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Trovato CM, Capriati T, Bolasco G, Brusco C, Santariga E, Laureti F, Campana C, Papa V, Mazzoli B, Corrado S, Tambucci R, Maggiore G, Diamanti A. Enteral formula compared to Nissen-Fundoplication: Data from a retrospective analysis on tolerance, utility, applicability, and safeness in children with neurological diseases. Front Nutr 2023; 10:1093218. [PMID: 36969827 PMCID: PMC10034170 DOI: 10.3389/fnut.2023.1093218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 03/11/2023] Open
Abstract
Objectives and studyApproximately 46–90% of children with neurological disorders (NDs) suffer from gastrointestinal diseases, such as gastro-esophageal reflux disease (GERD), constipation, or malnutrition. Therefore, enteral feeding is often necessary to achieve nutritional requirements. The treatment of GERD could be based on pharmacological therapy, nutritional treatment (changing the type of formula), or surgical treatment (Nissen Fundoplication, NF). The aim of this study was to describe and compare resource consumption between NE based on different formulas and NF in patients with ND.MethodsWe performed a retrospective analysis on all children with neurological damage (age: 29 days−17 years) treated from January 2009 to January 2019 due to nutritional problems and food and/or gastrointestinal intolerances. For all patients, demographic and anthropometric characteristics, symptoms, type of nutrition (formula and enteral access), and number and type of outpatient or emergency room visits were collected. Patients with <24 months of age at the closing of the database and with <24 months of follow-up were excluded.ResultsOut of 376 children, 309 children (M: 158; median age: 4 IQR 1–10) were enrolled, among which, 65 patients (NF group M: 33; median age: 5.3 IQR 1.8–10.7) underwent NF. Vomit, GERD, and dysphagia were more represented in the NF group (p < 0.05). Our analysis shows that the NF group seems to present a lower number of hospitalization and a lower number of visits for non-GI disorders, but a higher number of visits for GI disorders compared to non-NF. In the NF group, a higher prevalence of the use of amino-acid-based formula and free diet is observed, with a trend for the lower prevalence of casein-based or whey+casein-based formula (Fisher test p = 0.072). The median cost of a patient enrolled in the database is € 19,515 ± 540 ($ 20,742.32 ± 573.96) per year, with no significant difference between the two groups. Regarding formula, at baseline, 76 children consumed a free diet, 24 a casein-based formula, 139 a whey+casein-based formula, 46 a whey-based formula, and 24 an amino-acid-based formula.ConclusionsIn conclusion, compared to EN, NF may not improve the clinical aspect and related costs in children with NDs. Considering the psychological and QoL burden for patients, in a “step-up” strategy, EN could be proposed as an efficient alternative to NF.
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Affiliation(s)
- Chiara Maria Trovato
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Teresa Capriati
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Giulia Bolasco
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Carla Brusco
- Administrative Management, Istituto di Ricovero e Cura a Carattere Scientifico, Bambino Gesù Children's Hospital, Rome, Italy
| | - Emma Santariga
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Laureti
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Carmen Campana
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Valentina Papa
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Bianca Mazzoli
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Silvia Corrado
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Renato Tambucci
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Giuseppe Maggiore
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonella Diamanti
- Gastroenterology and Nutritional Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.), Bambino Gesù Children's Hospital, Rome, Italy
- *Correspondence: Antonella Diamanti
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Thompson K, Zendejas B, Kamran A, Svetanoff WJ, Meisner J, Zurakowski D, Staffa SJ, Ngo P, Manfredi M, Yasuda JL, Jennings RW, Smithers CJ, Hamilton TE. Predictors of anti-reflux procedure failure in complex esophageal atresia patients. J Pediatr Surg 2022; 57:1321-1330. [PMID: 34509283 DOI: 10.1016/j.jpedsurg.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anti-reflux procedures (ARP) in esophageal atresia (EA) patients can be challenging and prone to failure. These challenges become more evident with increasing complexity of EA. We sought to determine predictors of ARP failure in complex EA patients. METHODS Single-institution retrospective review of complex EA patients (e.g. long-gap EA, esophageal strictures, hiatal hernia, and reoperative ARP) who underwent an ARP from 2002 to 2019. ARP failure was defined as hiatal hernia recurrence, wrap migration/loosening, or need for reoperation. Predictors of failure were evaluated using univariate and multivariable time-to-event analysis. RESULTS 121 patients underwent 140 ARP at a median age of 13.5 months (IQR 7, 26.5). Nissen fundoplication (89%) was the most common ARP. Mesh (bovine pericardium) reinforcement was used in 41% of the patients. Median follow-up was 3.2 years (IQR 0.9, 5.8); 44 instances of ARP failure occurred (31%), though only 20 (14%) required reoperation. Median time to failure was 8.7 months (IQR 3.2, 25). Though fewer mesh-reinforced ARP failed (21% with vs 39% without, p = 0.02), on multivariable analysis only partial fundoplication (aHR 2.22 [95% CI 1.01-4.78]) and minimally invasive repair (aHR 2.57 [95% CI 1.12-6.01]) were significant predictors of ARP failure. CONCLUSION In our practice of complex EA patients, where ARP fail in nearly one third of cases, a Nissen fundoplication performed via laparotomy provided the lowest risk of ARP failure.
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Key Words
- ARP, Anti-reflux procedure
- ARPF, Anti-reflux procedure failure
- Abbreviations: EA, Esophageal atresia
- Anti-reflux procedure
- EGD, esophagogastric duodenoscopy
- Esophageal atresia
- GEJ, gastroesophageal junction
- HH, hiatal hernia
- Hiatal hernia
- LGEA, Long gap esophageal atresia
- MFOIS, Modified functional oral intake scale
- MIS, minimally invasive surgery
- Nissen fundoplication
- SSI, surgical sight infection
- UGI, upper gastrointestinal series
- gerd, Gastroesophageal reflux disease
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Affiliation(s)
- Kyle Thompson
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA
| | - Benjamin Zendejas
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA
| | - Ali Kamran
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA
| | - Wendy Jo Svetanoff
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO USA
| | - Jay Meisner
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA USA
| | - Peter Ngo
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA USA
| | - Michael Manfredi
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA USA
| | - Jessica L Yasuda
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA USA
| | - Russell W Jennings
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA
| | - C Jason Smithers
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL USA.
| | - Thomas E Hamilton
- Department of General Surgery, Boston Children's Hospital, Boston, MA USA.
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Banerjee DB, Parekh P, Cross K, Blackburn S, Roebuck DJ, Curry J, Eaton S, Patel PA, De Coppi P. Long-term outcomes following failure of Nissen fundoplication. Pediatr Surg Int 2022; 38:707-712. [PMID: 35220458 DOI: 10.1007/s00383-022-05098-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the management and outcomes of patients with gastro-oesophageal reflux (GOR) that requires further intervention following failure of Nissen fundoplication (NF). METHODS After institutional audit department approval, a retrospective review of paediatric patients who had further intervention following failure of primary NF between January 2006 and December 2015 for GOR at our centre was performed. Data are presented as median (range). RESULTS Of 820 patients who underwent NF, 190 (23%) received further procedures for GOR management at a median of 21 months of age (6-186); 90/190 (47%) had gastro-jejunal feeding (GJ). Of these, 67 (74%) remained on GJ feeds up to a median of 48 months and 23/90 (26%) had a second NF after GJ feeding. 97/190 (51%) had a redo fundoplication without having had a GJ; thus, 120/190 (63%) of patients having a further procedure went on to have a second NF after a median period of 15 months (1-70 months). Three patients (2%) had early emergency wrap revision 4 days after first fundoplication (we classed this as an 'early complication'). Of the seven patients who failed a 3rd NF, 4 continued GJ feeding, 2 of had oesophagogastric dissociation; 2 had 4th NF of which 1 was successful and 1 patient had gastric pacemaker and is successfully feeding orally. Patients who were finally successfully managed with GJ underwent 2 (2-5) tube changes/year. We found patients who had a previous GJ were more likely to have failure of the redo fundoplication than those who had not to have the GJ (16/24 vs. 30/90, p = 0.005). CONCLUSION The chance of success decreases with every further attempt at fundoplication. The only factor significantly associated with failure of redo fundoplication was whether the patient previously had a GJ tube. In patients with failed fundoplications, when symptom free on jejunal feedings, further anti-reflux surgical intervention should be avoided. A randomized prospective study is needed for patient selection.
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Affiliation(s)
| | - Pooja Parekh
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kate Cross
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Simon Blackburn
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Derek J Roebuck
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Joe Curry
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Premal A Patel
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Paolo De Coppi
- UCL Great Ormond Street Institute of Child Health, London, UK
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Short and long-term outcomes after pediatric redo fundoplication. J Pediatr Surg 2022; 57:765-769. [PMID: 34175122 DOI: 10.1016/j.jpedsurg.2021.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/02/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Redo fundoplication (RF) is the most common surgical treatment for recurrent gastroesophageal reflux disease (GERD) in children, but outcomes after RF are rarely reported. The aim of this study was to assess short- and long-term outcomes after RF in childhood. METHODS The study is a follow-up study of patients undergoing RF from 2002 to 2020 at a teriary care center. Patients/parents were sent questionnaires recording symptoms of recurrent GERD, troublesome side-effects and satisfaction. Retrospective chart review was also performed. RESULTS 24/28 (86%) patients were included median 9 (1.6 months-17.7 years) years after RF. 16 (67%) had neurologic impairment. Indications for RF was recurrence of GERD (n = 18), discomfort or dysphagia from a herniated wrap (n = 5) and dysphagia from a slipped fundoplication (n = 1). Median operating time was 128 (95-250) min. Six (25%) patients experienced early major complications, of which two were gastrostomy related. Five (21%) patients experienced recurrence after RF. Three of these were symptom free at follow-up with medical treatment or re-RF. The most common symptom at follow-up was stomach pain (37%) and excessive flatulence (38%). 18/22 (95%) patients/parents would choose RF again, and 21/22 would recommend RF to someone in a similar situation. CONCLUSIONS RF is successful in treating recurrent GERD after primary fundoplication, and patient/parental satisfaction is high.
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Khan FA, Nestor K, Hashmi A, Islam S. To Wrap or Not? Utility of Anti-reflux Procedure in Infants Needing Gastrostomy Tubes. Front Pediatr 2022; 10:855156. [PMID: 35321013 PMCID: PMC8936420 DOI: 10.3389/fped.2022.855156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/25/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Gastrostomy tube (GT) insertion is commonly performed in children with failure to thrive. Pediatric patients' frequently have gastroesophageal reflux (GER) and discerning pathological GER can be challenging. Moreover, there is some evidence that GT insertion may lead to worsening GER and to avoid a subsequent anti-reflux procedure (ARP), though controversial some surgeons advocate considering an ARP concomitantly. The purpose of this report is to assess outcomes in infants who underwent a GT vs. GT with ARP. METHODS Retrospective review of all infants who had a GT placed at a single institution from 2009-2014. The patients were then divided into two cohorts based on the index operation i.e., GT vs GT with ARP and outcomes compared. RESULTS 226 operations (104 GT, 122 GT with ARP) were performed. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion of neurologically impaired patients. Preoperative GER was significantly higher in the GT with ARP cohort (91 vs. 18%). No difference in the rate of immediate complications was noted between the two groups. Postoperative increase in anti-reflux medications was significantly higher in the GT cohort (p = 0.01). Post-op GER needing a secondary procedure (ARP or GJ tube) was noted in 21/104 (20%) patients. Those needing an additional procedure vs. those with GT alone were similar in the proportion of patients with pre-op GER, neurologic impairment, type of feeds, and age. CONCLUSION Identifying patients who would benefit from a concomitant ARP remains challenging. A fifth of GT patients needed a subsequent procedure despite most high-risk patients having already undergone an ARP. Since the overall rate of complications remained similar, initial GT approach can be considered reasonable.
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Affiliation(s)
- Faraz A Khan
- Division of Pediatric Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA, United States
| | - Kelsey Nestor
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Asra Hashmi
- Department of Plastic Surgery, Loma Linda University, Loma Linda, CA, United States
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
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Ishii D, Miyagi H, Hirasawa M. Risk factors for recurrent gastroesophageal reflux disease after Thal fundoplication. Pediatr Surg Int 2021; 37:1731-1735. [PMID: 34448077 PMCID: PMC8563554 DOI: 10.1007/s00383-021-05001-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE The recurrence rate of gastroesophageal reflux disease (GERD) after fundoplication has been reported to be 7-25%. We investigated the risk factors for recurrence of GERD after Thal fundoplication (TF) in our department with the aim of further reducing the recurrence rate of GERD. METHODS We retrospectively analyzed 276 patients who underwent TF for GERD at our hospital between 2000 and 2019. Retrospectively considered variables were obtained from the medical records of patients. The variables included patient characteristics, GERD severity, surgery-related factors and postoperative course. RESULTS The postoperative GERD recurrence rate was 5.8%. In the univariate analysis, the presence of convulsive seizures (12/4 vs. 110/150, p = 0.046) and the absence of a tracheostomy (0/16 vs. 53/207, p = 0.048) at the time of TF were significantly associated with recurrence. In the multivariate analysis, the presence of convulsive seizures at the time of TF was the only factor significantly associated with recurrence. CONCLUSION The presence of convulsive seizures and the absence of a tracheostomy at the time of TF were significantly associated with GERD recurrence after TF. Active control of seizures and consideration of surgical indications, including assessment of respiratory status, are important in preventing the recurrence of GERD after TF.
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Affiliation(s)
- Daisuke Ishii
- grid.252427.40000 0000 8638 2724Division of Pediatric Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawa, 078-8510 Japan
| | - Hisayuki Miyagi
- grid.252427.40000 0000 8638 2724Division of Pediatric Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawa, 078-8510 Japan
| | - Masatoshi Hirasawa
- grid.252427.40000 0000 8638 2724Division of Pediatric Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawa, 078-8510 Japan
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Hudson AS, Stratton-Gadke K, Hatchette J, Blake KD. New Feeding Assessment Scale for individuals with genetic syndromes: Validity and reliability in the CHARGE syndrome population. J Paediatr Child Health 2021; 57:1234-1243. [PMID: 33682238 DOI: 10.1111/jpc.15434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/05/2021] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
AIM To develop a feeding scale for parents/care givers of individuals of all ages with genetic syndromes experiencing extensive feeding and swallowing problems. Second, to assess its validity and reliability in CHARGE syndrome. METHODS The new Feeding Assessment Scale (FAS) was adapted from a scale for children who need prolonged tube feeding (Paediatric Assessment Scale for Severe Feeding Problems, PASSFP). Ten parents piloted the new scale before it was sent out with the PASSFP and feeding history questions. A subset completed the new scale again 4-8 weeks later. RESULTS One hundred parents of individuals with CHARGE syndrome participated from around the world. The new scale had good construct validity, with a significant effect for an increased number of feeding risk factors having higher scale scores (P < 0.001). Face validity was high, as scores significantly differed between individuals whose parents identified their feeding difficulties as very mild, mild, moderate, severe and very severe (P < 0.001). Test-retest reliability (r = 0.94, P < 0.001) and internal consistency (Cronbach's alpha 0.91) were both high. There was significant convergent validity between the new scale and the PASSFP (r = -0.79, P < 0.001). CONCLUSIONS This new tool is reliable and valid for parents/care givers of individuals with CHARGE syndrome. It can be used to assess the current severity of feeding difficulties and to track progress before and after treatment. It expands upon previous existing tools in that it can be used in both individuals who are not tube fed, as well as in those who are, as well as across the life-span.
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Affiliation(s)
- Alexandra S Hudson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Kasee Stratton-Gadke
- Department of Counseling, Educational Psychology & Foundations, Mississippi State University, Starkville, Mississippi, USA
| | - Jill Hatchette
- Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Kim D Blake
- Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Shahi N, Phillips R, Acker SN, Meier M, Goldsmith A, Shirek G, Ladd P, Moulton SL, Bensard D. Enough is enough: Radiation doses in children with gastrojejunal tubes. J Pediatr Surg 2021; 56:668-673. [PMID: 32921427 DOI: 10.1016/j.jpedsurg.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies. METHODS All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy). RESULTS We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period. CONCLUSIONS Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy. LEVEL OF EVIDENCE IV TYPE OF STUDY: Treatment study.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Patricia Ladd
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Radiology, Children's Hospital Colorado
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Does retching matter? Reviewing the evidence-Physiology and forces. J Pediatr Surg 2019; 54:750-759. [PMID: 30193878 DOI: 10.1016/j.jpedsurg.2018.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/08/2018] [Accepted: 07/30/2018] [Indexed: 11/23/2022]
Abstract
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.
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10
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Singh RR, Eaton S, Roebuck DJ, Barnacle AM, Chippington S, Cross KMK, De Coppi P, Curry JI. Surgical jejunostomy and radiological gastro-jejunostomy tube feeding in children: risks, benefits and nutritional outcomes. Pediatr Surg Int 2018; 34:951-956. [PMID: 30014290 PMCID: PMC6105265 DOI: 10.1007/s00383-018-4303-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Rashmi R. Singh
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Simon Eaton
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Derek J. Roebuck
- Department of Radiology, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Alex M. Barnacle
- Department of Radiology, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Samantha Chippington
- Department of Radiology, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Kate M. K. Cross
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Paolo De Coppi
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Joe I. Curry
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
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11
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Impact of Esophageal Atresia on the Success of Fundoplication for Gastroesophageal Reflux. J Pediatr 2018; 198:60-66. [PMID: 29628411 DOI: 10.1016/j.jpeds.2018.02.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/13/2018] [Accepted: 02/27/2018] [Indexed: 11/21/2022]
Abstract
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.
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12
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Blake KD, Hudson AS. Gastrointestinal and feeding difficulties in CHARGE syndrome: A review from head-to-toe. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:496-506. [PMID: 29082627 DOI: 10.1002/ajmg.c.31586] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 09/12/2017] [Accepted: 09/22/2017] [Indexed: 12/28/2022]
Abstract
CHARGE syndrome is an autosomal dominant genetic condition that is primarily diagnosed based on clinical features, with genetic testing available for confirmation. The CHARGE mnemonic stands for some of the common characteristics: coloboma, heart defects, atresia/stenosis of the choanae, retardation of growth/development, genitourinary anomalies, and ear abnormalities (CHARGE). However, many of the common clinical features are not captured by this mnemonic, including cranial nerve dysfunction, considered by some to be one of the major diagnostic criteria. Over 90% of individuals experience feeding and gastrointestinal dysfunction, which carries great morbidity and mortality. The aim of this review is to examine the nature of gastrointestinal (GI) symptoms and feeding difficulties in CHARGE syndrome, focusing on their underlying pathology, associated investigations, and available treatment options. We also provide information on available tools (for parents, clinicians, and researchers) that are important additions to the lifelong healthcare management of every individual with CHARGE syndrome. We review how cranial nerve dysfunction is one of the most important characteristics underlying the pervasive GI and feeding dysfunction, and discuss the need for future research on gut innervation and motility in this genetic disorder.
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Affiliation(s)
- Kim D Blake
- IWK Health Center, Halifax, Nova Scotia, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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13
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Jancelewicz T, Lopez ME, Downard CD, Islam S, Baird R, Rangel SJ, Williams RF, Arnold MA, Lal D, Renaud E, Grabowski J, Dasgupta R, Austin M, Shelton J, Cameron D, Goldin AB. Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review. J Pediatr Surg 2017; 52:1228-1238. [PMID: 27823773 DOI: 10.1016/j.jpedsurg.2016.09.072] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the surgical treatment of pediatric gastroesophageal reflux disease (GERD). METHODS Five questions were addressed by searching the MEDLINE, Cochrane, Embase, Central, and National Guideline Clearinghouse databases using relevant search terms. Consensus recommendations were derived for each question based on the best available evidence. RESULTS There was insufficient evidence to formulate recommendations for all questions. Fundoplication does not affect the rate of hospitalization for aspiration pneumonia, apnea, or reflux-related symptoms. Fundoplication is effective in reducing all parameters of esophageal acid exposure without altering esophageal motility. Laparoscopic fundoplication may be comparable to open fundoplication with regard to short-term clinical outcomes. Partial fundoplication and complete fundoplication are comparable in effectiveness for subjective control of GERD. Fundoplication may benefit GERD patients with asthma, but may not improve outcomes in patients with neurologic impairment or esophageal atresia. Overall GERD recurrence rates are likely below 20%. CONCLUSIONS High-quality evidence is lacking regarding the surgical management of GERD in the pediatric population. Definitive conclusions regarding the effectiveness of fundoplication are limited by patient heterogeneity and lack of a standardized outcomes reporting framework. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly level 3-4).
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Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105.
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, Program Director, Pediatric Surgery Fellowship, University of Louisville, Louisville, KY
| | | | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC
| | - Shawn J Rangel
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105
| | - Meghan A Arnold
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Dave Lal
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth Renaud
- Department of Surgery, Division of Pediatric Surgery, Albany Medical Center, Albany, NY
| | - Julia Grabowski
- Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Mary Austin
- Department of Pediatric Surgery, The University of Texas Medical School at Houston and in Surgical Oncology and Pediatrics at the UT M.D., Anderson Cancer Center, Houston, TX
| | - Julia Shelton
- Division of Pediatric Surgery, University of Iowa Children's Hospital, Iowa City, IA
| | - Danielle Cameron
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
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14
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Hudson A, Macdonald M, Friedman J, Blake K. CHARGE syndrome gastrointestinal involvement: from mouth to anus. Clin Genet 2017; 92:10-17. [DOI: 10.1111/cge.12892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/01/2016] [Accepted: 10/02/2016] [Indexed: 11/29/2022]
Affiliation(s)
- A. Hudson
- Dalhousie Medical School; Halifax Canada
| | | | - J.N. Friedman
- Department of Pediatrics; The Hospital for Sick Children, University of Toronto; Toronto Canada
| | - K. Blake
- Division of Medical Education; Dalhousie University Faculty of Medicine; Halifax Canada
- Department of Pediatrics; IWK Health Centre; Halifax Canada
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15
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Mauritz FA, Conchillo JM, van Heurn LWE, Siersema PD, Sloots CEJ, Houwen RHJ, van der Zee DC, van Herwaarden-Lindeboom MYA. Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study. Surg Endosc 2016; 31:1101-1110. [PMID: 27369283 PMCID: PMC5315717 DOI: 10.1007/s00464-016-5070-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/21/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS. METHODS Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a 13C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS. RESULTS After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001). CONCLUSIONS In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.
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Affiliation(s)
- Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands. .,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J M Conchillo
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L W E van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R H J Houwen
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - D C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - M Y A van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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16
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Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children. Pediatr Surg Int 2016; 32:277-83. [PMID: 26711122 DOI: 10.1007/s00383-015-3853-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
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.
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17
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Schlager A, Arps K, Siddharthan R, Rajdev P, Heiss KF. The "omega" jejunostomy tube: A preferred alternative for postpyloric feeding access. J Pediatr Surg 2016; 51:260-3. [PMID: 26681348 DOI: 10.1016/j.jpedsurg.2015.10.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
| | - Kelly Arps
- Emory University Department of Surgery, USA
| | | | | | - Kurt F Heiss
- Emory University/Children's Healthcare of Atlanta, USA
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18
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Abstract
BACKGROUND Tracheomalacia is a condition that may result in acute life-threatening events. Aortopexy has become a generally accepted mode of treatment, although the impact of a thoracotomy is considerable. With the advent of minimal invasive surgery the impact of such a procedure may be greatly reduced. This study evaluates the outcome of thoracoscopic aortopexy for tracheomalacia. METHODS Retrospective analysis of a database containing all patients with thoracoscopic aortopexy. Based on symptomatology, on indication 24 h pH study and/or rigid tracheo-bronchoscopy were carried out to confirm the diagnosis. A three-trocar technique was used on the left side together with intra-operative flexible tracheoscopy through the tube. Follow-up continued for the duration of the study. RESULTS Between January 2002 and December 2012, 16 patients presented with severe tracheomalacia. Fourteen of them had a history of esophageal atresia. Age at time of aortopexy varied from 2 weeks to 12 months. All procedures were performed thoracoscopically without intra-operative complications. In five children, there was a recurrence of symptoms within 2-4 weeks for which a re-thoracoscopic aortopexy was carried out successfully. With a follow-up of 6 months to 10 years all patients are thriving and are without incidents. CONCLUSION This is the largest single-center series of thoracoscopic aortopexy for tracheomalacia so far. All procedures were completed successfully without complications. Although recurrences occur, as in open surgery, the ultimate results are satisfactory. In an era of minimal invasive surgery the thoracoscopic approach is feasible and safe, even in redo-procedures.
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19
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Horwood JF, Calvert W, Mullassery D, Bader M, Jones MO. Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children--a single centre experience. J Pediatr Surg 2015; 50:275-9. [PMID: 25638618 DOI: 10.1016/j.jpedsurg.2014.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 11/02/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Gastrooesophageal reflux disease (GERD) is a significant problem in children with neurological impairment (NI) with high failure rates for fundoplication. Fundoplication with vagotomy and pyloroplasty (FVP) can improve the outcome by altering the sensory or motor dysfunction associated with the reflux. We report our comparative outcomes for simple fundoplication (SF) and FVP in NI children. METHODS Case records of all patients having fundoplication under a single consultant at a tertiary UK paediatric surgical centre between January 1997 and December 2012 were retrospectively assessed for recurrent symptoms and redo surgery. The data were collected using a Microsoft Excel database and analysed on Graphpad prism software program. Data are median (range). P value<0.05 was considered significant. RESULTS Data were available for 244 out of 275 patients who underwent fundoplication during this period (157 SF and 87 FVP). Neurological disease or known syndromes were recorded in 158 patients. Thirty-five children had congenital anatomical abnormalities. Laparoscopic fundoplication was done in 37 cases. Revisional surgery for recurrent symptoms was performed in 22 patients. In the neurologically normal children, all of whom had SF, the revision rate was 6.5%. In the NI children the revision rates were 18.5% for SF and 3.9% for FVP, respectively (Fisher's exact, P<0.05). The median time to redo surgery was 10 (1-63) months, and the median time to follow up was 19.5 (2-177) months. CONCLUSIONS There appears to be a significantly lower need for redo surgery following FVP than SF in children with NI.
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Affiliation(s)
- J Fraser Horwood
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - William Calvert
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhanya Mullassery
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohammed Bader
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Matthew O Jones
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
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20
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Esophagogastric dissociation reduces the re-operation rate for persistent gastroesophageal reflux in severely neurologically impaired children. Pediatr Surg Int 2014; 30:997-1001. [PMID: 25139158 DOI: 10.1007/s00383-014-3584-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE In this study we want to demonstrate the effectiveness of the esophagogastric dissociation as a first level operation in treatment of the gastroesophageal reflux in severe neurologically impaired children, in term of a reduction of reoperation rate. METHODS We divided patients operated from 1998 to 2005 in a group A, composed by children treated with fundoplication, and in a group AR, composed by the patients of group A who had a recurrence of reflux and that was treated with esophagogastric dissociation. Patients operated from 2005 to 2013 were selected on the basis of the severity of the neurological impairment and were divided in a group B, treated with fundoplication, and in a group C of more severe impaired children, treated with esophagogastric dissociation. Data regarding the complications of the A and C groups were analyzed with Fisher's test. RESULTS We evaluated 63 patients: 34 (54%) in group A, 11 in group AR, 15 (23.6%) in group B, 14 (22.4%) in group C. The Fisher's test showed a non significant difference with a p value of 0.2. CONCLUSION Despite of statistic result we believe that TOGD is a useful procedure as the first choice of surgical management in severe neurological impaired children affected by gastroesophageal reflux.
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21
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Yoo BG, Yang HK, Lee YJ, Byun SY, Kim HY, Park JH. Fundoplication in neonates and infants with primary gastroesophageal reflux. Pediatr Gastroenterol Hepatol Nutr 2014; 17:93-7. [PMID: 25061584 PMCID: PMC4107226 DOI: 10.5223/pghn.2014.17.2.93] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/10/2014] [Accepted: 03/25/2014] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Gastroesophageal reflux in infant is a physiological process. However, surgery is performed in high risk infants with severe gastroesophageal reflux disease (GERD) when medical management fails. This study focuses on efficacy and safety of Nissen fundoplication for GERD in infants under age 12 months. METHODS This study was a retrospective case analysis of 11 neonates and infants under 12 months of age who underwent Nissen fundoplication following a failure of medical treatment between June 2010 and June 2013 at Pusan National University Children's Hospital. The records were reviewed to determine the effect of fundoplication on symptoms and post-operative complications. RESULTS A total of 11 infants consist of four males and seven females. Mean birth weight was 2,305.5±558.6 g (1,390-3,130 g). They had some underlying disease, which are not related with GERD such as congenital heart disease (54.5%), prematurity (45.5%), neurologic disease (18.2%), respiratory disease (18.2%), and other gastrointestinal disease. Mean body weight at surgery was 3,803.6±1,864.9 g (1,938.7-5,668.5 g). Mean age at operation was 99.9±107.6 days (17-276 days). Duration from operation to full enteral feeding was 10.9 days. Symptoms related GERD disappeared in all patients including one who got reoperation. One infant died of congenital heart disease unrelated to surgery. There were no complications related to fundoplication. CONCLUSION Fundoplication is effective and safe treatment in the neonates and infants with severe GERD.
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Affiliation(s)
- Byung Geon Yoo
- Postgraduate School of Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Hea Kyoung Yang
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Yeoun Joo Lee
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Shin Yun Byun
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Hae Young Kim
- Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae Hong Park
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
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22
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Pacilli M, Eaton S, McHoney M, Kiely EM, Drake DP, Curry JI, Lindley KJ, Pierro A. Four year follow-up of a randomised controlled trial comparing open and laparoscopic Nissen fundoplication in children. Arch Dis Child 2014; 99:516-21. [PMID: 24532685 PMCID: PMC4033109 DOI: 10.1136/archdischild-2013-304279] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To evaluate the 4-year results following a randomised controlled trial (RCT) comparing open (ONF) and laparoscopic (LNF) Nissen fundoplication in children. BACKGROUND It is assumed that long-term results of ONF and LNF are comparable. No randomised studies have been performed in children. METHODS A follow-up study was performed in children randomised to ONF or LNF (clinicaltrials.gov identifier NCT00259961). Recurrent gastro-oesophageal reflux (GER) was documented by upper gastrointestinal contrast study and/or 24-h pH study. Nutritional status, retching and other symptoms were investigated. A questionnaire was used to assess the quality of life before and after surgery. RESULTS Thirty-nine children were randomised to ONF (n=20) or LNF (n=19). There were 15 ONF and 16 LNF neurologically impaired children. One patient (ONF group) was lost to follow-up. Follow-up was 4.1 years (3.1-5.3) for ONF group and 4.1 years (2.6-5.1) for LNF group (p=0.9). Seven neurologically impaired children had died by the time of follow-up (3 ONF, 4 LNF). Incidence of recurrent GER was 12.5% in the ONF and 20% in the LNF (p=ns). One patient in each group underwent redo-Nissen fundoplication. Nutritional status improved in both groups, as indicated by a significant increase in weight Z-score (p<0.01). Gas bloat and dumping syndrome were present in both groups (p=ns). Incidence of retching was lower in the laparoscopic group (p=0.01). Quality of life improved in both groups (p=ns). CONCLUSIONS Open and laparoscopic Nissen provide similar control of reflux and quality of life at follow-up. LNF is associated with reduced incidence of retching persisting at 4-year follow-up. TRIAL REGISTRATION NUMBER NCT00259961.
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Affiliation(s)
- Maurizio Pacilli
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - Simon Eaton
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - Merrill McHoney
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - Edward M Kiely
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - David P Drake
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - Joseph I Curry
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - Keith J Lindley
- Gastroenterology Units, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
| | - Agostino Pierro
- Department of Surgery, Institute of Child Health and Great Ormond Street Hospital, University College London, London, UK
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23
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Complete versus partial fundoplication in children with gastroesophageal reflux disease: results of a systematic review and meta-analysis. J Gastrointest Surg 2013; 17:1883-92. [PMID: 23943388 DOI: 10.1007/s11605-013-2305-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/29/2013] [Indexed: 01/31/2023]
Abstract
Complete fundoplication (Nissen) has long been accepted as the gold standard surgical procedure in children with therapy-resistant gastroesophageal reflux disease (GERD); however, increasingly more evidence has become available for partial fundoplication as an alternative. The aim of this study was to perform a systematic review and meta-analysis comparing complete versus partial fundoplication in children with therapy-resistant GERD. PubMed (1960 to 2011), EMBASE (from 1980 to 2011), and the Cochrane Library (issue 3, 2011) were systematically searched according to the PRISMA statement. Results were pooled in meta-analyses and expressed as risk ratios (RRs). In total, eight original trials comparing complete to partial fundoplication were identified. Seven of these studies had a retrospective study design. Short-term (RR 0.64; p = 0.28) and long-term (RR 0.85; p = 0.42) postoperative reflux control was similar for complete and partial fundoplication. Complete fundoplication required significantly more endoscopic dilatations for severe dysphagia (RR 7.26; p = 0.007) than partial fundoplication. This systematic review and meta-analysis showed that reflux control is similar after both complete and partial fundoplication, while partial fundoplication significantly reduces the number of dilatations to treat severe dysphagia. However, because of the lack of a well-designed study, we have to be cautious in making definitive conclusions. To decide which type of fundoplication is the best practice in pediatric GERD patients, more randomized controlled trials comparing complete to partial fundoplication in children with GERD are warranted.
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Vernon‐Roberts A, Sullivan PB. Fundoplication versus postoperative medication for gastro-oesophageal reflux in children with neurological impairment undergoing gastrostomy. Cochrane Database Syst Rev 2013; 2013:CD006151. [PMID: 23986351 PMCID: PMC7264825 DOI: 10.1002/14651858.cd006151.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Children with neurological impairments frequently experience feeding difficulties, which can lead to malnutrition and growth failure. Gastrostomy feeding is now the preferred method of providing nutritional support to children with neurological impairments who are unable to feed adequately by mouth. Complications may arise as a result of gastrostomy placement, and the development or worsening of gastro-oesophageal reflux (GOR) has been widely reported. This has led to the frequent use of surgical antireflux treatment in the form of a fundoplication, or other antireflux procedures. Fundoplication is associated with a high recurrence rate, surgical failure, and significant morbidity and mortality.Since proton pump inhibitors (PPIs) were introduced in the 1990s, they have come to play a larger part in the medical management of GOR in children with neurological impairments. Uncontrolled studies suggest that PPIs may be a safe, appropriate treatment for GOR. Other agents currently used include milk thickeners, acid suppression drugs, acid buffering agents, gut motility stimulants and sodium alginate preparations.There are risks and benefits associated with both surgical and medical interventions and further comparison is necessary to determine the optimal treatment choice. OBJECTIVES To compare the effectiveness of antireflux surgery and antireflux medications for children with neurological impairments and GOR who are undergoing placement of a gastrostomy feeding tube. SEARCH METHODS We searched the following databases on 23 March 2012: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, EMBASE, CINAHL, LILACS and ISI Web of Science. Previously, we searched the Child Health Library in June 2009. We also performed online searches of trial registries, medical journals, conference proceedings, dissertations and theses. We contacted specialists in the medical and industry setting for knowledge of completed or ongoing trials. SELECTION CRITERIA We sought to include randomised controlled trials that recruited children up to the age of 18 years with neurological impairments and GOR who were undergoing gastrostomy tube insertion. DATA COLLECTION AND ANALYSIS The review authors worked independently to select trials; none were identified. MAIN RESULTS We identified no trials that satisfied the criteria for this review. AUTHORS' CONCLUSIONS There remains considerable uncertainty regarding the optimal treatment when faced with the decision of fundoplication surgery versus antireflux medications for children with GOR and neurological impairment who are undergoing gastrostomy insertion. There is a need for robust scientific evidence in order to provide data on the comparable risks or benefits of the two interventions.
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Affiliation(s)
- Angharad Vernon‐Roberts
- Oxford Children's HospitalOxford University Department of PaediatricsLevel 2HeadingtonOxfordUKOX3 9DU
| | - Peter B Sullivan
- Oxford Children's HospitalOxford University Department of PaediatricsLevel 2HeadingtonOxfordUKOX3 9DU
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A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children. J Pediatr Surg 2013; 48:1306-11. [PMID: 23845623 DOI: 10.1016/j.jpedsurg.2013.03.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/08/2013] [Indexed: 11/23/2022]
Abstract
AIM The objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children. METHODS After Institutional Review Board approval (5100277), data for children under 18 years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo. Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence. RESULTS There were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years). Factors associated with redo were: younger age at first fundoplication, (p=0.002), hiatal dissection (p<0.001), and male gender (p=0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45-29.11), retching, OR: 3.59 (95% CI: 1.56-8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97-0.98). CONCLUSION The incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.
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Hill SJ, Wulkan ML. Cardiaplication as a Novel Antireflux Procedure for Infants: A Proof of Concept in an Infant Porcine Model. J Laparoendosc Adv Surg Tech A 2013; 23:74-7. [DOI: 10.1089/lap.2012.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sarah J. Hill
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Mark L. Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Esposito C, De Luca C, Alicchio F, Giurin I, Miele E, Staiano AM, Settimi A. Long-term outcome of laparoscopic Nissen procedure in pediatric patients with gastroesophageal reflux disease measured using the modified QPSG Roma III European Society for Pediatric Gastroenterology Hepatology and Nutrition's questionnaire. J Laparoendosc Adv Surg Tech A 2011; 22:937-40. [PMID: 22047187 DOI: 10.1089/lap.2011.0254] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND/PURPOSE Laparoscopic fundoplication (LF) represents the gold standard for surgical treatment for pediatric patients with gastroesophageal reflux disease (GERD). METHODS We report the results of long-term outcome of 36 patients who had undergone LF from January to December 1998, with a follow-up longer than 10 years (range, 11-12 years). The patients were invited, by phone, to undergo a clinical follow-up. All patients underwent the modified European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)'s Roma III questionnaire; however, only 22 out of 36 patients accepted to be controlled in a day hospital setting, and 10 out of 36 accepted to undergo a telephonic questionnaire. Our study is focused on the data of these 32 patients. RESULTS Twenty-eight out of 32 (87.5%) patients had completely recovered; 4 out of 32 patients (12.5%) had a mild persistent GER; 9 out of 32 patients (28%) referred a mild dysphagia; 21 out of 32 (66%) patients could burp; and only 9 out of 32 (28%) patients could vomit. The cosmetic result was good in 30 out of 32 (94%) patients. The weight/height ratio was satisfactory in 28 out of 32 (87.5%) patients. The quality of life was good in 28 out of 32 (87.5%) patients. CONCLUSIONS Our experience shows that the long-term follow-up after LF produces a good clinical result and a good quality of life. The modified ESPGHAN's Roma III questionnaire seems an effective way to check the long-term results, because it avoids submitting patients to long and not well tolerated instrumental exams.
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Affiliation(s)
- Ciro Esposito
- Department of Pediatrics, Federico II University of Naples, Naples, Italy.
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González Jiménez D, Díaz Martin J, Bousoño García C, Jiménez Treviño S. Patología gastrointestinal en niños con parálisis cerebral infantil y otras discapacidades neurológicas. An Pediatr (Barc) 2010; 73:361.e1-6. [DOI: 10.1016/j.anpedi.2010.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 02/07/2010] [Accepted: 03/07/2010] [Indexed: 12/27/2022] Open
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IPEG guidelines for the surgical treatment of pediatric gastroesophageal reflux disease (GERD). J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:x-xiii. [PMID: 19371153 DOI: 10.1089/lap.2009.9982.supp] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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30
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Vicente AMB, Cardoso SR, Servidoni MDFCP, Meirelles LRD, Silva JMB, Costa-Pinto EALD. [Clinical and endoscopic outcome after Nissen fundoplication for gastroesophageal reflux disease]. ARQUIVOS DE GASTROENTEROLOGIA 2009; 46:138-43. [PMID: 19578616 DOI: 10.1590/s0004-28032009000200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 08/07/2008] [Indexed: 11/21/2022]
Abstract
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.
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Kane TD, Brown MF, Chen MK. Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association. J Pediatr Surg 2009; 44:1034-40. [PMID: 19433194 DOI: 10.1016/j.jpedsurg.2009.01.050] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 01/23/2009] [Indexed: 12/18/2022]
Abstract
The use of the laparoscopic approach to perform antireflux procedures has increased dramatically since its introduction in 1991. To date, no prospective randomized studies comparing open surgery to the minimal invasive approach in children have been reported. Many retrospective reviews and case series have demonstrated that laparoscopic antireflux procedures are safe and effective once the learning curve is achieved. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize the available evidence to identify the risks and benefits of laparoscopic antireflux procedures.
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Affiliation(s)
- Timothy D Kane
- Minimally Invasive Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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IPEG guidelines for the surgical treatment of pediatric gastroesophageal reflux disease (GERD). J Laparoendosc Adv Surg Tech A 2009; 19:x-xiii. [PMID: 19226225 DOI: 10.1089/lap.2009.9998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
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- International Pediatric Endosurgery Group (IPEG), Los Angeles, CA 90064, USA.
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IPEG guidelines for the surgical treatment of pediatric gastroesophageal reflux disease (GERD). J Laparoendosc Adv Surg Tech A 2009; 18:x-xiii. [PMID: 19105663 DOI: 10.1089/lap.2008.9988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lopez M, Kalfa N, Forgues D, Guibal MP, Galifer RB, Allal H. Laparoscopic redo fundoplication in children: failure causes and feasibility. J Pediatr Surg 2008; 43:1885-90. [PMID: 18926226 DOI: 10.1016/j.jpedsurg.2008.05.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2007] [Revised: 05/16/2008] [Accepted: 05/18/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE This retrospective study reports our experience in laparoscopic approach after failure of antireflux surgery. It evaluates the results and circumstances of failure of the initial procedure to understand indications of refundoplication. METHODS Four hundred seventeen patients were operated on for a gastroesophageal reflux disease (GERD) by laparoscopy in our unit from August 1993 to February 2005. Thirty redo procedures (7.19%) were performed. The indications were 24 (80%) recurrent reflux resistant to the medical treatment and 6 (20%) severe dysphagia resistant to iterative dilatations. The average age was 57.6 months. Nineteen patients (63%) were males and 11 patients (37%) were females. The time between the first and the redo procedure was an average of 16 months. Ten (33%) of them were neurologically impaired (NI); in 7 patients, a percutaneus gastrostomy was also associated. The techniques previously used were 13 Nissen, 7 Nissen-Rossetti, and 10 Toupet. RESULTS The redo procedure was performed by laparoscopy in 27 cases. A conversion was necessary in 3 children because of a difficult dissection. In the 24 cases of recurrent reflux, we realized a valve disassembly, reconstruction of hiatus and Nissen refundoplication. In 3 cases of dysphagia, the release of the hiatus needed a complete valve redo. The mean operative time was 140 minutes (110 to 240 minutes). The sole complication was a pleural perforation. All patients were fed on the first day. The mean duration of hospitalization was 3.1 days. The follow-up was from 48 months to 12 years. A new recurrent reflux occurred in 6 patients; 5 of them were NI. CONCLUSION The failure rate of the antireflux laparoscopic surgery is similar to the conventional surgery. The redo procedure is possible by laparoscopic with a success rate similar to the open redo surgery. The rate and morbidity of complications are acceptable and decrease with experienced surgeons. The indications of redo procedures should be similar to conventional surgery.
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Affiliation(s)
- Manuel Lopez
- Department of Pediatric Surgery, University Lapeyronie Hospital, Montpellier 34275, France.
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Ostlie DJ, Holcomb GW. Reiterative laparoscopic surgery for recurrent gastroesophageal reflux. Semin Pediatr Surg 2007; 16:252-8. [PMID: 17933667 DOI: 10.1053/j.sempedsurg.2007.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Laparoscopic Nissen fundoplication is successful in preventing reflux in more than 95% of patients. However, over time, there appears to be failure of the fundoplication either with wrap breakdown and/or transmigration of the wrap through the esophageal hiatus in 5% to 10% of patients. It is unlikely that medical management will be successful in controlling the reflux symptoms following either wrap breakdown and/or transmigration. Thus, operative repair for control of recurrent symptoms is required in most cases. This article outlines the etiology for recurrent gastroesophageal reflux disease, presentation of the patient with wrap failure or transmigration, steps which the authors have taken to help prevent these complications from developing, and our approach for those patients who require re-operation.
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Affiliation(s)
- Daniel J Ostlie
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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36
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Ngerncham M, Barnhart DC, Haricharan RN, Roseman JM, Georgeson KE, Harmon CM. Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg 2007; 42:1478-85. [PMID: 17848234 DOI: 10.1016/j.jpedsurg.2007.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND/PURPOSE Recurrent gastroesophageal reflux disease (rGERD) is a common problem after fundoplication. Previous studies attempting to identify risk factors for rGERD have failed to control for confounding variables. The purpose of this study was to identify significant risk factors for rGERD after controlling for potential confounding variables. METHODS A retrospective, matched case-control study was conducted at a tertiary children's hospital. Cases (n = 116) met 1 of these criteria: reoperation for rGERD, symptomatic rGERD (confirmed by upper gastrointestinal series, esophagogastroduodenoscopy, or pH monitoring), or postoperative reinstitution of antireflux medication for more than 8 weeks. Controls (n = 209) were matched for surgeon, approach (laparoscopic/open), technique (partial/complete), and approximate operative date. Univariate and multivariable associations were analyzed by conditional logistic regression. RESULTS Significant risk factors for rGERD were age of less than 6 years (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-7.5), preoperative hiatal hernia (OR, 3.2; 95% CI, 1.4-7.3), postoperative retching (OR, 5.1; 95% CI, 2.6-10.0), and postoperative esophageal dilatation (OR, 10.8; 95% CI, 1.8-65.4). Interestingly, significant association was not found between neurologic impairment and rGERD after controlling for potential confounding variables. CONCLUSION Age of less than 6 years, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilatation are independently associated with increased risk of rGERD. Neurologic impairment alone does not increase the risk of developing rGERD.
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Affiliation(s)
- Monawat Ngerncham
- Department of Epidemiology and International Health, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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37
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Wagener S, Sudhakaran N, Cusick E. Watson fundoplication in children: a comparative study with Nissen fundoplication. J Pediatr Surg 2007; 42:1098-102. [PMID: 17560228 DOI: 10.1016/j.jpedsurg.2007.01.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nissen fundoplication is the gold standard antireflux procedure in children. In 1996, one pediatric surgeon adopted the anterior fundoplication described by Watson in 1991. This procedure is reported to achieve good reflux control while permitting burping, active vomiting, and reducing gas bloat. An audit project was undertaken to compare the clinical outcome of children undergoing Nissen and Watson fundoplication. METHODS The case notes of 144 children undergoing open fundoplication between February 1995 and February 2002 were reviewed retrospectively. RESULTS Results of 72 boys and 59 girls comprising 76 Nissen and 55 Watson fundoplications were assessed. In each group, one death occurred within 1 month of operation. Chest infections occurred in 6.6% (Nissen) and 1.8% (Watson), and wound infections in 2.6% and 1.8%, respectively. Dysphagia was recorded in 7.9% of Nissen and 1.8% of Watson fundoplications. Follow-up data were analyzed in 70 children with Nissen and 48 children with Watson fundoplication. When overall clinical outcome was assessed for those patients with a minimum follow-up of 1 year, 85.1% Nissen and 88.2% Watson were judged good/excellent; 14.9% Nissen and 11.8% Watson were judged poor/bad. CONCLUSION Watson fundoplication can safely be performed in children with comparable clinical outcome to Nissen fundoplication.
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Affiliation(s)
- S Wagener
- Bristol Royal Hospital for Children, UK
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Pacilli M, Eaton S, Maritsi D, Lopez PJ, Spitz L, Kiely EM, Drake DP, Curry JI, Pierro A. Factors predicting failure of redo Nissen fundoplication in children. Pediatr Surg Int 2007; 23:499-503. [PMID: 17216234 DOI: 10.1007/s00383-006-1859-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Recurrence of gastro-oesophageal reflux (GOR) following redo Nissen fundoplication represents a significant clinical problem. The aim of this study was to identify factors predicting failure of redo Nissen fundoplication. The notes of children who underwent redo Nissen fundoplication for recurrent GOR in a single institution between June 1994 and May 2005 were reviewed. Data are reported as median (range), or as numbers of cases. Multiple logistic regression analysis, using type of first fundoplication, neurological status, presence of gastrostomy, age-weight, retching-gas bloat after first fundoplication, associated anomalies, oesophageal atresia and length of follow-up as factors, was used to generate a model to identify factors predicting recurrent vomiting (failure) after redo. Eighty-one children underwent redo Nissen fundoplication 15.9 months (0.2-176) after the initial Nissen fundoplication. In 29, the first Nissen was laparoscopic. Age at redo Nissen fundoplication was 3.3 years (0.3-15.9) and weight 12.8 kg (5-60). Thirty-four children (42%) presented with recurrent vomiting (failure). Overall, the model successfully predicted vomiting (failure) after redo fundoplication (P = 0.009). Open surgery at first fundoplication (P = 0.011) and neurological impairment (P = 0.046) were both significant predictors of redo failure in the model, whereas presence of gastrostomy (P = 0.035) and older-heavier age-weight (P = 0.028) were associated with significantly better results. Retching-gas bloat, associated anomalies and oesophageal atresia were not significant predictors of failure. Redo Nissen fundoplication has a high failure rate. Risk factors are open fundoplication at first operation and neurological impairment. Redo fundoplication after primary laparoscopic Nissen has a lower risk of failure.
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Affiliation(s)
- Maurizio Pacilli
- Institute of Child Health and Great Ormond Street Hospital for Children, University College London, London, UK
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Abstract
BACKGROUND Complications and unsatisfactory long-term results after antireflux surgery in children have received increased attention. The aim of this study was to report parental assessment of outcome after Nissen fundoplication. METHODS Ninety-three patients operated with primary Nissen fundoplication between 1990 and 2001 were included. Medical records were reviewed, and parents were interviewed for evaluation of postoperative results. RESULTS Of the 93 children, 51 were neurologically impaired and 14 children had repaired esophageal atresia. Median follow-up time was 6.0 years. Total mortality for the patient population was 13%. Five children died as a complication of the surgery, whereas eight deaths were unrelated to the Nissen fundoplication. Ninety-two percent of the parents reported better well-being of the child after the Nissen fundoplication, and 83% were completely satisfied with the postoperative results. Pulmonary symptoms were reduced in 59%, and quality of sleep improved in 68% of the children. Nine children (10%) had been operated with a redo NF. CONCLUSION The majority of parents were satisfied with the long term results of the Nissen fundoplication.
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Affiliation(s)
- C Kristensen
- Surgical Department, Faculty Divisional Rikshospitalet, Faculty of Medicine, University of Oslo, Norway
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Nadler EP, Leung S, Axelrod FB, Ginsburg HB. A reinforced suture line prevents recurrence after fundoplication in patients with familial dysautonomia. J Pediatr Surg 2007; 42:653-6. [PMID: 17448761 DOI: 10.1016/j.jpedsurg.2006.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Long-term follow-up of fundoplication in patients with familial dysautonomia (FD) has revealed a high rate of recurrent gastroesophageal reflux. This may be because of the unique characteristics of patients with FD which include autonomic denervation accompanied by cyclic vomiting and retching. We reviewed our results with adaptations to the Nissen fundoplication to determine which would be most effective in preventing the need for reoperation. METHODS We reviewed the records of 108 patient with FD who underwent fundoplication by a single pediatric surgeon from November 1978 to July 1, 2004. Patients were divided into 4 groups based on the operative technique: standard Nissen fundoplication, Nissen with a posterior gastropexy, Nissen with posterior gastropexy and a superior anchoring suture, and Nissen with a reinforced suture line in addition to the previous modifications. Demographic data and surgical outcomes were abstracted. RESULTS Patients who underwent a Nissen fundoplication with a reinforced suture line were significantly less likely to require a reoperation for recurrent reflux than any other patients (P = .05, Fisher's Exact test) despite the fact that they were younger than patients who underwent a standard Nissen alone. CONCLUSION The addition of a reinforced suture line to the standard Nissen fundoplication decreases the failure rate for patients with gastroesophageal reflux and FD. A reinforced suture line may be an attractive modification for patients where the fundoplication may be under continued physical stress caused by autonomic perturbations, or other conditions such as uncontrolled seizures or progressive neurologic decline.
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Affiliation(s)
- Evan P Nadler
- Division of Pediatric Surgery, Department of Surgery, New York University School of Medicine, New York, NY 10016, USA.
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Vernon-Roberts A, Sullivan PB. Fundoplication versus post-operative medication for gastro-oesophageal reflux in children with neurological impairment undergoing gastrostomy. Cochrane Database Syst Rev 2007:CD006151. [PMID: 17253583 DOI: 10.1002/14651858.cd006151.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Children with neurological impairments (NI) frequently experience feeding difficulties which can lead to malnutrition and growth failure. Gastrostomy feeding is now the preferred method of providing nutritional support to children with NI who are unable to feed adequately by mouth. Complications may arise as a result of gastrostomy placement and the development or worsening of gastro-oesophageal reflux (GOR) has been widely reported. This has led to the frequent use of surgical anti-reflux treatment in the form of a fundoplication, or other Anti-Reflux Procedures. Fundoplication is associated with a high recurrence rate, surgical failure and significant morbidity and mortality. Since Proton Pump Inhibitors (PPIs) were introduced in the 1990s they have come to play a larger part in the medical management of GOR in children with NI. Uncontrolled studies suggest that PPIs may be a safe, appropriate treatment for GOR. Other agents currently used include milk thickeners, acid suppression drugs, acid buffering agents, gut motility stimulants and sodium alginate preparations. There are risks and benefits associated with both surgical and medical interventions and further comparison is necessary to determine the optimal treatment choice. OBJECTIVES To compare the effectiveness of anti-reflux surgery and anti-reflux medications for children with NI and GOR who are undergoing placement of a gastrostomy feeding tube. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) up to Issue 2, 2006, MEDLINE (1966 to June 2006), EMBASE (1980 to week 33, 2006), CINAHL (1982 -to May, week 4, 2006), LILACS (1982 to June 2006), ISI Web of Science (1970 to June 2006) and the Child Health Library (searched June 2006). We also performed online searches of trial registries, medical journals, conference proceedings, dissertations and theses. Specialists in the medical and industry setting were contacted for knowledge of completed or ongoing trials. SELECTION CRITERIA We sought to include only randomised controlled trials that recruited children up to the age of 18 years with NI and GOR who were undergoing gastrostomy tube insertion. DATA COLLECTION AND ANALYSIS Two reviewers worked independently on selected trials and performed data extraction and assessment of trial quality. MAIN RESULTS No trials were identified that satisfied the criteria for this review. AUTHORS' CONCLUSIONS There remains considerable uncertainty regarding the optimal treatment when faced with the decision of fundoplication surgery versus anti-reflux medications for gastro-oesophageal-reflux in the child with neurological impairment who is undergoing gastrostomy insertion. There is a need for robust scientific evidence in order to provide data on the comparable risks or benefits of the two interventions.
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Affiliation(s)
- A Vernon-Roberts
- John Radcliffe Hospital, University Department of Paediatrics, Level 4, Oxford, UK, OX3 9DU.
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Durante AP, Schettini ST, Fagundes DJ. Vertical gastric plication versus Nissen fundoplication in the treatment of gastroesophageal reflux in children with cerebral palsy. SAO PAULO MED J 2007; 125:15-21. [PMID: 17505680 PMCID: PMC11014701 DOI: 10.1590/s1516-31802007000100004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 12/05/2006] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Association between neurological lesions and gastroesophageal reflux disease (GERD) in children is very common. When surgical treatment is indicated, the consensus favors the fundoplication technique recommended by Nissen, despite its high morbidity and relapse rates. Vertical gastric plication is a procedure that may have advantages over Nissen fundoplication, since it is less aggressive and more adequately meets anatomical principles. The authors proposed to compare the results from the Nissen and vertical gastric plication techniques. DESIGN AND SETTING Randomized prospective study within the Postgraduate Surgery and Experimentation Program of UNIFESP-EPM, at Hospital do Servidor Público Estadual (IAMSPE) and Hospital Municipal Infantil Menino Jesus. METHODS Fourteen consecutive children with cerebral palsy attended between November 2003 and July 2004 were randomized into two groups for surgical treatment of GERD: NF, Nissen fundoplication (n = 7); and VGP, vertical gastric plication (n = 7). These were clinically assessed by scoring for signs and symptoms, evaluation of esophageal pH measurements, duration of the operation, intra and postoperative complications, mortality and length of hospital stay. RESULTS The mean follow-up was 5.2 months; symptoms were reduced by 42.8% (NF) (p = 0.001) and 57.1% (VGP) (p = 0.006). The Boix-Ochoa score was favorable for both groups: NF (p < 0.001) and VGP (p < 0.042). The overall mortality was 14.28% in both groups and was due to causes unrelated to the surgical treatment. CONCLUSION The two operative procedures were shown to be efficient and efficacious for the treatment of GERD in neuropathic patients, over the study period.
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Goessler A, Huber-Zeyringer A, Hoellwarth ME. Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication. Acta Paediatr 2007; 96:87-93. [PMID: 17187611 DOI: 10.1111/j.1651-2227.2006.00005.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIM To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP). METHODS From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed. RESULTS Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively). CONCLUSION Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.
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Affiliation(s)
- A Goessler
- Department of Pediatric Surgery, University of Graz, Medical School, Auenbruggerplatz, Graz, Austria.
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Celik A, Loux TJ, Harmon CM, Saito JM, Georgeson KE, Barnhart DC. Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children. J Pediatr Surg 2006; 41:2081-5. [PMID: 17161211 DOI: 10.1016/j.jpedsurg.2006.08.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Ahmet Celik
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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Raval MV, Phillips JD. Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement. J Pediatr Surg 2006; 41:1679-82. [PMID: 17011268 DOI: 10.1016/j.jpedsurg.2006.05.050] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7223, USA
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Lopez PJ, Veness J, Wojcik A, Curry J. How reliable is intracorporeal laparoscopic knot tying? J Laparoendosc Adv Surg Tech A 2006; 16:428-32. [PMID: 16968200 DOI: 10.1089/lap.2006.16.428] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Are knots tied laparoscopically as reliable as those tied in open surgery? The aim of our study was to try to answer this question. MATERIALS AND METHODS Using a standardized technique, one senior laparoscopic surgeon tied 3 suture materials using 3 methods of knotting: hand, instrument, and laparoscopic (in a simulator). The tension in the knots was measured using a tension gauge at the time of knotting and 5 minutes later. The surgeon was blinded to the value. The experiment was repeated 4 times. The 36 sutures were then analyzed using a materials-testing machine. The force achieved prior to breakage, the extension, and the breaking points were recorded. The scientist performing the analysis was blinded as to the method of tying and tensions produced. RESULTS There were no significant differences in tension at 5 minutes between suture materials or method of knot tying. The mean extension achieved prior to breakage for 33 sutures was 29.71 mm with a force of 16.09 N. In 3 sutures the knot slipped completely while tension was being increased, thus no measure of breakage force could be obtained. These 3 sutures were monofilament and tied laparoscopically. CONCLUSION There were no significant changes in suture tension after 5 minutes regardless of material or method of knot tying. Three of the 12 knots tied laparoscopically came undone under strain testing. All 3 knots were monofilament suture. This may have important implications when choosing suture material. Further studies are planned to expand the analysis of different knotting techniques with different suture materials.
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Affiliation(s)
- Pedro-Jose Lopez
- Department of Paediatric Surgery, Great Ormond Street Hospital and University College of London, London, United Kingdom
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Goessler A, Huber-Zeyringer A, Hoellwarth ME. Does epilepsy influence the outcome of antireflux procedures in neurologically impaired children? Pediatr Surg Int 2006; 22:485-90. [PMID: 16736214 DOI: 10.1007/s00383-006-1686-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
In neurologically impaired patients (NIP), surgical management of gastroesophageal reflux disease (GERD) has become a widespread standard. Several follow-up studies have shown a high incidence of complications and recurrent reflux. As one of the possible causes epilepsy is mentioned repeatedly in the literature. The aim of this study was to determine the effective impact of epilepsy on the postoperative outcome by comparing results of our patients suffering from epilepsy to those without this disorder. From 1984 to 1999, a total of 45 NIP underwent antireflux surgery, including 20 patients suffering from epilepsy (EP) and 25 patients without this disorder (nEP). The existence of epileptic disorders, incidence of epileptic seizures and administration of anticonvulsatory drugs as well as results of diagnostic procedures, postoperative complications and incidence and time of recurrence of pathologic GER were recorded and analysed retrospectively. Preoperatively all patients had pathologic results in 24 h pH-monitoring. Median RI was 15.75 (EP, range 5.2-28.6) and 17.55 (nEP; range 7.2-26.5). 12-months-postoperative 24 h pH-monitoring showed a median RI of 3.8 (EP; range 1.3-25.6) versus a median RI of 3.3 (nEP; range 0.7-26.3). During the long-term follow-up evaluation of 3.9 years, 17 EP suffered from persistent epileptic seizures despite medical treatment. 19 patients (42%) developed recurrent reflux. This included seven EP (35%) and 12 nEP (48%). The necessity of reoperation was higher in nEP (n = 5, 20%) than in EP (n = 1, 5%). This analysis did not show a significant correlation between recurrence of pathologic GER after fundoplication and the incidence of epileptic seizures. We consider our findings to strongly question the widespread opinion considering this correlation. We conclude, that cerebral seizures alone do not alter the operative outcome of antireflux surgery in NIP.
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Affiliation(s)
- A Goessler
- Department of Pediatric Surgery, University of Graz, Medical School, Auenbruggerplatz 34, 8036, Graz, Austria.
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Abstract
Antireflux surgery has been a mainstay of treatment for gastro-oesophageal reflux disease in children for some 40 years. In recent years, enthusiasm for antireflux surgery seems only to have increased, despite its often poor outcome, and the availability of highly effective medical therapy in the form of proton pump inhibitors (PPIs). Reports show that many children undergo surgery without reflux disease as the demonstrable cause of their symptoms/signs, and without evidence of having failed optimised medical management. Very few studies report objective testing postoperatively--those that do show high rates of failure within the first 1-3 years following surgery. Treatment with PPIs is an effective and safe alternative to surgery in many cases.
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Affiliation(s)
- E Hassall
- Division of Pediatric Gastroenterology, BC Children's Hospital/University of British Columbia, 4480 Oak St, Vancouver, BC V6H 3V4, Canada.
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Diaz DM, Gibbons TE, Heiss K, Wulkan ML, Ricketts RR, Gold BD. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol 2005; 100:1844-52. [PMID: 16086723 DOI: 10.1111/j.1572-0241.2005.41763.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Antireflux surgery is performed frequently in children with gastroesophageal reflux disease (GERD). Few comparative studies exist which assess the indications for and short- or long-term outcome of open Nissen fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric GERD. We investigated the frequency of reoperation and factors that might influence its occurrence. METHODS We performed a retrospective, follow up cohort study of all children </=5 years, who underwent LNF or ONF at our institution from January 1, 1997 to December 31, 2002, where five pediatric surgeons perform fundoplication. Mean follow up time was 36.2 months. The following information was obtained: surgical indications, hospital course data, and long-term surgical outcomes. Data were analyzed using univariate and multiple logistic regressions. RESULTS Overall, 456 (150 [32.9%] ONF vs. 306 [67.1%] LNF) cases were analyzed. Reoperation was performed in 55 (12.06%), LNF 43 (14.05%), and ONF 12 (8%). The mean interim to reoperation for LNF was 11 months compared to 17 months for ONF (p= 0.007). The reoperation rate at 12 and 24 months were 10.5%, 13.4% and 4%, 6.7% respectively, when LNF was compared to ONF (p= 0.01). The multivariate analysis showed that initial LNF and prematurity were the main predictors for reoperation. CONCLUSIONS The majority of reoperations for both LNF and ONF occurred in the first year after initial operation; LNF had a significantly higher reoperation rate than ONF. The probability of reoperation for LNF and ONF increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions.
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Affiliation(s)
- Diego M Diaz
- Pediatric Gastroenterology and Nutrition, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Abstract
In children with medically refractory gastroesophageal reflux disease (GERD), fundoplication is effective and safe. However, in a subset of patients, gastrointestinal dysfunction occurs postoperatively. Symptoms include chest pain, persistent dysphagia in 5%, gas bloat in 2% to 4%, diarrhea in up to 20%, and dumping syndrome in up to 30%. Symptoms are often nonspecific, arising from recurrent or persistent GERD, anatomic complications such as disrupted or herniated wrap, functional disturbances such as rapid gastric emptying or altered gastric accommodation, or alternative diagnoses such as cyclic vomiting syndrome or food allergy. Detailed investigation, including various combinations of pHmetry, videofluoroscopy, endoscopy, motility studies, and dumping provocation testing, may be required to clarify pathophysiology and guide management.
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Affiliation(s)
- Frances Connor
- Department of Gastroenterology, Hepatology and Nutrition, Royal Children's Hospital, Herston Road, Herston, Brisbane, QLD 4029, Australia.
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