Nissen fundoplication in the treatment of children with familial dysautonomia

Need for a consensus definition of chronic dehydration: A scoping review

Dehydration is common in older adults and impacts their clinical outcomes. Chronic dehydration is especially important as it has been under-recognized. This scoping review aimed to summarize the available definitions of chronic dehydration to identify gaps between each definition and discuss future research needs. Four databases (Pubmed, CINAHL, Cochrane Library, Science Direct) were systematically searched for peer-reviewed articles that clearly described the definition of chronic dehydration published from inception to June 8th, 2023. Two researchers reviewed the articles independently, and any disagreement was solved upon discussion. We identified five articles with a wide range of subjects from children to older adults. Chronic dehydration was defined as a state of persistently elevated blood urea levels; weight loss ≥ 1% as a result of fluid loss; a ratio of blood urea nitrogen to creatinine > 20; serum osmolarity ≥ 295 mOsm/kg; and a dehydrated state lasting 72 hours or longer. The definition varied among studies, indicating the need to establish an international consensus on the definition of chronic dehydration.

Does retching matter? Reviewing the evidence-Physiology and forces

Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure. Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking. Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown. Retching needs to be addressed if we are to reduce the incidence of wrap failure. Level of Evidence V.

Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations

BACKGROUND

Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia.

METHODS

We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy.

CONCLUSIONS

Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.

Pathology of emesis: its autonomic basis

Vagal and non-vagal pathways as well as several brainstem nuclei participate in vomiting in response to different emetic stimuli. Autonomic pathways involved in nausea are less well understood. Numerous gastrointestinal disorders with prominent nausea and vomiting including gastroparesis, cyclic vomiting syndrome, and motion sickness have associated autonomic nervous system dysfunction. Autonomic disturbances are also seen with non-gastrointestinal diseases with gut manifestations such as migraine headaches, orthostatic intolerance, and familial dysautonomia. Stimulation of emetic pathways involves activation of a range of receptor subtypes. Agents acting on these receptors form the basis for antiemetic therapies. Chemotherapy-induced nausea and vomiting, a prevalent and severe consequence of anticancer treatment, is preventable in many instances by agents acting on the autonomic nervous system. Likewise, non-medication therapies may act in part via modulation of some of these same autonomic pathways.

A world without pain or tears

The world of the child with familial dysautonomia (FD), a genetic disorder affecting development of the sensory and autonomic nervous system, is not idyllic. However, over the last 35 years advances in supportive treatments have improved morbidity and mortality. Recent genetic breakthroughs have further expanded thinking about this disorder and suggested innovative approaches to modifying genetic expression. This article reviews the current supportive treatment modalities and their rationale, as well as the suggested new treatments that may alter the function and prognosis of an individual affected with FD.

Perioperative management of familial dysautonomia: a systematic review

BACKGROUND AND OBJECTIVE

Familial dysautonomia (FD), a rare genetic disorder, is characterized by autonomic instability, pulmonary infections, oesophageal dysmotility, spinal abnormalities and episodic "dysautonomic crisis" characterized by rash, vomiting, sweating and hypertension. Frequent anaesthetic complications have been reported.

METHODS

We performed a comprehensive literature search of perioperative management of FD using an OVID-based search strategy. Identified reports were reviewed to identify perioperative complications as well as anaesthetic techniques and perioperative management strategies developed to minimize or prevent these complications.

RESULTS

Eighteen case reports or series of perioperative management of FD were identified in the literature for a total of 179 patients undergoing 290 anaesthetics. Intraoperative cardiovascular lability, including cardiac arrests and postoperative pulmonary complications were commonly reported. Preoperative hydration, minimizing the use of volatile anaesthetic agents, postoperative ventilation, use of regional anaesthesia and minimally invasive surgical techniques reduced the incidence of these complications.

CONCLUSIONS

While patients with FD are reported to have a relatively high rate of various perioperative complications, a full understanding of its pathophysiology can be used to develop a perioperative management strategy to anticipate and prevent many of these complications.

Anesthesia management of familial dysautonomia

Familial dysautonomia (FD) is an autosomal recessive inherited disorder, predominantly affecting the Ashkenazi Jewish population that is characterized by sensory and autonomic neuropathy. The protean manifestations and perturbations result in high morbidity and mortality. However, as a result of supportive measures and centralized care, survival has improved. As surgical options are increasing to symptomatically treat FD, anesthesiologists need to be familiar with this disorder. Because the Dysautonomia Center at NYU Medical Center is a referral center for FD patients, we have attained considerable anesthetic experience with FD. This article reviews clinical features of FD that could potentially affect anesthetic management and outlines our present practices.

Familial dysautonomia: a review of the current pharmacological treatments

Treatment of familial dysautonomia, a genetic disorder affecting neuronal development and survival, has improved morbidity and survival for this disorder. Although this is primarily a neurological disorder causing sensory and autonomic dysfunction, there are secondary systemic perturbations affecting ophthalmological, gastrointestinal, respiratory, cardiovascular, orthopaedic and renal function. Penetrance is complete, but there is marked variability in expression. Preventative and supportive treatments have included measures to maintain eye moisture, fundoplication with gastrostomy, the use of central agents such as benzodiazepines and clonidine to control vomiting and the dysautonomic crisis, and fludrocortisone and midodrine to combat cardiovascular lability. With the identification of the familial dysautonomia gene, it has been suggested that it may be possible to treat patients by modifying production and expression of the genetic product.

Gastroesophageal reflux in familial dysautonomia: correlation with crisis frequency and sensory dysfunction

OBJECTIVES

Familial dysautonomia (FD), a genetic disorder resulting in sensory and autonomic nervous system dysfunction, is associated with a high frequency of gastroesophageal reflux (GER). In this study the authors attempted to determine if GER prevalence correlated with dysautonomic crisis frequency and small fiber sensory dysfunction.

METHODS

Of an initial population of 252 FD patients who had survived past their seventh year and were alive during the year of study from June 1, 2001 to June 1, 2002, 174 (69.0%) had sufficient data in their patient files to be included in this retrospective analysis. Subjects were stratified into three groups: those with no GER, those medically treated for GER and those surgically treated for GER with fundoplication. Data were obtained regarding frequency and severity of dysautonomic crises and sensory function including pain sensation, cold and warm thresholds and vibration perception.

RESULTS

There were no significant differences among the three groups regarding age or severity of sensory dysfunction. However, dysautonomic crises were significantly more frequent in FD patients who were presumed to have more intractable GER, as they had required fundoplication (P < 0.05).

CONCLUSIONS

The data confirm the high incidence of GER in the FD population and demonstrate that GER is independent of severity of sensory dysfunction. In addition, the authors demonstrate that fundoplication does not alleviate the central autonomic cause of retching, the dysautonomic crisis.

Familial dysautonomia

Familial dysautonomia (FD) is a neurodevelopmental genetic disorder within the larger classification of hereditary sensory and autonomic neuropathies, each caused by a different genetic error. The FD gene has been identified as IKBKAP. Mutations result in tissue-specific expression of mutant IkappaB kinase-associated protein (IKAP). The genetic error probably affects development, as well as maintenance, of neurons because there is neuropathological and clinical progression. Pathological alterations consist of decreased unmyelinated and small-fiber neurons. Clinical features reflect widespread involvement of sensory and autonomic neurons. Sensory loss includes impaired pain and temperature appreciation. Autonomic features include dysphagia, vomiting crises, blood pressure lability, and sudomotor dysfunction. Central dysfunction includes emotional lability and ataxia. With supportive treatment, prognosis has improved greatly. About 40% of patients are over age 20 years. The cause of death is usually pulmonary failure, unexplained sudden deaths, or renal failure. With the discovery of the genetic defect, definitive treatments are anticipated.

Familial dysautonomia: deep sedation and management in endoscopic procedures

OBJECTIVES

Familial dysautonomia is a rare genetic disorder that affects the development of the central nervous system, causing GI dysfunction. Because of an improved prognosis, elective surgical procedures are more common and present a unique problem to the anesthesiologist. All patients reported in the literature underwent these interventions under general anesthesia in the operating theater. We report our preliminary experience with deep sedation in the endoscopy room in patients with this rare syndrome.

METHODS

Four girls (7-16 yr old) underwent percutaneous endoscopic gastrostomy insertion and/or endoscopic retrograde cholangiopancreaticography. Preprocedure management consisted of adequate hydration and anxiolysis. Intraprocedure management consisted of stabilization of an erratic autonomic nervous system. Midazolam (0.1-0.2 mg/ kg) was administered i.v. before the procedure. Deep sedation was accomplished with propofol i.v. (0.5-1 mg/kg) and maintained with a propofol drip (50-100 microg/kg/min). Recovery was managed in the gastroenterology unit of our facility.

RESULTS

Body temperature, ventilation, heart rate, blood pressure, oxygen saturation, and end-tidal CO2 were stable during the endoscopies. The patients regained consciousness at the end of the endoscopy and were able to drink or to eat as normal. Pain that could precipitate a crisis was present in two patients and was successfully treated with a simple analgesic. No other complications occurred.

CONCLUSION

This rare genetic disorder presents unique management problems to the anesthesiologist, resulting in morbidity and mortality when general anesthesia is used. Our patients received appropriate management before endoscopy, and we performed the procedure under deep sedation. No complications occurred. We are thus confident that deep sedation in the endoscopy suite is safe in this rare syndrome.

Epidural anaesthesia and familial dysautonomia (the Riley Day syndrome). Three case reports

Epidural anaesthesia in Familial Dysautonomia (FD) or the Riley Day syndrome has not previously been reported. Three children with FD presenting for redo Nissen fundoplication were managed with epidural anaesthesia. Cases 1 and 2 had had their original Nissen fundoplication without epidural anaesthesia. In Case 3, FD had not yet been diagnosed when she had her first operation, and it was performed with epidural anaesthesia. The anaesthetic management of these cases with and without epidural anaesthesia is described and discussed.

Tubefeeding and mortality in children with severe disabilities and mental retardation

OBJECTIVE

To study the contribution of tubefeeding to mortality for children with severe disabilities and mental retardation. Previous research has suggested an association between tubefeeding and mortality. However, risk has never been determined using population-based data or defined in regard to patient variables.

METHODS

Retrospective analysis of a comprehensive statewide data set comprised of 4921 children with severe disabilities and mental retardation living in community and congregate care settings. The outcome measure was mortality; primary study variables included the presence of a feeding tube, measures of functional independence, type of residence, and medical comorbidity.

RESULTS

There were four findings. First, the use of a feeding tube was associated with virtually every disability. Second, when no study variables were controlled, statistically significant differences in mortality rates were noted between children who were tubefed and those who were not. The relative risk of mortality associated with use of a feeding tube was 2.1. Third, the use of a feeding tube was associated with a reduction in relative risk of mortality in children with tracheostomy (relative risk of mortality: .55). However, this association did not achieve statistical significance. Fourth, when study variables were controlled in a multivariate analysis, feeding tube use was associated with no identifiable increase in mortality among children with very severe disabilities, but was associated with an approximated doubled mortality rate among those with less severe disabilities.

CONCLUSIONS

We hypothesize that the increased mortality associated with tubefeeding may be attributable to a differential increase in pulmonary disease secondary to overly vigorous nutritional maintenance and subsequent aspiration after tube placement. For children with tracheostomy this risk may be reduced. If tracheostomy proves to be associated with a relatively more favorable outcome for tubefeeding, we hypothesize that it would reflect the benefits of tracheostomy in allowing access to the airway for suctioning and ventilation. Given the observed higher mortality rates among the less severely disabled children who are tubefed and the substantial costs associated with tubefeeding, a prospective, controlled study may be clinically indicated, ethically justifiable, and economically warranted.

Laparoscopic-modified Nissen fundoplication in children with familial dysautonomia

Children with familial dysautonomia (FD) often require an antireflux operation and gastrostomy to prevent the detrimental effects of aspirated gastric juice on the lungs and to facilitate liquid feeding. The aim of this study was to examine whether a laparoscopic procedure in such patients is as safe and effective as the traditional open technique. The data for all pediatric patients who underwent a laparoscopic antireflux procedure for familial dysautonomia were reviewed and compared with those the last pediatric patients with FD who were operated upon using the open technique, before the introduction of the laparoscopic procedure. Of the 61 children who underwent an antireflux procedure for FD (1978-1996), 13 were operated on laparoscopically. The authors found that the postoperative course of these patients was less complicated than that of patients who had the traditional laparotomy procedure. There was no need for mechanical ventilation during the postoperative course, and there were no respiratory complications. The mean hospitalization period was significantly shorter (7.9 days v 13.2 days). There were no complications attributable to laparoscopy, and the antireflux procedure has been effective in all patients (short-term follow-up). The authors conclude that laparoscopic procedures that include a modified Nissen fundoplication, gastrostomy, and appendectomy are feasible and as safe as conventional surgery for the treatment of FD in children. It appears that this approach has fewer complications than laparotomy, might reduce the need for postoperative mechanical ventilation, and is associated with a shorter postoperative stay.

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.