Use of intraoperative esophageal manometrics in surgical treatment of gastroesophageal reflux in pediatric patients

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.

Intraoperative esophageal manometry and early postoperative esophageal pH monitoring in children

Intraoperative esophageal manometry has not been correlated with early postoperative extended esophageal pH monitoring (EEpHM) in children with gastroesophageal reflux. Twenty-seven children were studied with the following design: (1) abnormal preoperative EEpHM; (2) intraoperative measurement of lower esophageal high pressure zone (LEHPZ) pressure and length prior to and upon completion of an antireflux procedure; and (3) EEpHM seven to ten days postoperatively. Sixteen had a Nissen or modified Thal fundoplication and eleven a Boerema gastropexy. The postoperative EEpHM was normal in patients with fundoplication regardless of the increase in LEHPZ pressure (-4 to 36 mmHg) or length (0 to 2.5 cm). Four of the patients (36%) who had a gastropexy had abnormal EEpHM. The postoperative frequency of reflux was related inversely to the elevation of LEHPZ pressure (-3 to 39 mmHg), but not to the LEHPZ length (0 to 4.5 cm). Duration of reflux was independent of observed intraoperative manometric changes. In conclusion, early postoperative EEpHM in children having a gastropexy correlates with intraoperative increases in the LEHPZ pressure. There is no such correlation in children having a fundoplication procedure.

Fundoplication and pediatric esophageal manometry: actuarial analysis over 7 years

Sixty-one children and infants who had significant gastroesophageal reflux and associated complications underwent 73 surgical procedures to control the reflux. In order to evaluate the procedure, several esophageal manograms were obtained from each patient, before, during, and after the operation. Delayed follow-up reports were also obtained from follow-up visits, letter and telephone contact, in order to assess how the patient had progressed. The results were evaluated by actuarial analytic methods. Ninety-four percent of the patients remained alive over the 7-year follow-up period. At the completion of the seventh year, 62% of these patients (actuarially calculated) remained event free. All events occurred within 18 months of surgery. One patient could not be traced at long-term follow-up, which was therefore 92% complete. The 7-year actuarial probability of failure of the fundoplication at this institution is 24% when performed using this technique in these patients. These findings support that manometric calibration of the antireflux procedure tends to give uniform results in pediatric patients, but, compared with other published series has not proved to be superior to procedures that employ only a rubber bougie in the esophagus as an obdurator to prevent a repair that will be too tight.

Current thinking on the role of surgery in gastroesophageal reflux

Gastroesophageal reflux is common in infants and children. In most cases it causes little more than inconvenience and remits spontaneously with time and maturation. A small and select group of refluxing children, however, will develop complications of reflux severe enough to justify operative control when medical treatment fails. Recurrent pulmonary infections, obstructive apnea, nutritional wasting, and progressive inflammatory injury to the esophagus all qualify as surgical indications, provided a reasonable cause-effect relationship with reflux can be established. The procedure of choice depends very much upon the skill and experience of the surgeon. The complete fundoplication seems to offer more complete control of reflux, but it has the potential for more frequent and more complicated side-effects.

Management of the patient with benign esophageal stricture

Benign esophageal strictures are a diagnostic and therapeutic challenge. If the investigation is carefully performed, the etiologic factors can almost always be clearly established. At all times, the possibility of malignant disease must be considered. With an appropriate combination of medical management, bougienage, or surgery, almost all patients can be effectively treated.

Follow-up studies on patients undergoing Nissen fundoplication utilizing intraoperative manometry

Intraoperative esophageal manometry has been developed for use in children as a guide to optimizing the surgical results of Nissen fundoplication. Eighty-two Nissen fundoplication operations were performed using intraoperative manometry. Follow-up manometry was performed within 6 wk postoperatively in 45 patients and later than 6 wk postoperatively in 33 patients. The mean preoperative lower esophageal sphincter pressure (LESP) was 13 mm Hg. The mean postoperative LESP was 42 mm Hg. LESP was found to drop in the early postoperative period nearly 40%. There was minimal further decline in LESP between the early and late follow-up determinations. Lower esophageal sphincter length (LESL) was measured both pre- and postoperatively in 56 patients with an average increase of 1.4 cm. There was a very mild decline in LESL in the late follow-up period. The clinical course of these patients was correlated with manometric findings. The routine use of gastrostomy has been found to be unnecessary.

Gastroesophageal reflux: medical and surgical management

The assessment of gastroesophageal reflux requires a carefully taken history and appropriate selection of the relevant diagnostic tests from among the many such tests available. Gastroesophageal reflux is generally produced by an imbalance between the intragastric pressure on the one hand and the degree of competence of the lower esophageal sphincter on the other. Medical management incorporates measures designed to promote gastric emptying, augment the resting tone of the lower esophageal sphincter, and favorably alter the nature of the refluxed material by dietary and pharmacological means. The surgical techniques commonly applied for the prevention of gastroesophageal reflux aim to restore an intraabdominal segment of esophagus and to augment sphincter competence by either a partial or complete fundoplication. Comparison of results obtained with various operations is difficult, as assessment is often imprecise, subjective, and partisan. Development of a uniform method of postoperative assessment, free from observed bias, would be a major advance.

Incidence and significance of gastroesophageal reflux following repair of esophageal atresia and tracheoesophageal fistula and the need for anti-reflux procedures

Patients with esophageal atresia and/or tracheoesophageal fistula are known to have disordered esophageal motility, but the incidence of significant gastroesophageal reflux requiring anti-reflux surgery remains undocumented. We have studied a series of patients from 2 wk to 13 yr post-repair, utilizing manometric motility and acid reflux techniques. All demonstrated abnormalities of esophageal motility, including aperistalsis, low amplitude contraction, and simultaneous contractions. Lower esophageal sphincter pressures ranged from 7 to 50 mm Hg. Fourteen patients demonstrated signifcant reflux and six patients required anti-reflux surgery for recurrent pneumonia or recurrent stricture. The incidence of significant gastroesophageal reflux requiring antireflux surgery appears significant following repair of esophageal atresia and/or tracheoesophageal fistula.