The past and present of antireflux surgery in children

Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement

BACKGROUND

Gastroparesis is a chronic digestive disorder with symptoms of nausea, vomiting, bloating, and abdominal pain resulting in a poor quality of life. Surgeons are increasingly asked to treat patients with gastroparesis as medical options have become limited due to safety concerns of many prokinetics. Surgical options include gastric stimulator implantation, sub-total gastrectomy, and pyloroplasty. We report our experience with minimally invasive pyloroplasty as sole surgical treatment for adult gastroparesis.

MATERIALS AND METHODS

A retrospective review of prospectively collected data of 28 patients who underwent minimally invasive pyloroplasty alone as treatment for gastroparesis from Jan 2007 to Sept 2010. Pre- and postoperative symptom severity score (SSS), gastric emptying scintigraphy (GES), and medication use were reviewed.

RESULTS

A laparoscopic Heineke-Mikulicz pyloroplasty was performed in 26 patients. A laparoscopic assisted, flexible trans-oral endoscopic circular stapled pyloroplasty was used in two patients. Prokinetic use was significantly reduced from 89% to 14% (p = <0.0001). The mean GES T1/2 decreased from 320 to 112 min (p = 0.001) and normalized in 71%. Significant improvements in the SSS were seen at 1 month for nausea (p = <0.0001), vomiting (p = <0.0001), bloating (p = 0.0023), abdominal pain (p = <0.0001), and gastroesophageal reflux disease (GERD) symptoms (p = 0.0143). Significant improvement persisted at 3 months for nausea (p = <0.0001), vomiting (p = <0.0001), bloating (p = 0.0004), abdominal pain (p = 0.0001) and GERD symptoms (p = 0.013). The average length of stay was 3.71 days. Overall, 83% of patients' indicated that they saw improvement at 1 month follow-up.

CONCLUSION

Minimally invasive pyloroplasty provides excellent outcomes for patients with gastroparesis and should be considered as a primary treatment along with diet and medications as it is effective and does not eliminate the option for additional surgical options in the future for refractory disease. With technological advancements, a totally endoscopic pyloroplasty may be a less invasive option.

Outcomes of pyloroplasty and pyloric dilatation in children diagnosed with nonobstructive delayed gastric emptying

BACKGROUND

Pyloroplasty and pyloric dilatation are methods used to ameliorate the symptoms of nonobstructive delayed gastric emptying in children. Our purpose was to review the results of these methods with respect to symptomatic improvements.

METHODS

We retrospectively reviewed the records of children who, exclusive of fundoplications, in the 11-year period before December 31, 2005, had undergone at our institution a Heineke-Mikulicz pyloroplasty (HMP) and/or a fluoroscopically guided balloon pyloric dilatation (FGBD). We recorded evidence of either short- or long-term subjective improvement of symptoms.

RESULTS

Twenty-three children underwent HMP. Five had no prior medical treatment. Of the 23, 3 had no subjective improvement in symptoms. Of the 20 who had subjective evidence of improvement recorded, 13 (56.5%) proved to be long-term and 7 short-term improvement. Eight children had FGBD. All 8 had prior medical treatment that had failed. There were 3 who displayed no subjective evidence of improvement, whereas 5 had subjective evidence of improvement-3 (37.5%) long term and 2 short term.

CONCLUSIONS

Heineke-Mikulicz pyloroplasty and FGBD in this study demonstrated only in limited numbers long-term improvement of symptoms. Efforts to understand more fully gastric emptying and to define those children who should undergo FGBD or HMP are needed.

Postfundoplication Complications in Children

The optimal "treatment" of postfundoplication complications is preoperative prevention of them. Nonreflux causes of the symptom prompting surgery should be carefully eliminated preoperatively. Failure to respond to optimal powerful antireflux pharmacotherapy suggests that GERD was not the cause of symptoms. Neurologic or respiratory disease, delayed gastric emptying or retching, short esophagus, and esophageal dysmotility may predispose patients to complications, and may require careful tailoring of the fundoplication. The optimal antireflux surgery, with a wrap neither too loose nor too tight, may require a nadir lower esophageal sphincter pressure of more than 5 mm Hg to prevent reflux, but less than some value to prevent dysphagia. This latter value may be approximately 10 mm Hg, but depends on swallowing parameters such as peristaltic pressure, lower esophageal sphincter opening diameter, swallowed bolus diameter, and other considerations. Infants may require a gastrostomy tube for venting because of their lower gastric compliance to deal with swallowed air. Children with delayed gastric emptying may benefit from pyloroplasty, but this is debated. When complications occur, re-evaluate the diagnosis and the competence of the fundoplication with barium fluoroscopy, endoscopy with histology, pH probe, and other modalities as indicated. Initially try conservative management of the patient's complications, including dietary and feeding modifications. Give a trial of antireflux pharmacotherapy for recurrent reflux or pharmacotherapy directed at the specific side-effect of the fundoplication if one is present. Consider endoscopically dilating a persistently tight wrap or surgically revising the fundoplication if it is suggested by the evaluation.