgery was 11years (range 3months-23years). Eleven patients had failed previous alternative feeding access or antireflux procedures. All patients eventually reached their feeding goals. Eight were at goal feeds in <10days. Two achieved goal feeds <1month, one <4months, and one within 7months. There was one OJ failure because of fistula formation requiring surgical revision, and one child was treated successfully but died of unrelated causes. Four children eventually transitioned to PO or G-tube feeds, and six were tolerating feeds via OJ at last follow-up (8-74months).

CONCLUSIONS

OJ provides a durable alternative to gastrojejunostomy tube for patients who are poor candidates for or have failed Nissen fundoplication. It is technically easier to perform than a gastroesophageal disconnect procedure, has minimal surgical comorbidities, and can provide durable feeding access and achievement of goal feeds in a complex and refractory patient subset.

Physical outcome and quality of life after total esophagogastric dissociation in children with severe neurodisability and gastroesophageal reflux, from the caregiver's perspective

BACKGROUND/PURPOSE

The objective of this study is to retrospectively assess the surgical outcome and the quality of life (QOL) from the caregiver's perspective after total esophagogastric dissociation in neurologically impaired (NI) children with gastroesophageal reflux (GOR).

METHODS

Based on O'Neill questionnaire, a QOL questionnaire was designed, which was completed by the caregivers recording the child's well being and caregiver's satisfaction preprocedure, immediately (6 months), and long-term postprocedure (median, 21 months; range, 4-38). Statistical analysis was done using Kruskal-Wallis Test and Dunn's multiple comparisons test.

RESULTS

Twenty-three children underwent surgery between 2003 and 2008; 19 families participated. Ease of feeding improved significantly both immediately and long term. Statistically significant improvements were also seen in comfort and ability of the child to enjoy life, frequency of medical visits, vomiting, retching, and choking. Postoperatively, caring for the child became easier, and the caregiver's frustration in caring improved statistically, but the caregiver's overall QOL did not improve significantly.

CONCLUSIONS

Total esophagogastric dissociation has huge positive impact on the physical well being of the NI children experiencing GOR. The overall view of the procedure is one of success surpassing all expectations. Therefore, it should be considered alongside other antireflux procedures in NI children.

[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.

Gastric volvulus in infants and children

INTRODUCTION

Gastric volvulus is an important cause of nonbilious emesis that must be recognized early to ensure a good outcome. We reviewed 7 cases from our institution, Children's Healthcare of Atlanta (Egleston campus). In addition, we reviewed all gastric volvulus cases in children published to date in the English literature to draw general conclusions about the presentation and treatment of this unusual disease.

METHODS

An electronic literature search was performed to find all published cases of pediatric gastric volvulus. The care of all children from January 2002 to December 2007 who were treated for gastric volvulus was also reviewed.

RESULTS

There have been 581 cases of gastric volvulus in children published in English between 1929 and 2007. Of these, 252 were acute and 329 were chronic cases. The most common presentation of acute gastric volvulus is in a child <5 years old with nonbilious emesis, epigastric distention, and abdominal pain. Acute gastric volvulus is often associated with deformities of adjacent organs. Definitive diagnosis is made with upper gastrointestinal studies, and definitive therapy requires repair of associated defects and anterior fixation of the stomach to the abdominal wall. The most common presentation of chronic volvulus is in an infant <1 year old with emesis, epigastric distention, feeding difficulties, and growth failure. Treatment may be medical or surgical depending on the underlying etiology of the volvulus.

CONCLUSIONS

Acute gastric volvulus is a potentially life-threatening occurrence with a good outcome when treated in a timely fashion. Chronic volvulus may be more difficult to recognize. The common features of acute and chronic gastric volvulus described in this review should assist pediatric health care providers in promptly diagnosing and treating this disease.

Total esophagogastric dissociation in adult neurologically impaired patients with severe gastroesophageal reflux: an alternative approach

Patients with neuromuscular impairment, such as cerebral palsy or myotonic dystrophy, often suffer from oropharyngeal neuromuscular incoordination and severe gastresophageal reflux (GER). In 1997, Bianchi proposed total esophagogastric dissociation (TEGD) as an alternative to fundoplication and gastrostomy to eliminate totally the risk of recurrence of GER in neurologically impaired children. Little information exists about the best management for adult patients with severe neurological impairment in whom recurrent GER develops after failed fundoplication. We present our experience in three adult patients with neurological impairment in whom TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy was performed for permanent treatment of GER.

Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children

PURPOSE

Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication.

METHODS

The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed.

RESULTS

Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 +/- 1.0 and 2.6 +/- 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth.

CONCLUSION

Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.

Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement

PURPOSE

Long-term feeding access in children who fail initial gastrostomy is a management quandary. Although image-guided gastrojejunal feeding tube placement (IGJ) is becoming the access of choice in many centers, few studies have compared long-term results with surgical jejunostomy (SJ). The authors compare outcomes with these 2 techniques.

METHOD

A retrospective review of 20 children requiring jejunal feeding access after failing initial gastrostomy was done. Procedures were performed at a tertiary referral center by interventional radiologists (IGJ) or board-certified pediatric surgeons (SJ).

RESULTS

Initially, patients underwent IGJ (n = 14) or SJ (n = 6). Image-guided gastrojejunal feeding tube placement patients required gastrostomy at an average age of 23.8 months, with conversion to IGJ an average of 17.2 months later. SJ patients required gastrostomy at average age of 16.2 months, with conversion to SJ 30.7 months later. Of 14 patients undergoing IGJ, 7 (50%) eventually required SJ because of recurring tube management issues. Thus, 13 patients ultimately had SJ, with 11 (85%) Roux-en-Y jejunostomies. Mean operating time for SJ was 158 minutes, with an average of 5.1 days to initiation of feeds, 11 days to full feeds, and 19.9 days to discharge (range, 3-66 days). Image-guided gastrojejunal feeding tube placement patients averaged 4.6 tube adjustments per year requiring fluoroscopic guidance. Surgical jejunostomy averaged 1.5 tube adjustments per year requiring outpatient hospital visits. Image-guided gastrojejunal feeding tube placement patients averaged 3.9 hospital d/y secondary to feeding tube management issues, whereas SJ patients averaged 1.4 hospital days per year.

CONCLUSION

In this group of children with long-term jejunal feeding access, half of those with IGJ eventually required SJ. Surgical jejunostomy required fewer adjustments and hospitalizations per year. Although initially more invasive than IGJ, SJ may provide more stable feeding access with fewer complications. This represents the first published report comparing long-term outcomes between IGJ and SJ.

Long-term results of boerema anterior gastropexy in children

OBJECTIVES

To analyze the long-term results of Boerema anterior gastropexy using the Visick grading system in a university teaching hospital.

METHODS

Retrospective review of 247 children with severe or complicated gastroesophageal reflux disease (GERD). Patients who underwent primary gastropexy between 1990 and 2001 were divided in 3 groups: (A) neurologic impaired patients (n = 83); (B) esophageal atresia patients (n = 36); and (C) patients without underlying disease (n = 128). The median length of follow-up after gastropexy was 7 years and 8 months (range, 1.5-13 years). Follow-up was carried out using a standardized questionnaire and was obtained by telephone. Postoperative recurrence of symptoms during follow-up was considered as failure of the operation.

RESULTS

Postoperative complications occurred in 20 patients (24%) in group A, in 13 patients (36%) in group B and in 23 patients (18%) in group C. Thirty-three patients died during the follow-up period, 5 of whom during the postoperative period. Six children could not be traced; thus, 208 were available for long-term follow-up. Postoperative failures occurred in 12 patients (23%) in group A, in 11 patients (31%) in group B and in 17 patients in group C (14%). Reoperation for recurrence of symptoms due to GERD was performed in 6 patients in group A, in 7 patients in group B and in 2 patients in group C. The final outcome at the time of interview was successful in 81% of group A, in 88% of group B and in 91% of group C.

CONCLUSIONS

In the long term, Boerema anterior gastropexy is an effective operation for complicated GERD in children without underlying disease as well as in neurologically impaired children and patients with esophageal atresia.

Total oesophagogastric dissociation: experience in 2 centres

BACKGROUND/PURPOSE

Neurologically impaired (NI) children have an increased incidence of gastroesophageal reflux and many will require surgery.

METHODS

The case notes of 50 NI children who underwent total oesophagogastric dissociation (TOGD) were reviewed. Thirty-four were done as a primary procedure, and 16 were rescues for failed fundoplications.

RESULTS

There was no operative mortality. Morbidity consisted of 1 subphrenic collection, 1 oesophagojejunal dehiscence and 2 stenoses that responded to dilatation, and 2 bowel obstructions. In 1 case, partial gastric resection was needed because of transhiatal herniation of stomach. Gastrostomy feeding was established by 3 to 5 days. The mean hospital stay was 10.9 days. At 4 months to 11 years of follow-up, there was no recurrence of reflux. Children who could swallow enjoyed oral feeds. Their general health and weight SD scores improved. Food aspiration, chest infections, and hospitalizations were reduced, with an improvement in quality of life. There were 5 late deaths in the "primary" and 7 in the "rescue" group from deterioration in their original condition.

CONCLUSION

Total oesophagogastric dissociation is a safe and versatile procedure without immediate mortality and limited surgery-related morbidity. Review of our practice suggests TOGD should be considered as a primary procedure in severely NI children with gastroesophageal reflux and significant oropharyngeal incoordination and dependence on enteral tube feeding. Rescue TOGD carries a greater morbidity because of previous surgery with consequent difficult dissection, poor oesophageal tissue, and higher incidence of vagal nerve injury.

Esophagogastric dissociation in the neurologically impaired: an alternative to fundoplication?

BACKGROUND/PURPOSE

Gastroesophageal reflux is common in children with severe neurological impairment. Fundoplication may produce symptomatic improvement but has a high failure rate. Esophagogastric dissociation (EGD) is an alternative procedure for treatment of gastroesophageal reflux. The aim of this study is to evaluate the results of EGD in our institution and compare them with a neurologically matched group of children who had Nissen fundoplication.

METHODS

Twenty consecutive patients who had EGD were retrospectively evaluated and the results were compared with a neurologically matched group of 20 consecutive patients who had Nissen fundoplication.

RESULTS

Twenty patients had EGD, 17 as a primary procedure. There was no operative mortality but 5 have died of other causes. Resolution of reflux-associated symptoms occurred in all patients. Of the 15 survivors, 5 remain on antireflux medication. Twenty patients had fundoplication. There was no operative mortality, but 8 patients have died of other causes. Failure occurred in 5 patients necessitating further surgery. Of the 10 unreoperated survivors, 6 remain on antireflux medication.

CONCLUSIONS

Esophagogastric dissociation is an effective antireflux procedure when compared with fundoplication. It has a lower failure rate. We recommend EGD as a primary procedure in selected children with severe neurological impairment.

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.

The failed fundoplication

Fundoplication is the standard surgical approach to gastroesophageal reflux (GER) in a child. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurologic impairment, and young infants. Fundoplication failure can take the form of persistent reflux-related symptoms, symptoms that are caused by complications of the surgery, or anatomic problems such a para-esophageal hernia or migration of the wrap into the mediastinum. The most effective strategy for treatment of the child undergoing fundoplication is to prevent failure by careful patient selection, individualization of the operation based on the patient's anatomy and physiology, and meticulous attention to the technical details of the operation. Options for the child with a failed fundoplication include medical management, jejunal feeding using a percutaneous tube or a Roux-en-Y jejunostomy, revision of the fundoplication, or esophagogastric dissociation. If the fundoplication is to be revised, the same principles of patient selection, individualization of the operation, and attention to technique must be used to optimize the chance of success. The primary goal in the treatment of GER is to improve quality of life for the patient and the family.

Omeprazole maintenance therapy for gastroesophageal reflux disease after failure of fundoplication

BACKGROUND

Recurrence of gastroesophageal reflux (GER) in children after failed fundoplication poses a therapeutic challenge. The authors report the experience with long-term omeprazole for children with severe GER after failed fundoplication.

METHODS

The authors reviewed the charts of all children who were treated with omeprazole for GER subsequent to failed fundoplication from 1990 to 1999. All underwent endoscopic and clinical assessment of the treatment at baseline, at 3-5 months, at 6-9 months, and annually.

RESULTS

Eighteen children presented with GER, after a total of 27 fundoplications. Ten had corrected esophageal atresia, 6 had neurologica impairment, and 2 had hiatal hernia. The mean age of presentation of children with recurrence of GER was 7.8 years, and symptoms of GER occurred 4.9 years (range, 0.6-13) after last fundoplication. Fifteen patients had a mean follow-up of 4.4 years for omeprazole. Ten patients had grade III/IV esophagitis and 5 had grade II esophagitis at presentation after fundoplication. Marked improvement was noted in symptoms of GER and severity of esophagitis while taking omeprazole. Remission of esophagitis was maintained while the patient was taking omeprazole and none had further surgery. There was no recurrence of peptic strictures in eight of nine children on omeprazole, after initial esophageal dilatations. Except for benign gastric polyps in three patients, no clinical adverse effects were observed.

CONCLUSIONS

Omeprazole is an effective long-term drug for gastroesophageal reflux disease after failed fundoplication in children. Omeprazole was well-tolerated by all children and should be tried before subsequent surgical intervention.

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.

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.

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.

Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients

OBJECTIVE

The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication.

SUMMARY BACKGROUND DATA

Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%.

METHODS

Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed.

RESULTS

One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy.

CONCLUSION

Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.

Gastrointestinal problems in the neurologically impaired child

Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux, with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children. Early recognition of an infant with neurological impairment that is compromising the normal feeding process is crucial. Detailed assessment of the nature of the feeding difficulties will help to predict the anticipated future nutritional needs and will allow decisions to be made about the appropriateness of input from different professionals (speech therapy, dietitians, gastroenterologists). Only when such information has been carefully assembled will rational and directed medical and surgical therapy be possible. Nutritional rehabilitation of disabled children can be associated with increased mortality and morbidity secondary to gastro-oesophageal reflux, retching, dumping syndrome or aspiration. It may also entail an increased work for care givers and increase costs of care. It is therefore necessary to document the impact of such rehabilitation on growth and quality of life for both patient and care giver.

Total esophagogastric dissociation: an alternative approach

BACKGROUND/METHODS

The authors report experience with five children, four of whom underwent esophagogastric dissociation with a Roux-en-Y esophagojejunal anastomosis and jejuno-jejunostomy after recurrent failure of fundoplication to control gastroesophageal reflux. A fifth child had a similar temporary gastric dissociation because of life-threatening aspiration caused by reflux into a colonic neoesophagus. Reversal is planned when the child has achieved sufficient physical growth and accepts a substantial oral intake. Feeding into the dissociated stomach was by intermittent catheterization of a nonrefluxing gastrostomy in four children and a Stamm tube gastrostomy in one child. The postoperative course and follow-up were notable for the rapid improvement in the children's general condition and nutritional status and the reduction in the frequency of pneumonitis. Reflux did not recur.

RESULTS

Review of the postoperative course led to a restructuring of surgical management with the development of tailored 'patient-specific' plans based on short-term and long-term prognosis. Failure to thrive, difficulty in child handling, gastroesophageal reflux, and neurological and physical impairment are particular considerations.

CONCLUSIONS

The author's limited experience leads us to suggest that esophagogastric dissociation with Roux-en-Y esophagojejunostomy and a nonrefluxing feeding gastrostomy is a useful temporary or permanent 'rescue' procedure. Furthermore, it is the author's view that the procedure may have a useful role as the primary form of management when normal oral feeding is unlikely to become established.

Modified Nissen fundoplication for reduction of fundoplication failure

Failure of the Nissen fundoplication can be secondary to disruption of the wrap or slippage of the stomach upward within the wrap. A modification of the Nissen fundoplication was devised and implemented between 1982 and 1995 to eliminate these complications. This report describes the modification and the results. Commonly, the Nissen fundoplication uses a single anterior row of sutures securing the wrapped stomach to the esophagus. This modification reinforces the wrap with two additional rows of suture, one right lateral and one left lateral, each further anchoring the wrapped stomach to the esophagus. This retrospective analysis compares the Nissen and modified Nissen fundoplications performed at our institution. Fundoplication operations were considered a failure if they required a reoperation secondary to wrap disruption or stomach slippage. Data were analyzed using the chi 2 method. A total of 948 fundoplication procedures were performed; 326 Nissen and 622 modified Nissen. Follow-up ranged from 0.5 to 13 years (mean, 6 years). Thirteen wrap disruptions and six stomach slippages occurred in the Nissen group (5.8%); 10 wrap failures and no stomach slippages occurred in the modified Nissen group (1.6%), P < .05. The authors conclude that this modification of the Nissen fundoplication significantly reduces wrap disruptions and stomach slippages.

Gastroesophageal reflux in childhood

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

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

OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Results and complications of Toupet partial posterior wrap: 10 years' experience

A 270 degrees posterior wrap, described by Toupet, was performed in 112 patients with medically refractory gastroesophageal reflux (GER) over a 10-year period. The mean age was 39 months (range, 2 months to 19 years). Thirty percent of the patients were neurologically impaired (NI). The approximation of the crura, the posterior fixation of the wrap, and the posterior partial fundoplication were performed with nonabsorbable sutures, over a bougie. Thirty percent of the NI and 15% of the neurologically normal (NN) children underwent a gastrostomy. Early postoperative complications were found in 24% of NI and 18% of NN children; these were treated medically, except for two bowel obstructions. Eight patients died for reasons unrelated to surgery, and nine were lost to follow-up. The mean follow-up period for the 95 remaining patients was 3.5 years for NI and 4.9 years for NN children. The evaluation showed that 6 patients had temporary dysphagia and two had food impaction. Nine wrap herniations (10%) were found; three of them without symptoms were noted by routine upper gastrointestinal series and received no treatment. Six wrap herniations with recurrent reflux were reoperated on successfully. With 90% of patients free of symptoms, the results of the Toupet procedure compare favorably with those of the Nissen fundoplication because of the retained ability to belch or vomit.

Weight gain and triceps skinfolds fat mass after gastrostomy placement in children with developmental disabilities

OBJECTIVE

To determine appropriate outcome indicators of nutritional status that are measurable over time after gastrostomy placement in children with severe neurologic impairments.

DESIGN

Twenty-two nonambulatory children met the selection criteria: feeding by gastrostomy of at least 50% of total energy, age between 1 and 12 years, diagnosis of neurologic impairments, and presurgical recommendation for weight gain. Each child served as his or her own control; three assessments were made after gastrostomy placement.

SETTING

Children were seen in specialty outpatient clinics.

STATISTICAL ANALYSES

Scores and Pearson product moment correlations.

RESULTS

Outcomes of gastrostomy placement were (a) increase in actual weight, (b) increase in weight-age equivalent, (c) rate of weight accretion as expected by National Center for Health Statistics growth charts and improved z scores for half of the children, and (d) improvement in triceps skinfolds percentiles for nearly half (n = 10) of the children. The results reflect the heterogeneity of children with severe disabilities. Pearson correlations showed a significant relationship between chronologic age and weight-age equivalent (r = .96), but not for weight for age and weight-age equivalent, or triceps skinfolds fat mass and weight-age equivalent.

CONCLUSIONS/APPLICATIONS

Weight and triceps skinfolds fat mass were appropriate outcome indicators of nutritional status measurable over time. Weight-age equivalent and z scores were more helpful than standard growth plots for interpreting weight gain over time. Our data also support findings that undernutrition limits growth before gastrostomy placement in patients with disabilities. Nutritionists are encouraged to track improvement in nutritional status after gastrostomy placement with measurements of triceps skinfolds fat mass and to use the information to support families facing decisions about the need for this surgery.

Fundoplication in 160 children under 2 years of age

The natural history of fundoplication in young children with gastroesophageal reflux (GER) had not been analyzed previously. The authors reviewed the charts of 160 children who underwent gastric fundoplication (GF) before the age of 2 years (mean age [+/- SD], 9 +/- 7 months; range, 1 week to 2 years), from 1974 to 1992. Reflux was documented by upper gastrointestinal series in 124 patients, by 24-hour pH probe monitor in 98 patients, and by both in 68 patients. Clinical indications for GF included failure to thrive (FTT) in 68%, emesis (Ems) in 58%, and aspiration pneumonia (Asp) in 53%. Neurological impairment (NI) was present in 47% of all patients, and 13% had esophageal atresia (EA). The type of GF used was a Nissen fundoplication in 79% and an anterior fundoplication (AF) in 21%. Of the 160 patients, 24 (15%) died of unrelated causes. Of the remaining 136, follow-up of at least 2 years was obtained for 96 (mean follow-up period, 5.3 +/- 3.0 years; range, 2 to 15 years). Clinical resolution of symptoms/findings after GF occurred in 87% of children with FTT, 92% with Ems, 70% with Asp, and 71% overall. A second fundoplication was required for 15 children (16%) because of documented recurrent reflux. The type of GF, the age of the patient, and the presence of EA or NI did not significantly affect the success of GF.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic lung disease is the leading risk factor correlating with the failure (wrap disruption) of antireflux procedures in children

Recurrent gastroesophageal reflux (GER) after antireflux procedures (ARP) has been correlated with significant neurological impairment (NI). Other major risk factors for recurrent GER have not been extensively characterized. The authors reviewed their experience with ARPs in children to better characterize the risk factors for recurrent GER and identify successful management strategies for these patients. The charts of 281 consecutively treated children who had an ARP at our institution (1985 to 1992) were reviewed. The neurological status of each child was assessed as normal or impaired (cerebral palsy, seizures, mental retardation, spasticity), and other medical diagnoses such as chronic pulmonary disorders (eg, interstitial disease, cystic fibrosis, bronchopulmonary dysplasia, asthma, etc), and congenital malformations and syndromes were identified. The average follow-up period was 3 years (range, 1 to 7.5 years). Patients with symptoms of recurrent GER were evaluated with an upper gastrointestinal study. Patients with a radiologically intact fundoplication and suspected GER were further evaluated with a 24-hour pH probe. Statistical analyses were performed using the Fisher's Exact Test. Of the 281 patients who underwent ARP, 39 had documented recurrent GER (average, 16 months after surgery). Twenty-five (64%) of these children had chronic pulmonary disease (CPD). Thirty-two percent of all children with CPD had recurrent GER after ARP, versus 7% of those without CPD (P < .0001). For children with NI and CPD there was an increased risk (P < .0001) of failure when compared with the risk in the normal subgroup (children without CPD or NI) who underwent ARP.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastroesophageal reflux in children

Operations for the control of complicated gastroesophageal reflux in children are commonly performed procedures in large pediatric centers. The comprehensive diagnostic scheme includes radiologic and endoscopic work-up coupled with extended pH probe analysis. Medical therapy remains the principle form of management, with surgery reserved for treatment failure.

Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux

To determine the optimal method of providing enteral feeding to neurologically impaired children with gastroesophageal reflux, Nissen fundoplication with simultaneous gastrostomy tube placement (NGT) was compared with anterograde percutaneous gastrojejunostomy (APGJ), a nonsurgical procedure performed under fluoroscopic guidance. The records of 112 neurologically impaired children with gastroesophageal reflux were retrospectively reviewed; 68 had undergone NGT and 44 APGJ. Follow-up data were available for 45 NGT patients (mean age, 6.4 years) and 34 APGJ patients (mean age, 7.9 years). Mean follow-up was 1.8 years in the NGT group and 2.5 years in the APGJ group. Complications resulting from either procedure were classified either as major, which included treatment failures or morbidity resulting in prolonged hospitalization, or as minor, those requiring outpatient treatment only or not directly caused by the procedure. The NGT group had a significantly higher incidence of major complications in comparison with the APGJ group (33.3% vs 11.8%, p < 0.05). Ten patients (22.2%) in the NGT group required reoperation for complications; six required a second NGT for wrap hernia, failure, and continued gastroesophageal reflux. Two patients (5.9%) in the APGJ group required surgery for complications; one of these eventually required an NGT, and the other had an intussusception that necessitated a small-bowel resection. Minor complications were more common in the APGJ group than in the NGT group (44.1% vs 6.6%); the majority of complications were related to the jejunostomy tube. Premature replacement or reinsertion of the jejunostomy tube was necessary in 14 APGJ patients (32%). The mortality rate was 8.8% in the NGT group and 5.9% in the APGJ group (p = not significant). No death occurred within 30 days of either procedure. We conclude that APGJ is a safe alternative method for feeding the neurologically impaired child with gastroesophageal reflux.

Efficacy of the Nissen fundoplication in the management of gastroesophageal reflux following esophageal atresia repair

From January 1974 to December 1988, 80 patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) were treated at the C.S. Mott Children's Hospital with division of their TEF and esophagoesophagostomy. Thirty-four in this group developed gastroesophageal reflux (GER). After an unsuccessful trial of medical management, 21 underwent Nissen fundoplication, and an additional child with refractory GER died intraoperatively before completion of her fundoplication. Following fundoplication, only eight patients had an uncomplicated course with elimination of reflux and no postoperative dysphagia. Wrap disruption and recurrent reflux occurred in 7 of the 21 (33%), a markedly higher incidence than the 10% figure seen in 220 children without EA who have undergone fundoplication at this institution. Upward tension on the wrap due to the presence of a shortened esophagus probably predisposes to an increased frequency of fundoplication failure in the EA child. In addition, postoperative dysphagia requiring prolonged gastrostomy feedings complicated eight otherwise successful initial or redo-fundoplications. Prolonged dysphagia in this group is likely related to the inability of the dyskinetic esophagus, common in EA, to overcome the increased resistance caused by the Nissen fundoplication. Three deaths (14%) from complications related to antireflux surgery occurred in the series. Although 15 of the 21 children (71%) eventually had excellent long-term results following initial or redo-fundoplication with elimination of reflux and normalization of oral intake, morbidity and mortality were clearly significant. Due to the high incidence of postoperative dysphagia and recurrent reflux, the transabdominal Nissen fundoplication may not be appropriate in EA patients.

Current surgical considerations in gastroesophageal reflux disease in infancy and childhood

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.