Surgery in children with gastroesophageal reflux and respiratory symptoms

Outpatient respiratory management of the child with severe neurological impairment

Most paediatricians will have faced the challenge of managing respiratory problems in the child with severe neurological impairment. These children are under-represented in clinical trials, and data is therefore often extrapolated from other groups, for example children with cystic fibrosis. This means that robust evidence for respiratory management in children with severe neurological impairment is often lacking. Here we have attempted to piece together the existing evidence to provide a rational approach to the management of respiratory problems in children with severe neurological impairment. We also hope to highlight areas of uncertainty, in order to aid honest discussions with families. The respiratory management of the child with neuromuscular disease is beyond the scope of this article.

Duodenal tube feeding: an alternative approach for effectively promoting weight gain in children with gastroesophageal reflux and congenital heart disease

We tested whether duodenal tube feeding effectively improves the clinical symptoms and body weight gain in children with congenital heart disease (CHD) and gastroesophageal reflux (GER). In the retrospective analysis of 17 consecutive children with CHD who were treated with duodenal tube feeding for symptomatic GER, we found that clinical symptoms of persistent emesis or respiratory wheezing after feeding disappeared with duodenal tube feeding in all patients. Duodenal tube feeding facilitated a stable nutritional supply, resulting in marked improvement of weight gain from 6 to 21 g/day (P < .0001). In a patient with trisomy 21 and persistent pulmonary hypertension after the closure of a ventricular septal defect, duodenal tube feeding ameliorated pulmonary hypertension, as evidenced by the improvement of the pressure gradient of tricuspid regurgitation from 77 to 41 mm Hg. In 14 of the 17 patients, the duodenal tube was successfully removed, with the spontaneous improvement of GER (median duration of duodenal tube feeding: 7 months). In conclusion, duodenal tube feeding improves the weight gain of infants with GER who need treatment for CHD-associated heart failure. It also allows for the improvement of pulmonary hypertension.

Fundoplication in children with gastro-oesophageal reflux disease

OBJECTIVES

The associations between gastro-oesophageal reflux (GOR), chronic respiratory symptoms and gastrointestinal complications have been well described. The aim of this study was to compare the characteristics of children in whom the main indication for fundoplication was respiratory disease with children who had gastrointestinal indications for surgery.

METHODS

A retrospective review of 79 children who underwent fundoplication between January 1995 and December 1999.

RESULTS

Forty-nine of the children (62%) had a respiratory indication for fundoplication. Children with neurological impairment tended to have a respiratory rather than a gastrointestinal indication for surgery. Congenital anomalies were present in 47%. Fundoplication in older children was more likely to be for a gastrointestinal indication. Children with neurological impairment were more likely to have a gastrostomy compared to children with normal neurological status (P < 0.01). Children with a respiratory indication were more likely to have three or more diagnostic investigations (P < 0.001). Ninety-two per cent of children with a respiratory indication and 90% with a gastrointestinal indication for fundoplication had at least one positive test for GOR (barium meal or 24-h oesophageal pH monitoring). Oesophagoscopy showed reflux oesophagitis in 46/61. Eighty-five per cent of the children had complete resolution of their symptoms after fundoplication.

CONCLUSIONS

Neurological comorbidity was common in children who had surgery for gastro-oesophageal reflux disease, whether for gastrointestinal or respiratory indications. The majority of fundoplications were performed for respiratory indications.

Management of supraesophageal complications of gastroesophageal reflux disease in infants and children

Therapy of supraesophageal manifestations of gastroesophageal reflux disease (GERD) in infants and children nearly always includes "lifestyle modifications" (conservative or nonpharmacologic therapy). Depending on the severity of the GERD manifestation, pharmacotherapy is often added. Although data to support the practice are not abundant, it is rational to begin with prokinetic pharmacotherapy and to add acid suppression if pathologic effects of acid contact with the esophagus or airway are suspected. Pathologic effects of acid produce most forms of supraesophageal GERD; the exception is infantile regurgitation, the most common example of supraesophageal GERD, which is often unaccompanied by either esophagitis or evidence of acid entry into the airway. Currently, fundoplication is rarely required for pediatric GERD, but the supraesophageal complications of GERD are more common indications for this surgery than the esophageal complications in children. Other management options for supraesophageal symptoms in children include delivery of nutrients by tube feeding slowly and continuously into the stomach or, better, small intestine. Short-term or trial tube feeding uses a transnasal tube, for example, for nasojejunal feeding; longer-term tube feeding is simplified by a gastrostomy, which can be placed relatively noninvasively using endoscopy or fluoroscopy.

Gastroesophageal reflux after repair of atrioventricular septal defect in infants with trisomy 21: a comparison of medical and surgical therapy

BACKGROUND

Gastroesophageal reflux and dysmotility are common in children with trisomy 21. Children with trisomy 21 and congenital heart disease are at increased risk for complications of gastroesophageal reflux even after repair of their cardiac abnormalities. The optimal management of reflux in these patients is not known.

METHODS

The authors studied 24 consecutive infants (5.3+/-3.1 months) with trisomy 21 and atrioventricular septal defect who had symptoms or signs of gastroesophageal reflux and a positive esophageal pH study finding early after repair of their cardiac anomaly. Ten patients were given standardized medical therapy with upright positioning during and after feedings, thickening of feedings, metoclopramide, and an H2-receptor antagonist. The other 14 underwent primary surgical management consisting of Nissen fundoplication through a minilaparotomy.

RESULTS

All 10 medically treated patients required readmission within 2 weeks for complications related to reflux, including aspiration or pneumonia (n = 6), persistent failure to thrive (n = 2), and frequent apneic episodes (n = 2). No surgically treated patients had reflux-related complications requiring readmission. The total duration of hospitalization in the medically treated patients, including the initial hospitalization and the rehospitalization, was significantly longer than in patients who underwent fundoplication (35.8+/-9.8 v. 10.4+/-2.2 days, P<.001). At follow-up (24 to 56 months), all patients were alive except for 1 medically treated patient who died of aspiration pneumonia 28 days after readmission. Two medically treated patients required a Nissen, and 3 patients in the surgical group underwent redo fundoplication, all within 1 year. Three other patients in the medically treated group required a total of 8 hospitalizations for complications of reflux. No patient in either group required placement of a gastrostomy tube. Weight percentile for age was higher in surgical than medical patients.

CONCLUSIONS

Infants with trisomy 21 and atrioventricular septal defect who undergo fundoplication are less likely to experience major complications of reflux early after cardiac surgery than those treated with a medical regimen of upright posture, thickened feedings, metoclopramide, and H2-receptor blockade.

Antireflux surgery in children suffering from reflux-associated respiratory diseases

The aim of our study was to evaluate the success, complications, and morbidity following a modified Thal fundoplication in children with reflux-associated respiratory disease (RARD). We used a procedure consisting of retroesophageal hiatal plasty, wrapping the gastric fundus around the gastroesophageal junction 180 degrees, and fixation of the lesser curvature at the abdominal wall. Follow-up by questionnaire of 128 (77 male, 51 females) out of 196 antireflux procedures between 1992 and 1995 was achieved. Surgical therapy was considered justified whenever there was gastroesophageal reflux resulting in severe recurrent respiratory symptoms. Eleven percent of the children suffered from bronchiectasis. The diagnosis of RARD was based on a high index of suspicion, barium swallow with fluoroscopy, 24-hr two-level pH-monitoring, bronchoscopy, bronchoalveolar lavage and detection of lipid-laden alveolar macrophages, esophago-gastroscopy, and esophageal biopsy. Patients with bronchopulmonary diseases such as allergy, immunodeficiency, cystic fibrosis, primary ciliary dyskinesia, and malformation of the bronchial tree or vessels had been excluded. "Evident improvement" as a result of surgery was reported in 88%, "no change" in 10%, and a "change for the worse" in 2% of patients. Persistent mild difficulties in swallowing were observed in 11%. Paraesophageal hernia, gas-bloat syndrome, and dumping syndrome were not observed. Two children needed a second operation because of relapse. The use of emergency steroidal medication for acute respiratory distress decreased impressively (219 single doses/year before surgery vs. 30 single doses/year after surgery). The need for more than 4 times/year of antibiotic therapy before surgery was reduced from 52. 3% before to 14% after surgery. Most (90.6%) of the parents stated they would agree to have surgery done again if medically indicated. In conclusion, Thal fundoplication is sufficient, safe, and effective in the management of RARD. Complications of the procedure were minor and of little consequence to the patient.

Increased levels of prostaglandins and nitric oxide in esophageal mucosa of children with reflux esophagitis

BACKGROUND

Prostaglandin E2 (PGE2) is said to be both protective and detrimental for esophageal mucosal integrity. Nitric oxide (NO) controls several esophageal neuromuscular functions, including relaxation of the lower esophageal sphincter. The purpose of this study was to verify PGE2 and NO levels in esophageal mucosa of children with reflux esophagitis.

METHODS

The patients were 10 children, age range 7 to 12 years, affected by reflux esophagitis. The control subjects were 10 children, age range 6 to 11 years, with recurrent abdominal pain. Tissue fragments obtained by esophageal biopsies were placed in a culture medium and processed to obtain a cell suspension. Cells were incubated for 24 hours at 37 degrees C. Thereafter, supernatants were collected and divided into aliquots to determine the amounts of PGE2 and NO metabolites.

RESULTS

Esophageal cells obtained from reflux esophagitis patients synthesize and release a significantly higher (p < 0.01) amount of PGE2 and NO (PGE2 1.9 +/- 0.56 ng/10(6) cells per 24 hours; NO 124.94 +/- 18.36 microM/10(6) cells per 24 hours) than did the control group (PGE2 0.66 +/- 0.14 ng/10(6) cells per 24 hours; NO 68.03 +/- 12.3 microM/10(6) cells per 24 hours).

CONCLUSIONS

These results suggest that in esophageal mucosa, PGE2 and NO, in low concentrations, are protective, whereas, at high doses, they can be harmful. Higher amounts of PGE2 and NO in the esophageal mucosa of reflux esophagitis patients suggest that similar noxious stimuli trigger the inducible forms of the respective enzyme.

Is mis-swallowing or smoking a cause of respiratory symptoms in patients with gastroesophageal reflux disease?

Respiratory symptoms were studied in 119 patients operated on for fundoplication and crural repair because of gastroesophageal reflux disease (GERD). The effect of antireflux surgery and of smoking habits on their respiratory symptoms was evaluated. A questionnaire was completed before and after surgery in connection with esophageal investigations. Chronic bronchitis was present in 20% of the patients, 38% of whom were smokers. In the rest of the patients, 18% were smokers. Cough was reported by 34% and expectoration by 21%. After surgery the number of patients with cough and chronic bronchitis was reduced significantly in nonsmokers and to some extent in smokers. It is believed that fundoplication with distal anchoring of the longitudinal esophageal muscle will improve pharyngoesophageal function and thereby decrease aspiration and respiratory symptoms due to mis-swallowing.

Gastroesophageal reflux occurring after repair of congenital diaphragmatic hernia

Over the past 2 decades, 110 patients with congenital diaphragmatic hernia (CDH) were treated in the authors' hospital. Eighty-six survived; of these, 10 patients (11.6%) had gastroesophageal reflux (GER) after repair of CDH. Seven occurred in the past 5 years, during which time advanced intensive care including extracorporeal membrane oxygenation (ECMO) was used. Vomiting started within 4 weeks after repair of CDH in eight cases, and hiatal hernia was demonstrated in six cases. Three patients responded to conservative therapy; the other seven required antireflux surgery. Several factors are believed to be possible causes of the development of GER in CDH cases. Among them, slow pulmonary expansion of the affected side was thought to be the most important. Namely, in a case of CDH associated with severe hypoplastic lung, the esophagus may be deviated to the affected side before the lung is expanded. After expansion, the abdominal esophagus shortens, and GER or a hiatal hernia can occur in severe cases. There were seven such patients in our series of 10. With the increase in the survival rate of CDH cases associated with severe hypoplastic lung, the number of such patients also may increase. Therefore, some additional procedure to prevent the lower esophagus from sliding will be necessary in the repair of diaphragmatic hernia.

Sudden infant death syndrome prevention and an understanding of selected clinical issues

The etiology and prevention of sudden infant death syndrome (SIDS) are among the more frustrating topics in pediatrics. This article addresses several clinically relevant issues, including the relationships between apnea and SIDS, the nature of the "terminal event," effectiveness of home monitoring, the role of gastroesophageal reflux in apparent life-threatening events, and the association between the prone sleeping position and SIDS. This article is intended to provide the clinician with an awareness of the issues and the scientific basis needed to understand their contribution to SIDS.

Scintigraphic evaluation of esophageal transit and gastric emptying in familial dysautonomia

Gastroesophageal dysfunction is a major cause of morbidity and mortality in patients with familial dysautonomia (FD). Most studies evaluating esophageal and gastric function in FD patients are either insensitive or invasive. Thus we have used a "milk" scan to quantitate abnormalities in esophageal transit and gastric emptying, while searching for gastroesophageal reflux and aspiration in these patients. The quantitative scintigraphic evaluation was performed in 35 patients with FD, 10 of whom were studied after fundoplication, pyloroplasty and gastrostomy. A prolonged esophageal transit time, ranging from 8 s to more than 60 s duration, was demonstrated in 11 patients. Gastroesophageal reflux was detected in 26 patients. In 16 patients delayed gastric emptying ranging from 63-94% was detected at 30 min, and in 13 patients delayed emptying ranging from 37-86% was observed at 120 min. Pulmonary aspiration was detected in 8 non-operated patients, four of whom had abnormal gastric emptying. The scintigraphic analysis of both esophageal transit and gastric emptying in familial dysautonomia is presented, and its role in evaluation and management of these patients discussed.

Efficacy and safety of omeprazole for severe gastroesophageal reflux in children

Omeprazole, a potent inhibitor of acid secretion, is effective in adults with severe gastroesophageal reflux, but no such data are available on children. We studied 15 children in whom treatment with histamine (type 2) blockers and prokinetic agents had failed; 4 had also had one or more fundoplications. Their ages were 0.8 to 17 years (mean, 8.1 years) and weights were 7.5 to 30.7 kg (mean, 18.6 kg). Of the 15 children, 8 were neurologically handicapped. All patients had endoscopic and histologic evidence of esophagitis; most had esophagitis grade 3 to 4. Patients were initially given omeprazole at 10 to 20 mg; the dose was titrated upward until results of a subsequent 24-hour intraesophageal pH study was normal. Symptoms and signs abated and evidence of esophagitis diminished in all patients. Omeprazole was given for periods of 5.5 to 26 months (mean, 12.2 months). The effective total dose was 20 to 40 mg (0.7 to 3.3 mg/kg) in 11 patients, 10 mg (0.7 mg/kg) in 1 patient, and 60 mg (1.9 to 2.4 mg/kg) in 3 patients. The dosage range was 0.7 to 3.3 to mg/kg per day (mean, 1.9 mg/kg). Mildly elevated transaminase values in 7 patients and elevated fasting gastrin levels in 11 patients were present; in 6 of the 11, gastrin levels were 3 to 5.5 times the upper limit of normal. We found omeprazole to be highly effective in this group of patients with severe esophagitis refractory to other measures. We recommend a starting dose of 0.7 mg/kg as a single morning dose; the adequacy of reflux control is then determined by follow-up 24-hour intraesophageal pH studies. Omeprazole appears to be safe for short-term use, but further studies are needed to assess long-term safety because the significance of chronically elevated gastrin levels in children is unknown.

Current surgical considerations in gastroesophageal reflux disease in infancy and childhood

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

A novel endoscopic transgastric fundoplication procedure for gastroesophageal reflux: an initial animal evaluation

Complications of gastroesophageal reflux are common in adults and children. A variety of surgical procedures have been successfully used to treat this condition. All current techniques require open surgery and are associated with significant morbidity and mortality, particularly in the high risk, neurologically damaged child. The authors have developed a novel method of creating a gastric fundoplication using an endoscopic transgastric approach in pigs. The procedure involves the creation of an esophageal intussusception into the stomach under direct vision with an endoscope. The gastric fundus is then plicated around the esophagus using a custom stapling device. The transgastric approach allows creation of a fundoplication, is easily performed, is potentially effective at preventing gastroesophageal reflux, and has the obvious advantages of minimally invasive surgery over open techniques of fundoplication.

Epidemiology of gastro-esophageal reflux disease

Gastro-esophageal reflux disease encompasses a spectrum of disorders in which gastric reflux leads to symptoms and/or damage to the esophageal mucosa. Although a common problem in clinical practice, our understanding of the pathophysiology of the condition has not been matched by our knowledge of its epidemiology and natural history. This review examines some of the difficulties inherent in epidemiological studies with particular emphasis on the nature and variety of reflux symptoms and their relationship to esophagitis, the natural history and complications of reflux disease, Barrett's esophagus, and the possible role of gastroesophageal reflux in lung disease, especially asthma.

Fundoplication in preterm infants with gastro-oesophageal reflux

Gastro-oesophageal reflux in preterm infants may result in recurrent pulmonary insult due to aspiration of gastric contents, and intractable obstructive apnoea. Fundoplication is effective in controlling reflux when medical management has failed. Our experience between 1981 and 1990 was reviewed to assess the efficacy of early surgery in the management of 11 such infants. The infants had a median gestational age of 29 weeks and a median birthweight of 1032 g. Nine infants had fundoplication for recurrent aspiration pneumonitis and two for intractable apnoea. The median age at the time of surgery was 100 days and the median weight of the infants was 2640 g. Nine infants were oxygen dependent and two were still ventilated at the time of surgery. The operative procedure was well tolerated by 10 of the 11 infants. Surgery failed to control reflux in two infants, although good control was obtained in the one who had subsequent surgery. Three infants required prolonged ventilation postoperatively; two of them died later from pulmonary failure. The median time to discharge was 24 days (8-113 days). All infants with intractable apnoea were cured by surgery. Fundoplication is an effective method of management when used early in the treatment of chronic gastro-oesophageal reflux in preterm infants. There is minimal morbidity from the surgical procedure.

Gastro-oesophageal reflux and respiratory function in infants with respiratory symptoms

This study aimed to define the incidence and severity of gastro-oesophageal reflux (GOR), as measured using 24 hour oesophageal pH monitoring, in 38 infants with recurrent respiratory symptoms and to relate these findings to measures of respiratory function. Twenty one infants had a pH under 4 for more than 5% of the time (one definition of abnormal GOR) and nine had GOR exceeding age related normal values. Maximum expiratory flow at functional residual capacity was reduced in 37 infants, airways resistance was raised in 19 infants, and thoracic gas volume was abnormal in 11 infants. There was no association between indices of GOR and measures of lung function whether assessed by correlation or by chi 2 analysis for normal versus abnormal values. However, individual infants appeared to have respiratory symptoms produced by GOR. This suggests that host responsiveness to GOR may be of greater relevance than the amount of GOR.

The risk of sudden infant death from gastroesophageal reflux

Gastroesophageal reflux (GER) has been a suspected cause of infant deaths and sudden infant death syndrome (SIDS). We examined our 10-year experience with 499 consecutive infants 6 months of age or less who had extended (18 to 24 hours) esophageal pH monitoring performed to evaluate for GER. The data extracted from the esophageal pH records included the pH score, the pattern of GER (type I, II, or III), and the mean duration of reflux during sleep (ZMD). All infants were followed to determine the occurrence and cause of death during the first year of life. Of the 19 deaths found in the series, three were classified as SIDS and two were in-hospital deaths caused by reflux-induced aspiration. All five of these infants who died had a prolonged ZMD (greater than 3.8 minutes) and received either basic medical (n = 4) or no (n = 1) antireflux therapy. Four infants also had the type I pattern of GER. There was a 9.1% (4/44; 95% confidence limits, 2.5% to 21.7%) incidence of reflux-related or SIDS deaths in infants with type I GER and a prolonged ZMD who were treated nonoperatively, compared with none (0/83, P = .03) in the same group of infants treated with antireflux surgery. The incidence of SIDS was higher in infants with type I GER and a prolonged ZMD who were treated nonoperatively (3/44, 6.8%) compared with all other infants treated nonoperatively (0/265, 0%; P = .003).(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring

Gastroesophageal reflux (GER) usually presents with digestive symptoms, failure to thrive, and/or respiratory symptoms. During the 8-year period from 1981 to 1989, 1,153 children underwent 20-hour pH monitoring to assess GER. All patients were graded using the scoring system of Euler and Byrne. Patients were classified as severe (score greater than 50), moderate (score 25 to 50), and normal (score less than 25). Five hundred (43.3%) of these patients presented with respiratory symptoms including apnea, cyanosis, or "near miss" sudden infant death syndrome (36%), poorly controlled asthma (28%), recurrent bronchopneumonia (13%), bronchiolitis (9%), and miscellaneous symptoms such as intermittent dyspnea, chronic cough, and stridor (12%). Eight patients (2%) had cystic fibrosis. The ages ranged from 1 month to 20 years (mean, 19.5 months). Twelve patients had technically inadequate studies and were excluded. Severe reflux was present in 156 patients (31%) and moderate reflux in 159 patients (31%). All patients were treated initially by medical therapy for a minimum of 8 weeks. The majority of patients (81%) had resolution of their symptoms with change in position, thickened feedings, and, when indicated, additional therapy with metoclopramide, cisapride, or domperidone. Most of these patients were found to have a specific position, usually prone, which decreased reflux. The remaining 57 patients had documentation of persistent reflux by pH monitoring and underwent an antireflux procedure. Of those patients undergoing surgery 51 had severe reflux and 6 had moderate reflux. Forty-four patients had a posterior 270 degrees wrap (Toupet), 10 had a 360 degrees wrap (Nissen), and 3 had an anterior 180 degrees wrap (Boix-Ochoa).(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of respiratory complications from gastroesophageal reflux to prematurity in infants

The association between respiratory complications of gastroesophageal reflux (GER) and prematurity in infants has not been described completely. We studied 82 consecutive infants less than 6 months of age with major respiratory symptoms suspected to be caused by GER. Twenty-eight patients had bronchopulmonary dysplasia (BPD). Extended (18 to 24 hours) esophageal pH monitoring was used to document GER with a pH score. Respiratory complications were considered to be caused by GER if a prolonged mean duration of sleep reflux (ZMD) was found. Seventy-five of the 82 (91%) infants had documented GER, but only 45 (55%) had a prolonged ZMD. The incidence of GER was high regardless of the gestational age at birth, postconceptual age at time of study, and the presence of BPD. The incidence of a prolonged ZMD was higher in infants who were 34 to 39 weeks' gestation (10/12, 83%) than in infants who were less than 34 weeks' gestation at birth (15/37, 41%; P = .01). The incidence of a prolonged ZMD was lowest in infants 39 weeks or less postconceptual age at the time of study (4/14, 29%; P = .017). Most infants with BPD did not have a prolonged ZMD (12/28, 43%). However, 11 of the 12 (92%) infants with BPD and a prolonged ZMD showed dramatic improvement after effective antireflux therapy compared with 0 of 16 infants with BPD and normal ZMD (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of pulmonary manifestations of gastroesophageal reflux in children two years of age or less

Apnea and worsening bronchopulmonary dysplasia as well as recurrent aspiration pneumonia have been found to be consequences of gastroesophageal reflux in infants and young children. Antireflux procedures are effective in preventing gastroesophageal reflux; however, the effect of this operation on the course of these respiratory problems in very young patients is not known. We reviewed the results in 51 patients 2 years of age or less who underwent an antireflux fundoplication for pulmonary problems attributable to severe gastroesophageal reflux unresponsive to medical treatment. Twenty-eight patients had recurrent episodes of aspiration pneumonia, 14 had nonimproving or worsening bronchopulmonary dysplasia, and 9 had unexplained apneic episodes. Seventy-three percent of these patients had coexisting congenital anomalies or acquired problems. No operative deaths and no major surgical complications occurred. There were eight late deaths occurring between 1 and 25 months postoperatively: three were due to associated congenital anomalies or acquired problems, three to sepsis, and two to sudden infant death syndrome. Of the 43 surviving children, 91 percent with preoperative recurrent aspiration pneumonia had no additional episodes after Nissen procedure. Eighty-eight percent of the infants with unexplained apneic episodes showed marked benefit and 83 percent of those with bronchopulmonary dysplasia had clinical improvement. There were no late problems attributed to the operation even when it was performed in preterm infants. Therefore, we recommend fundoplication for patients 2 years of age or less who have a persistent pulmonary problem attributed to gastroesophageal reflux that does not respond to medical therapy.

Gastroesophageal reflux, fundoplication, and dumping: literature review and case study

This article describes a very uncommon phenomenon that can result from surgery to correct gastroesophageal reflux (GER). Although, GER is a common illness in infants, the methods of management and nursing care are diverse. Review of the literature on GER and dumping are discussed and a case study of a girl with dumping following a fundoplication is presented.

Gastroesophageal reflux and unexplained chronic respiratory disease in infants and children

Thirty-eight children, aged from a few weeks to 7 years, with severe chronic pulmonary disease and without gastrointestinal symptoms, were investigated for gastroesophageal reflux (GER), using prolonged pH probe monitoring and gastroesophageal scintiscanning. All treatments were discontinued before testing. GER was found in 24 patients (63%) (group I) and it was not observed in 14 patients (group II). All patients of group I received antireflux treatment, consisting of cisapride; in 22 of 24 patients, GER was controlled, as indicated by improvement of either pH monitoring or scintiscanning, or both. Eighteen of these 22 (82%) had remission of their pulmonary disease, and only two patients of group II (14%) had spontaneous remission of the respiratory symptoms. We concluded that GER was probably the cause of the respiratory disease in 63% of our patients, since treatment of GER was followed by disappearance of the respiratory complaints in most of them. The combination of gastroesophageal scintiscanning and pH probe study improved the diagnostic accuracy.

Association of lipid-laden alveolar macrophages and gastroesophageal reflux in children

The association of lipid-laden alveolar macrophages (LLAM) and gastroesophageal reflux (GER) was investigated prospectively in 115 patients in two groups. Group 1 included 74 children with chronic respiratory tract disorders and documented GER by prolonged esophageal pH monitoring, barium esophagram, and esophagoscopy; group 2 included 41 children with chronic respiratory tract disorders without GER. LLAM were present in 63 (85%) and eight (19%) children from groups 1 and 2, respectively (P less than 0.0001). Thus a strong association between the presence of LLAM and GER in children with chronic respiratory tract disorders was established. We suggest that LLAM from bronchial lavage may be a useful marker for tracheal aspiration in children with GER in whom chronic lung disease may subsequently develop.

Complications and reoperation after Nissen fundoplication in childhood

Over a 10 year period, 429 Nissen fundoplications were performed on children with gastroesophageal reflux. Postoperative complications occurred in 69 children (16 percent), including wrap herniation or breakdown in 29; postoperative bowel obstruction in 18; stricture in 10; intraabdominal abscess and enterocutaneous fistula in 3 patients each; and wound infection, wound dehiscence, and inadvertent splenectomy in 2 patients each. The postoperative mortality rate was 0.9 percent (4 of 429 patients) and was related to sepsis in 1 patient, a metabolic disorder in 1 patient, and underlying pulmonary disease in 2 patients. All four patients were neurologically impaired. Fundoplication successfully controlled symptoms of gastroesophageal reflux in 395 children (92 percent) over a follow-up period ranging from 6 months to 10 years. Thirty-eight patients (8.8 percent) required a second antireflux operation because of recurrent symptoms. Twenty-nine patients had severe neurologic impairment (76 percent), 5 had associated congenital malformations (13 percent), and 3 had significant pulmonary problems (8 percent). Only one child requiring reoperation was considered otherwise normal. Indications for reoperation included wrap breakdown or herniation (28 patients), stricture (6 patients), and inadequate wrap (4 patients). Twenty-four of 28 children with wrap herniation or breakdown had neurologic impairment. A second fundoplication was successful in 35 of 38 patients (92 percent). A second procedure failed in three children, who required subsequent resection and colon interposition.

Prevalence and treatment of silent gastro-oesophageal reflux in children with recurrent respiratory disorders

Thirty-six infants and children presenting with recurrent respiratory disorders (RRD) as the sole clinical symptom including bronchial asthma (6), recurrent obstructive bronchitis with or without wheezing (18), chronic nocturnal cough (3), recurrent episodes of pneumonia (3), recurrent pharyngitis (3) and recurrent laryngitis (3) were investigated for associated gastro-oesophageal reflux (GER) by oesophagram, endoscopy and continuous 24 h pH monitoring of the distal oesophagus. The pH monitoring criteria were selected on the basis of a preliminary study comparing statistically measurements of 32 variables recorded in 15 patients who all had clinical, radiological and endoscopic evidence of GER and in 8 asymptomatic controls. Although patients with symptomatic GER differed significantly from the asymptomatic ones for 27 variables examined, 6 variables emerged as having the highest value for discrimination (overlap score 0-1). Among these, the Euler-Byrne index (number of reflux pH less than 4 + 4 times the number of reflux episodes of more than 5 min), the percentage of total reflux time and the number of reflux episodes 1 h post-cibal scored 0 (no overlap). GER was considered to be present when at least five of these six parameters were abnormal. The overall incidence of GER in children with RRD was 41% (15) when detected by oesophagram and 61% (22) when diagnosed by pH monitoring criteria. In the children with bronchial asthma or with recurrent laryngitis, the percentage of reflux time during sleep was about 40 times higher than in asymptomatic controls and 2 times higher than in those with symptomatic GER.(ABSTRACT TRUNCATED AT 250 WORDS)

The surgical management of children with familial dysautonomia

Familial dysautonomia (FD) is a rare incurable genetic disorder with multisystem involvement. Most of its clinical manifestations are related to disorders of the autonomic nervous system. The disease is associated with specific disturbances of the upper gastrointestinal tract: pharyngoesophageal dyskinesia, gastroesophageal reflux, and prolonged gastric emptying. About 40% of the dysautonomic children manifest repeat vomiting crises. In view of the extensive gastrointestinal symptomatology, children with FD are prone to repeated aspiration pneumonia and chronic respiratory failure, while inadequate calory and fluid intake may lead to a chronic state of hypovolemia and severe failure to thrive. Control of vomiting, prevention of aspiration due to abnormal swallowing, and the assurance of adequate calory intake are three major objectives in the treatment of the dysautonomic child. Medical treatment of the gastrointestinal disorders using different drugs has had limited success. This study reviews the surgical experience in ten children with FD. The type of the procedure used was determined by the severity of the upper GI disturbances. Nine children underwent gastroesophageal Nissen fundoplication and gastrostomy. In seven of them, a pyloroplasty was added. Gastrostomy alone was done in one patient only. Postoperative complications included transient dysphagia in four patients, gastric dilatation in four patients, and dumping syndrome in one. There has been no incidence of immediate postoperative death. One child died 6 months after operation from severe and irreversible respiratory failure. Following operation, the patients still suffered from dysautonomic crises but these were not associated with vomiting.(ABSTRACT TRUNCATED AT 250 WORDS)

The significance of fat-filled macrophages in the diagnosis of aspiration associated with gastro-oesophageal reflux

Tracheal aspirates from 46 children were examined for the presence of fat-filled macrophages. They had no history suggestive of gastro-oesophageal reflux. The number of positive results from this group (46%) was compared with the number of positive results (73%) in a group of 40 children with proven gastro-oesophageal reflux. The difference in proportion of positive results between the two groups was statistically significant (P less than 0.05). In addition, subgroups of subjects, negative for gastro-oesophageal reflux and lower respiratory tract disease, were compared with children who had both conditions. A slightly greater difference, although at a similar level of significance, was found. The fact that 42% of subjects without lower respiratory tract disease or gastro-oesophageal reflux had tracheal aspirates positive for fat-filled macrophages would, however, suggest that this test is of limited clinical value and may need better quantitation before it can be recommended for widespread clinical use.

Chronic bronchopulmonary disease and gastroesophageal reflux in children

Fifty-four children who had chronic bronchopulmonary disease (CBPD) were investigated for the incidence of gastroesophageal reflux (GER). An activity score for CBPD and a numerical reflux score using criteria from a pH probe study were established. Results of barium esophagography, endoscopy, and prolonged esophageal pH probe monitoring were abnormal in 67, 78, and 53% of the patients, respectively. A significant relationship was found between the CBPD activity score and the reflux score; this strongly suggests that, in the patients studied, GER was responsible for the bronchopulmonary symptoms. Antireflux therapy resulted in an improvement of the CBPD activity score in all patients who had abnormal reflux scores. The mean CBPD activity score was 4.4 and 1.3 before and after antireflux therapy, respectively (P less than 0.01). Most patients who had normal reflux scores did not improve on antireflux therapy.

Gastroesophageal reflux in the infant with cystic fibrosis

The association of gastroesophageal reflux and its sequelae in the infant with cystic fibrosis has gone virtually unnoticed. Eight of 40 newly diagnosed infants with cystic fibrosis seen over a 24 month period had significant gastroesophageal reflux, characterized by vomiting (7 infants), recurrent pneumonia (7 infants), and failure to thrive (4 infants). Gastroesophageal reflux was demonstrated by a combination of barium swallow, scintiscan, manometry, and esophagoscopy. Three infants had rapid and permanent alleviation of symptoms after standard medical therapy; in five infants, therapy failed and they required a Nissen fundoplication. Three infants required postoperative ventilatory support for 1, 2, and 5 days. No tracheostomies were required. Postoperative hospital stay averaged 12 days (range 5 to 30 days). There were no complications or perioperative deaths. All children had complete relief of their preoperative symptoms. The group that required surgery presented earlier (mean 7 weeks of age) to the cystic fibrosis center than either the medically treated group (mean 5 months of age) or the group free of gastroesophageal reflux symptoms (5 1/2 months of age). Also, postoperative hospitalization time markedly decreased from 50 percent of 577 combined patient days preoperatively to 4 percent of 1,639 days postoperatively; this 4 percent then paralleled what was seen in the group without gastroesophageal reflux (3 percent of 19,966 combined patient days) and the group controlled medically (5 percent of 1,897 days). The pulmonary manifestations of cystic fibrosis are extremely variable, and evaluation of the effect that any intervention has on the natural history of the disease is difficult. Nonetheless, we believe that even this small series suggests that gastroesophageal reflux and its complications can significantly alter the courses of some children with cystic fibrosis. Gastroesophageal reflux should be managed as aggressively as it is in any child with reflux, and a successful and safe reduction of symptoms can be expected with intensive management.

Physiology and pathophysiology of the esophagus in childhood

Gastroesophageal reflux (GER) is the most important disorder of the esophagus and the lower esophageal sphincter (LES) in early childhood. Functional disturbances with inadequate relaxation of the LES have to be considered as pathogenetic factors. In the 1st month many newborns have some disorder of motor coordination of the esophagus. After that time, persisting GER may be seen as a delay in maturation, which fades away by the end of the first half year. GER after 6-9 months is to be considered as a definitively pathological condition that will not spontaneously normalize. Nevertheless, it is important to realize that the typical clinical signs of reflux stop generally between the 6th and 12th month, and so simulate healing independent of whether spontaneous maturation occurs or there is continued existence of reflux. Reflux-induced apneic spells are severe complications of this esophageal disorder in the 1st year of life. Esophagitis, usually a late complication, occurs when the aggressive factors win their fight against clearance and mucosal resistance of the esophagus. Brachyesophagus and endobrachyesophagus are severe late complications.

Gastro-oesophageal reflux and respiratory disease: the place of the surgeon

The association between gastro-oesophageal reflux (GER) and respiratory disease is well studied and established. A causal relationship, except in the case of clear cut aspiration, continues to elude proof but is supported by an increasing body of clinical experience. Barium oesophagram is the logical first test to demonstrate reflux, to rule out distal obstruction, and to provide good imaging of the oesophagus. Extended (24 h) oesophageal pH monitoring has proven to be the most reliable test in our hands for the identification of abnormal reflux. The false negative rate with this test was 12%, and false positives were seen only 6% of the time. Radionuclide scintigraphy offers the theoretical possibility for absolute correlation between reflux and aspiration, but in practice the results have been disappointing. Where other treatment measures have failed and where objective tests and clinical evidence point to the probability that respiratory disease is reflux-induced, anti reflux surgery is justified and most often strikingly successful. A Nissen fundoplication with a loose wrap and a short cuff is still the standard treatment for antireflux surgery. Long term follow-up suggests the benefits of antireflux surgery outweigh the occasional complications and side effects where operation is performed to control otherwise intractable reflux-associated symptoms.

Sleep-associated airway problems in children

Several of the most common and most important sleep-associated airway problems are discussed, including obstructive sleep apnea syndrome, gastroesophageal reflux and nocturnal aspiration, spasmodic croup, nocturnal asthma, and sleep hypoxemia in chronic lung disease, and guidelines are offered for the often difficult diagnosis and for treatment.

The Thal fundoplication for gastroesophageal reflux

The technique of anterior fundoplication for gastroesophageal reflux originally described by Alan Thal has been used in our institution in 605 patients. The description of the technique is the purpose of this paper. A brief description of the results in these 605 patients are also presented.

Chronic sclerosing tracheobronchitis

We report a child with wheezing and respiratory distress of 53 months duration which was undiagnosed and unresponsive to treatment. Necropsy examination of trachea and bronchi showed narrowing by chronic inflammation and fibrosis of mucosa and submucosa. Despite intensive investigations, the aetiology and pathogenesis remained undetermined.

Gastroesophageal reflux in association with congenital heart disease

The clinical course of 19 infants with severe respiratory symptoms associated with the presence of both congenital heart disease and gastroesophageal reflux is described. Down Syndrome or central nervous system disease was present in 12 of the 19 infants. The identification of reflux as a major or additional cause of the respiratory complications was often overlooked. Medical therapy alone was successful in only one of the 19 patients. Early repair or palliation of the cardiac malformation with or without subsequent antireflux surgical procedure was associated with relief of the symptoms in 13 patients.

Gastroesophageal reflux during sleep in asthmatic patients

To determine what relationship might exist between gastroesophageal reflux and nocturnal asthma, we studied nine patients with asthma and seven control subjects overnight in the sleep laboratory, monitoring sleep state, esophageal pH, tidal volume (including the relative contribution of rib cage and abdomen), and oxygen saturation. There were 15 episodes of gastroesophageal reflux, in three patients with asthma and four control subjects. There were no significant differences between the two groups in the number of reflux episodes, duration of the longest episode, and the percentage of reflux time. Thirteen of the 15 episodes occurred during the awake state or after movement arousal. None of the episodes caused coughing, wheezing, or changes in oxygen saturation in any of the subjects. These patients with chronic asthma did not have an increased incidence of gastroesophageal reflux at night, and reflux did not play any role in the production of their nighttime symptoms.

Gastroesophageal fundoplication and gastrostomy in familial dysautonomia

Gastric and esophageal dysfunction are components of familial dysautonomia. The limited success of various medical management programs, has led to two types of surgical intervention. Experience with nine patients who had gastrostomy alone and 12 patients who had gastroesophageal fundoplication is reviewed. Both surgical procedures decreased frequency of vomiting and pneumonias and had positive effects on weight gain. Although "dysautonomic crises" are not eliminated, sufficient modification in character occurs so that associated risks are lessened. It is suggested that if medical management cannot control recurrent pneumonia, postprandial vomiting, esophageal bleeding, and/or inadequate weight gain, then the patient should be evaluated for fundoplication and/or gastrostomy.