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Tighe MP, Andrews E, Liddicoat I, Afzal NA, Hayen A, Beattie RM. Pharmacological treatment of gastro-oesophageal reflux in children. Cochrane Database Syst Rev 2023; 8:CD008550. [PMID: 37635269 PMCID: PMC10443045 DOI: 10.1002/14651858.cd008550.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is characterised by the regurgitation of gastric contents into the oesophagus. GOR is a common presentation in infancy, both in primary and secondary care, affecting approximately 50% of infants under three months old. The natural history of GOR in infancy is generally of a self-limiting condition that improves with age, but older children and children with co-existing medical conditions can have more protracted symptoms. The distinction between gastro-oesophageal reflux disease (GORD) and GOR is debated. Current National Institute of Health and Care Excellence (NICE) guidelines define GORD as GOR causing symptoms severe enough to merit treatment. This is an update of a review first published in 2014. OBJECTIVES To assess the effects of pharmacological treatments for GOR in infants and children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and Web of Science up to 17 September 2022. We also searched for ongoing trials in clinical trials registries, contacted experts in the field, and searched the reference lists of trials and reviews for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any currently-available pharmacological treatment for GOR in children with placebo or another medication. We excluded studies assessing dietary management of GORD and studies of thickened feeds. We included studies in infants and children up to 16 years old. DATA COLLECTION AND ANALYSIS We used standard methodology expected by Cochrane. MAIN RESULTS We included 36 RCTs involving 2251 children and infants. We were able to extract summary data from 14 RCTs; the remaining trials had insufficient data for extraction. We were unable to pool results in a meta-analysis due to methodological differences in the included studies (including heterogeneous outcomes, study populations, and study design). We present the results in two groups by age: infants up to 12 months old, and children aged 12 months to 16 years old. Infants Omeprazole versus placebo: there is no clear effect on symptoms from omeprazole. One study (30 infants; very low-certainty evidence) showed cry/fuss time in infants aged three to 12 months had altered from 246 ± 105 minutes/day at baseline (mean +/- standard deviation (SD)) to 191 ± 120 minutes/day in the omeprazole group and from 287 ± 132 minutes/day to 201 ± 100 minutes/day in the placebo group (mean difference (MD) 10 minutes/day lower (95% confidence interval (CI) -89.1 to 69.1)). The reflux index changed in the omeprazole group from 9.9 ± 5.8% in 24 hours to 1.0 ± 1.3% and in the placebo group from 7.2 ± 6.0% to 5.3 ± 4.9% in 24 hours (MD 7% lower, 95% CI -4.7 to -9.3). Omeprazole versus ranitidine: one study (76 infants; very low-certainty evidence) showed omeprazole may or may not provide symptomatic benefit equivalent to ranitidine. Symptom scores in the omeprazole group changed from 51.9 ± 5.4 to 2.4 ± 1.2, and in the ranitidine group from 47 ± 5.6 to 2.5 ± 0.6 after two weeks: MD -4.97 (95% CI -7.33 to -2.61). Esomeprazole versus placebo: esomeprazole appeared to show no additional reduction in the number of GORD symptoms compared to placebo (1 study, 52 neonates; very low-certainty evidence): both the esomeprazole group (184.7 ± 78.5 to 156.7 ± 75.1) and placebo group (183.1 ± 77.5 to 158.3 ± 75.9) improved: MD -3.2 (95% CI -4.6 to -1.8). Children Proton pump inhibitors (PPIs) at different doses may provide little to no symptomatic and endoscopic benefit. Rabeprazole given at different doses (0.5 mg/kg and 1 mg/kg) may provide similar symptom improvement (127 children in total; very low-certainty evidence). In the lower-dose group (0.5 mg/kg), symptom scores improved in both a low-weight group of children (< 15 kg) (mean -10.6 ± SD 11.13) and a high-weight group of children (> 15 kg) (mean -13.6 ± 13.1). In the higher-dose groups (1 mg/kg), scores improved in the low-weight (-9 ± 11.2) and higher-weight groups (-8.3 ± 9.2). For the higher-weight group, symptom score mean difference between the two different dosing regimens was 2.3 (95% CI -2 to 6.6), and for the lower-weight group, symptom score MD was 4.6 (95% CI -2.9 to 12). Pantoprazole: pantoprazole may or may not improve symptom scores at 0.3 mg/kg, 0.6 mg/kg, and 1.2 mg/kg pantoprazole in children aged one to five years by week eight, with no difference between 0.3 mg/kg and 1.2 mg/kg dosing (0.3 mg/kg mean -2.4 ± 1.7; 1.2 mg/kg -1.7 ± 1.2: MD 0.7 (95% CI -0.4 to 1.8)) (one study, 60 children; very low-certainty evidence). There were insufficient summary data to assess other medications. AUTHORS' CONCLUSIONS There is very low-certainty evidence about symptom improvements and changes in pH indices for infants. There are no summary data for endoscopic changes. Medications may or may not provide a benefit (based on very low-certainty evidence) for infants whose symptoms remain bothersome, despite nonmedical interventions or parental reassurance. If a medication is required, there is no clear evidence based on summary data for omeprazole, esomeprazole (in neonates), H₂antagonists, and alginates for symptom improvements (very low-certainty evidence). Further studies with longer follow-up are needed. In older children with GORD, in studies with summary data extracted, there is very low-certainty evidence that PPIs (rabeprazole and pantoprazole) may or may not improve GORD outcomes. No robust data exist for other medications. Further RCT evidence is required in all areas, including subgroups (preterm babies and children with neurodisabilities).
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Affiliation(s)
- Mark P Tighe
- Department of Paediatrics, University Hospitals Dorset, Poole, UK
| | - Edward Andrews
- Department of Paediatrics, University Hospitals Dorset, Poole, UK
| | - Iona Liddicoat
- Department of Paediatrics, University Hospitals Dorset, Poole, UK
| | - Nadeem A Afzal
- Faculty of Science & Health, Portsmouth University, Portsmouth, UK
| | - Andrew Hayen
- Australian Centre for Public and Population Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - R Mark Beattie
- Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Cullis PS, Buckle RE, Losty PD. Is Roux-en-Y Feeding Jejunostomy a Safe and Effective Operation in Children? A Systematic Review Exploring Outcomes. J Pediatr Gastroenterol Nutr 2022; 74:e74-e82. [PMID: 34908017 DOI: 10.1097/mpg.0000000000003373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Roux-en-Y jejunostomy (REYJ) may establish feeding in children with foregut dysmotility or severe gastro-esophageal reflux disease (GERD). Nevertheless, concerns have been raised about safety and efficacy. We, therefore, evaluated outcomes of REYJ by systematic review to determine if this was a satisfactory option for achieving enteral autonomy in children with complex nutritional needs. METHODS A PRISMA-adherent systematic review was conducted of studies reporting children undergoing feeding REYJ. Two authors performed processes independently; the senior author resolved disagreements. Embase, CINAHL and Medline were searched (inception-01/21). Additional databases, references, and 'grey' literature were searched. Methodological Index for Non-randomized Studies (MINORS) and a bespoke system assessed methodological quality. RESULTS Of 362 articles, 10 met eligibility criteria (9 retrospective series; 1 conference proceeding). Unpublished data were also attained. Interobserver agreement for MINORS (kappa = 0.47) and bespoke scoring (kappa = 0.58) were moderate. After consensus, median MINORS score was 37.5% (IQR 6.3%) and bespoke 50% (IQR 20.8%), indicating poor methodological quality. One hundred sixty-four patients were reported (age range: 2 months to 19 years). Time to full feeds and length of stay were inadequately reported but most achieved enteral autonomy. No studies reported patient/caregiver-questionnaires. Seventy-six complications were documented (Clavien-Dindo grading was infeasible). Morbidity included peristomal leakage (N = 26), internal hernia/volvulus (N = 8), and SSI (N = 7). Thirty-eight patients died (2 procedure-attributable) during follow-up (range: 1 month to 15 years). CONCLUSIONS Up to 50% patients experience complications after REYJ (often minor) with 23% patients dying during follow-up, often comorbidity-attributable. REYJ can achieve enteral autonomy although parents/caregivers of children should be counselled accordingly.
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Affiliation(s)
- Paul S Cullis
- Department of Surgical Paediatrics, Royal Hospital for Children and Young People, Edinburgh
- School of Medicine, University of Glasgow
| | - Rheanan E Buckle
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow
| | - Paul D Losty
- Academic Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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Dreznik Y, Baazov A, Dvir N, Seguier-Lipszyc E, Zevit N, Nica A, Samuk I, Shamir R, Dlugi E, Freud E, Kravarusic D. Is fundoplication mandatory in children with neurological impairment undergoing gastrostomy? J Paediatr Child Health 2022; 58:588-592. [PMID: 34632661 DOI: 10.1111/jpc.15767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 11/29/2022]
Abstract
AIM Percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG) are common procedures in children with neurological impairment (NI) with swallowing difficulties. Pulmonary aspirations are a major concern and performing concomitant or delayed fundoplication is still controversial, especially among these patients. The aim of our study was to review our experience with fundoplication performed concomitantly with gastrostomy or later and to evaluate patient outcomes. METHODS This is a retrospective, cohort study including all paediatric patients who underwent SG or PEG with or without Nissen fundoplication at Schneider Children's Medical Center of Israel between the years 2007 and 2018. Patients' clinical and surgical data were recorded and analysed. RESULTS Between 2007 and 2018, 345 patients underwent SG or PEG. Of these, 89 patients underwent fundoplication. Of the patients who underwent PEG/SG, 158 (45.8%) were neurologically impaired. Most of the patients who underwent fundoplication (n = 69, 77.5%) were NI patients (P = 0.0001). NI patients with refractory seizures showed almost no improvement in terms of relief of gastro-oesophageal reflux disease symptoms following fundoplication (P = 0.0001) compared to NI patients without refractory seizures. CONCLUSION Our findings suggest that in NI patients a concomitant fundoplication is not mandatory and is not efficacious in preventing gastro-oesophageal reflux disease in patients with refractory seizures.
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Affiliation(s)
- Yael Dreznik
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Artur Baazov
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Dvir
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Emmanuelle Seguier-Lipszyc
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Noam Zevit
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel
| | - Adrianna Nica
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Inbal Samuk
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Shamir
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel
| | - Elena Dlugi
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Enrique Freud
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dragan Kravarusic
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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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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5
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Maassel NL, Shaughnessy MP, Solomon DG, Cowles RA. Trends in fundoplication volume for pediatric gastroesophageal reflux disease. J Pediatr Surg 2021; 56:1495-1499. [PMID: 33745746 DOI: 10.1016/j.jpedsurg.2021.02.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Fundoplication for gastro-esophageal reflux disease (GERD) has been commonly performed by pediatric surgeons, however there are no recent data documenting fundoplication trends. Changes in fundoplication volume impact pediatric surgical training and may reflect changes in care for children with severe GERD. MATERIALS & METHODS The Pediatric Health Information System (PHIS) was queried from 2010-2019 for children with ICD-9/ICD-10 codes for GERD, fundoplication, and gastrostomy. Institutional surgical volume and patient demographics were examined over time. A secondary analysis using the Accreditation Council for Graduate Medical Education case logs for pediatric surgery fellows was performed across the same years to assess effects upon surgical volume for trainees. RESULTS Mean institutional fundoplication case volume decreased from 50 in 2010 to 17 in 2019. Trends were similar between institutions with and without fellowship programs when corrected by total operative volume. Patient characteristics were relatively unchanged between 2010 and 2019. Fundoplication volume reported in fellow case logs decreased from 46 in 2010 to 26 in 2019, mirroring national data. CONCLUSIONS Institutional volume for fundoplication in children with GERD has seen a 3-fold decrease over the last decade, mirrored by an almost 2-fold decrease in case volume reported by pediatric surgery fellows.
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Affiliation(s)
- Nathan L Maassel
- Yale University School of Medicine, Department of Surgery, Division of Pediatric Surgery, New Haven, CT, USA
| | - Matthew P Shaughnessy
- Yale University School of Medicine, Department of Surgery, Division of Pediatric Surgery, New Haven, CT, USA
| | - Daniel G Solomon
- Yale University School of Medicine, Department of Surgery, Division of Pediatric Surgery, New Haven, CT, USA
| | - Robert A Cowles
- Yale University School of Medicine, Department of Surgery, Division of Pediatric Surgery, New Haven, CT, USA.
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Optimal management of gastrojejunal tube in the ENFit era - Interventions that changed practice. J Pediatr Surg 2021; 56:1430-1435. [PMID: 32921428 DOI: 10.1016/j.jpedsurg.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND We experienced a high incidence of jejunal tube (JEJ) displacement in children who underwent percutaneous endoscopic transgastric jejunostomy (PEGJ), ever since the introduction of ENFit connector (2017). METHODS Two interventions were introduced in 2018 - fixative suture to PEGJ ENFit connector, and conversion to balloon transgastric-jejunal feeding device (Balloon GJ) whenever possible. Children receiving PEGJ and Balloon GJ in 2.8 years were categorized into 3 eras: 2016 (pre-ENFit), 2017 (ENFit) and 2018 (interventional), for comparison of complications and sequelae. Kaplan-Meier survival curves with log-rank test (P < 0.05) were applied. RESULTS 100 children underwent 323 JEJ insertions - PEGJ (n = 237), Balloon GJ (n = 86). Complications occurred in 188 JEJs (58%), more frequently with PEGJ than Balloon GJ (69% vs. 29%, P < 0.0005). PEGJ had higher complication/1000-tube-days (6 vs. 0, P < 0.0005). In 2018, complication rate reduced from 76% to 30% (P < 0.0005) owing to effectiveness of PEGJ connector suture application (P = 0.019), and increased utilization of Balloon GJ (16% to 44%, P = 0.005). Balloon GJ showed better JEJ survival (P = 0.019), less morbidity (emergency attendance, X-ray) and greater cost-effectiveness than PEGJ. CONCLUSIONS Balloon GJ had better overall outcomes than PEGJ. Suture application to connector successfully reduced JEJ internal displacement in PEGJ; however, conversion to Balloon GJ should be strongly considered. LEVEL OF EVIDENCE II.
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7
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Prokinetics in Childhood Gastroesophageal Reflux Disease: Are They Indicated? J Pediatr Gastroenterol Nutr 2021; 72:e162-e163. [PMID: 33605660 DOI: 10.1097/mpg.0000000000003084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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8
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Richards CA. Postfundoplication retching: Strategies for management. J Pediatr Surg 2020; 55:1779-1795. [PMID: 32409173 DOI: 10.1016/j.jpedsurg.2020.03.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right. METHODS A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered. CONCLUSIONS Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future. Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided. LEVEL OF EVIDENCE II-V.
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Affiliation(s)
- Catherine A Richards
- Department of Paediatric Surgery, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
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9
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Cullis PS, Siminas S, Losty PD. Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review. Br J Surg 2020; 107:636-646. [PMID: 32083325 DOI: 10.1002/bjs.11488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/30/2019] [Accepted: 12/02/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antireflux surgery is commonly performed in children, yet evidence for its efficacy is limited. The aim of this review was to determine the effect of antireflux surgery with regard to objective measures of quality of life (QoL) and value of upper gastrointestinal investigations in neurologically normal (NN) and neurologically impaired (NI) children. METHODS A systematic review was conducted of articles reporting children undergoing antireflux surgery in whom preoperative and postoperative objective testing was performed. Primarily, Embase, CINAHL, MEDLINE and PubMed were searched from inception to April 2019. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess article quality. RESULTS Of 789 articles, 14 met the eligibility criteria, 12 prospective observational and 2 retrospective studies. The median MINORS score was 59·4 (i.q.r. 39 to 62·5) per cent. Seven studies reported assessment of validated QoL measures before and after antireflux surgery in 148 children. Follow-up ranged from 1 to 180 months. All studies confirmed significant improvements in QoL measures among NN and NI children at all follow-up points. Eleven studies reported on preoperative and postoperative investigations in between 416 and 440 children children. Follow-up ranged from 0·5 to 180 months. Nine studies confirmed improvements in gastro-oesophageal reflux using 24-h oesophageal pH monitoring with or without manometry, but conflicting results were identified for four studies reporting gastric emptying. No studies reported fluoroscopy or endoscopy adequately. CONCLUSION Based on the results of studies of low-to-moderate quality, antireflux surgery improved QoL and reduced oesophageal acid exposure in NN and NI children in the short and medium term. Although antireflux surgery is a common elective operation, the lack of rigorous preoperative and postoperative evaluation(s) in the majority of patient-reported studies is striking.
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Affiliation(s)
- P S Cullis
- Department of Paediatric Surgery, Royal Hospital for Sick Children Edinburgh, Edinburgh, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - S Siminas
- Department of Paediatric Surgery, Central Manchester Children's Hospital, Manchester, UK
| | - P D Losty
- Institute of Child Health, University of Liverpool, Liverpool, UK.,Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
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Abstract
BACKGROUND Gastro-oesophageal reflux (GER) and gastro-oesophageal reflux disease (GERD) are common in infants and children. AIMS To review the recent literature on GERD in children and to outline the approach to diagnosis and management. METHODS A literature search in PubMed was conducted with regard to the prevalence, clinical features, diagnosis and management of GER and GERD in children with special attention to low- and middle-income countries. Articles in English published during the last 25 years, the full text of which was available, were considered and the relevant information extracted. RESULTS Almost 50% of all healthy infants regurgitate at least once a day which peaks at 4 months of age and subsides by 12 months in 90% of cases. Conversely, the prevalence of GERD increases with age and, by adolescence, is similar to that in adults (20%). While GER in infancy does not require investigation or therapy, an empirical proton pump inhibitor (PPI) for 4-8 weeks is justified in older children with classical symptoms of GERD. There is no gold-standard investigation for GERD. In extra-oesophageal manifestations, a pH/impedance is useful and endoscopy in cases with oesophagitis. PPIs play a pivotal role in the management of GERD but have not been found useful in infants with GER. Anti-reflux surgery plays a minor role in GERD owing to the associated morbidity and high failure rate, especially in high-risk groups who most need it. CONCLUSIONS Unless there are warning features such as failure to thrive, haematemesis, abnormal posturing, choking/gagging or coughing while feeding, regurgitation in infancy need not be investigated. In older children and adolescents with typical reflux symptoms, empirical PPI therapy is justified. For extra-oesophageal manifestations, a pH/impedance study and endoscopy to detect oesophagitis are the investigations of choice. PPI is the mainstay of therapy in GERD, but not in GER.
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Affiliation(s)
- Ujjal Poddar
- a Department of Paediatric Gastroenterology , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
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Chiang J, Amin R. Respiratory Care Considerations for Children with Medical Complexity. CHILDREN-BASEL 2017; 4:children4050041. [PMID: 28534851 PMCID: PMC5447999 DOI: 10.3390/children4050041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/08/2017] [Accepted: 05/16/2017] [Indexed: 12/13/2022]
Abstract
Children with medical complexity (CMC) are a growing population of diagnostically heterogeneous children characterized by chronic conditions affecting multiple organ systems, the use of medical technology at home as well as intensive healthcare service utilization. Many of these children will experience either a respiratory-related complication and/or they will become established on respiratory technology at home during their care trajectory. Therefore, healthcare providers need to be familiar with the respiratory related complications commonly experienced by CMC as well as the indications, technical and safety considerations and potential complications that may arise when caring for CMC using respiratory technology at home. This review will outline the most common respiratory disease manifestations experienced by CMC, and discuss various respiratory-related treatment options that can be considered, including tracheostomy, invasive and non-invasive ventilation, as well as airway clearance techniques. The caregiver requirements associated with caring for CMC using respiratory technology at home will also be reviewed.
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Affiliation(s)
- Jackie Chiang
- Holland Bloorview Kids Rehabilitation Hospital, The University of Toronto, Toronto, ON M4G 1R8, Canada.
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, ON M5G 1X8, Canada.
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Tanaka A, Shimono R, Kubo H, Fujii T, Miyatake N. Evaluation of antireflux surgery using multichannel intraluminal impedance-pH measurement in neurologically impaired patients. Pediatr Surg Int 2015; 31:911-6. [PMID: 26285892 DOI: 10.1007/s00383-015-3768-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to evaluate esophageal function before and after antireflux surgery (ARS) in neurologically impaired (NI) patients using 24 h multichannel intraluminal impedance (MII)-pH measurement. METHODS Seven NI patients (age, 0-33 years; median, 13 years) were assessed before and after ARS using 24 h MII-pH. We described reflux parameters such as pH reflux index, bolus exposure index, number of acidic and nonacidic reflux episodes, mean acid clearance time and median bolus clearance time, and esophageal motility parameters in dry swallows such as bolus presence time (BPT), total bolus transit time (TBTT), and total propagation velocity (TPV). RESULTS The postoperative reflux parameters such as pH reflux index, acid clearance time, bolus exposure index, and the number of acidic reflux episodes significantly decreased (P < 0.05) compared with the preoperative ones. The esophageal motility parameters including all sites of BPTs, TBTT, and TPV did not change in the MII-pH measurement after ARS (P = non-significant). CONCLUSION ARS effectively reduced gastro-esophageal reflux (GER) in NI patients without the impairment of esophageal motility by MII-pH measurement. MII-pH was useful to detect the subtype of GER before and after ARS and appeared to be appropriate for evaluating esophageal motility.
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Affiliation(s)
- Aya Tanaka
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Ryuichi Shimono
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.
| | - Hiroyuki Kubo
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Takayuki Fujii
- Department of Pediatric Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Nobuyuki Miyatake
- Department of Hygiene, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
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Routine versus selective contrast imaging to identify the need for early re-intervention following laparoscopic fundoplication: A retrospective cohort study. Int J Surg 2015; 20:123-7. [PMID: 26118598 DOI: 10.1016/j.ijsu.2015.06.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 06/10/2015] [Accepted: 06/18/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND The prompt recognition of complications is essential in reducing morbidity following anti-reflux surgery. Consequently, many centres employ a policy of routine post-operative contrast studies. The study aimed to examine whether routine contrast studies more effectively recognised early post-operative complications following anti-reflux surgery compared with selective use. METHODS This was a retrospective analysis of 240 adults who had undergone primary anti-reflux surgery. Selective use of water-soluble contrast swallows was employed for 115 patients (Group 1) while 125 patients (Group 2) had routine studies. RESULTS 10 (0.9%) patients from Group 1 underwent contrast studies, four (40%) of which were abnormal. Routine studies in Group 2 identified thirty-two abnormalities (27%) however the inter-group difference was not significant (p = 0.32). Only one case from group 2 required immediate re-intervention. This was not statistically significant (p = 0.78). Multivariate analysis found no significant association between selective or routine imaging and re-intervention rates. One patient from group 2 presented three days following discharge with wrap migration requiring reoperation despite a normal post-operative study. CONCLUSION Routine use of contrast imaging following anti-reflux and hiatus hernia surgery is not necessary. It does not identify a significantly greater number of post-operative complications in comparison to selective use. Additionally, routine use of contrast studies does not ensure the diagnosis of all complications in the post-operative period.
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Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Pharmacological treatment of children with gastro-oesophageal reflux. Cochrane Database Syst Rev 2014; 2014:CD008550. [PMID: 25419906 PMCID: PMC8947620 DOI: 10.1002/14651858.cd008550.pub2] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is a common disorder, characterised by regurgitation of gastric contents into the oesophagus. GOR is a very common presentation in infancy in both primary and secondary care settings. GOR can affect approximately 50% of infants younger than three months old (Nelson 1997). The natural history of GOR in infancy is generally that of a functional, self-limiting condition that improves with age; < 5% of children with vomiting or regurgitation continue to have symptoms after infancy (Martin 2002). Older children and children with co-existing medical conditions can have a more protracted course. The definition of gastro-oesophageal reflux disease (GORD) and its precise distinction from GOR are debated, but consensus guidelines from the North American Society of Gastroenterology, Hepatology and Nutrition (NASPGHAN-ESPGHAN guidelines 2009) define GORD as 'troublesome symptoms or complications of GOR.' OBJECTIVES This Cochrane review aims to provide a robust analysis of currently available pharmacological interventions used to treat children with GOR by assessing all outcomes indicating benefit or harm. SEARCH METHODS We sought to identify relevant published trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5), MEDLINE and EMBASE (1966 to 2014), the Centralised Information Service for Complementary Medicine (CISCOM), the Institute for Scientific Information (ISI) Science Citation Index (on BIDS-UK General Science Index) and the ISI Web of Science. We also searched for ongoing trials in the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com).Reference lists from trials selected by electronic searching were handsearched for relevant paediatric studies on medical treatment of children with gastro-oesophageal reflux, as were published abstracts from conference proceedings (published in Gut and Gastroenterology) and reviews published over the past five years.No language restrictions were applied. SELECTION CRITERIA Abstracts were reviewed by two review authors, and relevant RCTs on study participants (birth to 16 years) with GOR receiving a pharmacological treatment were selected. Subgroup analysis was considered for children up to 12 months of age, and for children 12 months to 16 years of age, and for those with neurological impairment. DATA COLLECTION AND ANALYSIS Trials were critically appraised and data collected by two review authors. Risk of bias was assessed. Meta-analysis data were independently extracted by two review authors, and suitable outcome data were analysed using RevMan. MAIN RESULTS A total of 24 studies (1201 participants) contributed data to the review. The review authors had several concerns regarding the studies. Pharmaceutical company support for manuscript preparation was a common feature; also, because common endpoints were lacking, study populations were heterogenous and variations in study design were noted, individual drug meta-analysis was not possible.Moderate-quality evidence from individual studies suggests that proton pump inhibitors (PPIs) can reduce GOR symptoms in children with confirmed erosive oesophagitis. It was not possible to demonstrate statistical superiority of one PPI agent over another.Some evidence indicates that H₂antagonists are effective in treating children with GORD. Methodological differences precluded performance of meta-analysis on individual agents or on these agents as a class, in comparison with placebo or head-to-head versus PPIs, and additional studies are required.RCT evidence is insufficient to permit assessment of the efficacy of prokinetics. Given the diversity of study designs and the heterogeneity of outcomes, it was not possible to perform a meta-analysis of the efficacy of domperidone.In younger children, the largest RCT of 80 children (one to 18 months of age) with GOR showed no evidence of improvement in symptoms and 24-hour pH probe, but improvement in symptoms and reflux index was noted in a subgroup treated with domperidone and co-magaldrox(Maalox(®) ). In another RCT of 17 children, after eight weeks of therapy. 33% of participants treated with domperidone noted an improvement in symptoms (P value was not significant). In neonates, the evidence is even weaker; one RCT of 26 neonates treated with domperidone over 24 hours showed that although reflux frequency was significantly increased, reflux duration was significantly improved.Diversity of RCT evidence was found regarding efficacy of compound alginate preparations(Gaviscon Infant(®) ) in infants, although as a result of these studies, Gaviscon Infant(®) was changed to become aluminium-free and has been assessed in its current form in only two studies since 1999. Given the diversity of study designs and the heterogeneity of outcomes, as well as the evolution in formulation, it was not possible to perform a meta-analysis on the efficacy of Gaviscon Infant(®) . Moderate evidence indicates that Gaviscon Infant(®) improves symptoms in infants, including those with functional reflux; the largest study of the current formulation showed improvement in symptom control but was limited by length of follow-up.No serious side effects were reported.No RCTs on pharmacological treatments for children with neurodisability were identified. AUTHORS' CONCLUSIONS Moderate evidence was found to support the use of PPIs, along with some evidence to support the use of H₂ antagonists in older children with GORD, based on improvement in symptom scores, pH indices and endoscopic/histological appearances. However, lack of independent placebo-controlled and head-to-head trials makes conclusions as to relative efficacy difficult to determine. Further RCTs are recommended. No robust RCT evidence is available to support the use of domperidone, and further studies on prokinetics are recommended, including assessments of erythromycin.Pharmacological treatment of infants with reflux symptoms is problematic, as many infants have GOR, and little correlation has been noted between reported symptoms and endoscopic and pH findings. Better evidence has been found to support the use of PPIs in infants with GORD, but heterogeneity in outcomes and in study design impairs interpretation of placebo-controlled data regarding efficacy. Some evidence is available to support the use of Gaviscon Infant(®) , but further studies with longer follow-up times are recommended. Studies of omeprazole and lansoprazole in infants with functional GOR have demonstrated variable benefit, probably because of differences in inclusion criteria.No robust RCT evidence has been found regarding treatment of preterm babies with GOR/GORD or children with neurodisabilities. Initiation of RCTs with common endpoints is recommended, given the frequency of treatment and the use of multiple antireflux agents in these children.
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Affiliation(s)
- Mark Tighe
- Poole Hospital NHS Foundation TrustDepartment of PaediatricsLongfleet RoadPooleDorsetUKBH15 2JB
| | - Nadeem A Afzal
- University Hospital Southampton NHS Foundation TrustChild HealthTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation TrustDepartment of PharmacyTremona RoadSouthamptonHampshireUK
| | - Andrew Hayen
- University of TechnologyFaculty of HealthUltimoNSWAustralia2007
| | - Alasdair Munro
- Poole Hospital NHS Foundation TrustDepartment of PaediatricsLongfleet RoadPooleDorsetUKBH15 2JB
| | - R Mark Beattie
- University Hospital Southampton NHS Foundation TrustChild HealthTremona RoadSouthamptonHampshireUKSO16 6YD
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Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Pharmacological treatment of children with gastro-oesophageal reflux. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [PMID: 25419906 DOI: 10.1002/14651858.cd008550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is a common disorder, characterised by regurgitation of gastric contents into the oesophagus. GOR is a very common presentation in infancy in both primary and secondary care settings. GOR can affect approximately 50% of infants younger than three months old (Nelson 1997). The natural history of GOR in infancy is generally that of a functional, self-limiting condition that improves with age; < 5% of children with vomiting or regurgitation continue to have symptoms after infancy (Martin 2002). Older children and children with co-existing medical conditions can have a more protracted course. The definition of gastro-oesophageal reflux disease (GORD) and its precise distinction from GOR are debated, but consensus guidelines from the North American Society of Gastroenterology, Hepatology and Nutrition (NASPGHAN-ESPGHAN guidelines 2009) define GORD as 'troublesome symptoms or complications of GOR.' OBJECTIVES This Cochrane review aims to provide a robust analysis of currently available pharmacological interventions used to treat children with GOR by assessing all outcomes indicating benefit or harm. SEARCH METHODS We sought to identify relevant published trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5), MEDLINE and EMBASE (1966 to 2014), the Centralised Information Service for Complementary Medicine (CISCOM), the Institute for Scientific Information (ISI) Science Citation Index (on BIDS-UK General Science Index) and the ISI Web of Science. We also searched for ongoing trials in the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com).Reference lists from trials selected by electronic searching were handsearched for relevant paediatric studies on medical treatment of children with gastro-oesophageal reflux, as were published abstracts from conference proceedings (published in Gut and Gastroenterology) and reviews published over the past five years.No language restrictions were applied. SELECTION CRITERIA Abstracts were reviewed by two review authors, and relevant RCTs on study participants (birth to 16 years) with GOR receiving a pharmacological treatment were selected. Subgroup analysis was considered for children up to 12 months of age, and for children 12 months to 16 years of age, and for those with neurological impairment. DATA COLLECTION AND ANALYSIS Trials were critically appraised and data collected by two review authors. Risk of bias was assessed. Meta-analysis data were independently extracted by two review authors, and suitable outcome data were analysed using RevMan. MAIN RESULTS A total of 24 studies (1201 participants) contributed data to the review. The review authors had several concerns regarding the studies. Pharmaceutical company support for manuscript preparation was a common feature; also, because common endpoints were lacking, study populations were heterogenous and variations in study design were noted, individual drug meta-analysis was not possible.Moderate-quality evidence from individual studies suggests that proton pump inhibitors (PPIs) can reduce GOR symptoms in children with confirmed erosive oesophagitis. It was not possible to demonstrate statistical superiority of one PPI agent over another.Some evidence indicates that H₂antagonists are effective in treating children with GORD. Methodological differences precluded performance of meta-analysis on individual agents or on these agents as a class, in comparison with placebo or head-to-head versus PPIs, and additional studies are required.RCT evidence is insufficient to permit assessment of the efficacy of prokinetics. Given the diversity of study designs and the heterogeneity of outcomes, it was not possible to perform a meta-analysis of the efficacy of domperidone.In younger children, the largest RCT of 80 children (one to 18 months of age) with GOR showed no evidence of improvement in symptoms and 24-hour pH probe, but improvement in symptoms and reflux index was noted in a subgroup treated with domperidone and co-magaldrox(Maalox(®) ). In another RCT of 17 children, after eight weeks of therapy. 33% of participants treated with domperidone noted an improvement in symptoms (P value was not significant). In neonates, the evidence is even weaker; one RCT of 26 neonates treated with domperidone over 24 hours showed that although reflux frequency was significantly increased, reflux duration was significantly improved.Diversity of RCT evidence was found regarding efficacy of compound alginate preparations(Gaviscon Infant(®) ) in infants, although as a result of these studies, Gaviscon Infant(®) was changed to become aluminium-free and has been assessed in its current form in only two studies since 1999. Given the diversity of study designs and the heterogeneity of outcomes, as well as the evolution in formulation, it was not possible to perform a meta-analysis on the efficacy of Gaviscon Infant(®) . Moderate evidence indicates that Gaviscon Infant(®) improves symptoms in infants, including those with functional reflux; the largest study of the current formulation showed improvement in symptom control but was limited by length of follow-up.No serious side effects were reported.No RCTs on pharmacological treatments for children with neurodisability were identified. AUTHORS' CONCLUSIONS Moderate evidence was found to support the use of PPIs, along with some evidence to support the use of H₂ antagonists in older children with GORD, based on improvement in symptom scores, pH indices and endoscopic/histological appearances. However, lack of independent placebo-controlled and head-to-head trials makes conclusions as to relative efficacy difficult to determine. Further RCTs are recommended. No robust RCT evidence is available to support the use of domperidone, and further studies on prokinetics are recommended, including assessments of erythromycin.Pharmacological treatment of infants with reflux symptoms is problematic, as many infants have GOR, and little correlation has been noted between reported symptoms and endoscopic and pH findings. Better evidence has been found to support the use of PPIs in infants with GORD, but heterogeneity in outcomes and in study design impairs interpretation of placebo-controlled data regarding efficacy. Some evidence is available to support the use of Gaviscon Infant(®) , but further studies with longer follow-up times are recommended. Studies of omeprazole and lansoprazole in infants with functional GOR have demonstrated variable benefit, probably because of differences in inclusion criteria.No robust RCT evidence has been found regarding treatment of preterm babies with GOR/GORD or children with neurodisabilities. Initiation of RCTs with common endpoints is recommended, given the frequency of treatment and the use of multiple antireflux agents in these children.
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Affiliation(s)
- Mark Tighe
- Department of Paediatrics, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset, UK, BH15 2JB
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Affiliation(s)
- Louise Cremonesini
- Senior Lecturer, Children's Nursing and Health Visiting, University of Northampton; Health Visitor, Cambridgeshire Community Services
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New insights in gastroesophageal reflux, esophageal function and gastric emptying in relation to dysphagia before and after anti-reflux surgery in children. Curr Gastroenterol Rep 2014; 15:351. [PMID: 24014120 DOI: 10.1007/s11894-013-0351-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In children with gastroesophageal reflux (GER) disease refractory to pharmacological therapies, anti-reflux surgery (fundoplication) may be a treatment of last resort. The applicability of fundoplication has been hampered by the inability to predict which patient may benefit from surgery and which patient is likely to develop post-operative dysphagia. pH impedance measurement and conventional manometry are unable to predict dysphagia, while the role of gastric emptying remains poorly understood. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis (AIM) analysis, which relates bolus movement and pressure generation within the esophageal lumen.
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Kelly EA, Parakininkas DE, Werlin SL, Southern JF, Johnston N, Kerschner JE. Prevalence of pediatric aspiration-associated extraesophageal reflux disease. JAMA Otolaryngol Head Neck Surg 2014; 139:996-1001. [PMID: 23989194 DOI: 10.1001/jamaoto.2013.4448] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The role of aspiration-associated extraesophageal reflux disease (AERD) in patients with chronic respiratory symptoms is not well defined. Identifying the frequency of AERD in these patients may provide guidance in their treatment. OBJECTIVE To determine the prevalence of AERD in patients with chronic respiratory symptoms and to assess the utility of pepsin as a new marker for AERD. DESIGN Case-control study performed from 2008 through 2012.Western blot analysis for pepsin and oil red O staining for lipid-laden macrophages (LLMs) was performed on bronchoalveolar lavage fluid specimens. SETTING Tertiary referral center. PARTICIPANTS Sixty-five patients (aged 4.5 months to 24 years) with chronic pulmonary disease, with or without tracheostomy, were compared with controls undergoing elective surgery who had no history of pulmonary disease. MAIN OUTCOMES AND MEASURES Presence of pepsin and LLMs and quantity of LLMs in specimens. RESULTS Seventy-six total patients participated: 34 patients who underwent bronchoscopy, 31 patients with tracheostomy, and 11 controls. Pepsin-positive bronchoalveolar lavage fluid specimens were identified in 25 patients who underwent bronchoscopy (74%) and 22 patients with tracheostomy (71%). All specimens from controls were negative for pepsin. Presence of LLMs was identified in specimens from 31 patients in the bronchoscopy group (91%), 16 patients in the tracheostomy group (52%), and 7 controls (64%), with a similar distribution of the quantity of LLMs in each lavage fluid specimen among the groups. CONCLUSIONS AND RELEVANCE Patients with chronic pulmonary disease have a high prevalence of AERD, which may have important treatment implications. The presence of pepsin was a better predictor of AERD in patients with respiratory symptoms compared with controls than presence of LLMs. Detection of pepsin in bronchoalveolar lavage fluid specimens can serve as a biomarker for AERD and is potentially superior to the current method of measuring LLMs. Whereas there is a significant association between AERD and the presence of chronic respiratory symptoms, this study does not verify causation. Additional study investigating the mechanism of pepsin on the respiratory epithelium may further our understanding of the pathophysiologic characteristics of this association and provide additional management options for these patients.
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Outcomes of pediatric laparoscopic fundoplication: a critical review of the literature. Can J Gastroenterol Hepatol 2014; 28:97-102. [PMID: 24288692 PMCID: PMC4071886 DOI: 10.1155/2014/738203] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/OBJECTIVE Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure. METHODS Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality. RESULTS A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%. CONCLUSION The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.
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Sacco O, Mattioli G, Girosi D, Battistini E, Jasonni V, Rossi GA. Gastroesophageal reflux and its clinical manifestation at gastroenteric and respiratory levels in childhood: physiology, signs and symptoms, diagnosis and treatment. Expert Rev Respir Med 2014; 1:391-401. [DOI: 10.1586/17476348.1.3.391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Oliviero Sacco
- Pulmonology Unit, G. Gaslini Institute, Largo Gaslini 5, 16147 Genoa, Italy
| | - Girolamo Mattioli
- Division and Chair of Pediatric Surgery, Largo Gaslini 5, 16147 Genoa, Italy
| | - Donata Girosi
- Pulmonology Unit, G. Gaslini Institute, Largo Gaslini 5, 16147 Genoa, Italy
| | - Elena Battistini
- Pulmonology Unit, G. Gaslini Institute, Largo Gaslini 5, 16147 Genoa, Italy
| | - Vincenzo Jasonni
- Division and Chair of Pediatric Surgery, Largo Gaslini 5, 16147 Genoa, Italy
| | - Giovanni A Rossi
- Pulmonology Unit, G. Gaslini Institute, Largo Gaslini 5, 16147 Genoa, Italy
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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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McCrea N, O'Donnell R, Brown R. Outpatient respiratory management of the child with severe neurological impairment. Arch Dis Child Educ Pract Ed 2013; 98:84-91. [PMID: 23598256 DOI: 10.1136/archdischild-2012-302324] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Nadine McCrea
- Department of Paediatric Neurology, Addenbrookes Hospital, Cambridge, UK
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Loots C, van Herwaarden MY, Benninga MA, VanderZee DC, van Wijk MP, Omari TI. Gastroesophageal reflux, esophageal function, gastric emptying, and the relationship to dysphagia before and after antireflux surgery in children. J Pediatr 2013; 162:566-573.e2. [PMID: 23102795 DOI: 10.1016/j.jpeds.2012.08.045] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Revised: 07/13/2012] [Accepted: 08/28/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess gastroesophageal reflux (GER), esophageal motility, and gastric emptying in children before and after laparoscopic fundoplication and to identify functional measures associated with postoperative dysphagia. STUDY DESIGN Combined impedance-manometry, 24-hour pH-impedance, and gastric-emptying breath tests were performed before and after laparoscopic anterior partial fundoplication. Impedance-manometry studies were analyzed with the use of conventional analysis methods and a novel automated impedance manometry (AIM) analysis. RESULTS Children with therapy resistent GER disease (n = 25) were assessed before fundoplication, of whom 10 (median age 6.4 years; range, 1.1-17.1 years; 7 male; 4 with neurologic impairment) underwent fundoplication. GER episodes reduced from 97 (69-172) to 66 (18-87)/24 hours (P = .012). Peristaltic contractions were unaltered. Complete lower esophageal sphincter relaxations decreased after fundoplication (92% [76%-100%] vs 65% [29%-91%], P = .038). Four (40%) patients developed postoperative dysphagia, which was transient in 2. In those patients, preoperative gastric emptying was delayed compared with patients without postoperative dysphagia, 96 minutes (71-104 minutes) versus 48 minutes (26-68 minutes), P = .032, and AIM analysis derived dysphagia risk index was greater (56 [15-105] vs 2 [2-6] P = .016). Two patients underwent a repeat fundoplication. DISCUSSION Fundoplication in children reduced GER without altering esophageal motility. Four patients who developed dysphagia demonstrated slower gastric emptying and greater dysplasia risk index preoperatively. AIM analysis may allow detection of subtle esophageal abnormalities potentially leading to postoperative dysphagia.
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Affiliation(s)
- Clara Loots
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands.
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Poddar U. Diagnosis and management of gastroesophageal reflux disease (GERD): An indian perspective. Indian Pediatr 2013; 50:119-26. [DOI: 10.1007/s13312-013-0036-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Antireflux surgery in children with neurological impairment: caregiver perceptions and complications. J Pediatr Gastroenterol Nutr 2013; 56:46-50. [PMID: 22785414 DOI: 10.1097/mpg.0b013e318267c320] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the present study was to report caregiver perceptions to antireflux surgery and gastrostomy in children with severe neurological impairment and to report the complications of the surgery. METHODS Children were identified from a clinic database and clinical information and surgical complications were extracted from the database and hospital medical records. A cross-sectional questionnaire addressing severity of symptoms was administered to parents/caregivers and scored with a 5-point Likert scale (1 is much better to 5, much worse). RESULTS A total of 122 children, median age 74 months (interquartile range 29-124), 63% spastic quadriplegic cerebral palsy, had antireflux surgery. Laparoscopic surgery was performed in 77 of 122 (63%) and 117 of 122 (96%) had gastrostomy insertion. Questionnaire was completed by 89 of 122 (73%) children; median duration of time from fundoplication to questionnaire was 77 months (43-89). The majority of caregivers indicated that surgery improved or greatly improved weight gain, chest infections, vomiting, and feeding tolerance. Only 2 caregivers reported that they regretted consenting to surgery. Serious surgical complications occurred in 10%. CONCLUSIONS Serious complications were uncommon in this series of antireflux surgery in neurologically impaired children. Although gagging and retching were common following surgery, a high percentage of caregivers reported improved nutrition, reflux-related symptoms, and high levels of satisfaction.
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Brun AC, Størdal K, Johannesdottir GB, Fossum V, Bentsen BS, Medhus AW. Nissen fundoplication in children with cerebral palsy: influence on rate of gastric emptying and postprandial symptoms in relation to protein source in caloric liquid meals. Clin Nutr 2012. [PMID: 23196118 DOI: 10.1016/j.clnu.2012.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS The aim was to study the influence of Nissen fundoplication on rate of gastric emptying and postprandial symptoms in relation to protein source in liquid meals in children with cerebral palsy. METHODS Ten children with cerebral palsy and Nissen fundoplication and ten with cerebral palsy without Nissen fundoplication were studied. Patients had gastrostomy and received two meals, double-blinded, in random order, on separate days. Meals contained a standardised carbohydrate and fat base plus one of two protein modules (Meal A: 100% casein; Meal B: 40% casein/60% whey). The (13)C octanoic acid breath test was used to assess gastric emptying. Postprandial symptoms were recorded. Results are given as median. RESULTS For meal A and B, respectively, time until 50% of the meal had emptied (T1/2) was 110 in the Nissen fundoplication- and 181 min in the non-Nissen fundoplication group, (p = 0.35) and 50 and 85 min (p = 0.25). Seven in the Nissen fundoplication group reported postprandial symptoms to meal B, none in the non-Nissen fundoplication group (p < 0.01). CONCLUSIONS Compared with cerebral palsy-children without Nissen fundoplication, those with Nissen fundoplication have postprandial symptoms more frequently after receiving a rapid emptying meal. Gastric emptying alone, however, does not seem to explain the symptom occurrence. ClinicalTrials.gov: UUSKBK 28200706.
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Affiliation(s)
- Anne C Brun
- Paediatric Department, Vestfold Hospital, N-3103 Tønsberg, Norway.
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Knatten CK, Fyhn TJ, Edwin B, Schistad O, Emblem R, Bjørnland K. Thirty-day outcome in children randomized to open and laparoscopic Nissen fundoplication. J Pediatr Surg 2012; 47:1990-6. [PMID: 23163988 DOI: 10.1016/j.jpedsurg.2012.05.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 04/18/2012] [Accepted: 05/24/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Laparoscopic Nissen fundoplication (LNF) is considered by some to be superior to open Nissen fundoplication (ONF). To test this hypothesis, we compared early results after LNF and ONF in a randomized trial. METHODS All children accepted for antireflux surgery for gastroesophageal reflux disease were offered enrollment. Ethical approval and parental consent were obtained. Anesthesia, surgical methods, and postoperative treatment were standardized. Patient demographics, length of hospital stay (LOS), and complications occurring the first 30 postoperative days were registered. RESULTS Eighty-eight children were randomized to LNF (n = 44) or ONF (n = 44). The groups were comparable with regard to age, weight, and comorbidity. Duration of surgery was 150 ± 34 minutes for LNF and 89 ± 25 minutes for ONF (P < .001). Median LOS was 7.0 days (range, 3-57 days) and 7.5 days (range, 2-20 days) after LNF and ONF, respectively (P = .74). Postoperative complications occurred in 48 patients, 24 in both groups. Twenty-four patients (LNF: n = 12, ONF: n = 11) were readmitted to hospital because of complications occurring after discharge. CONCLUSIONS This study failed to show that LNF is superior to ONF when surgery duration, LOS, and complications occurring during the first postoperative month were compared. Apart from surgery duration, the results were surprisingly similar.
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Kahn D, Veyckemans F. L’induction en séquence rapide chez l’enfant : nouveaux concepts. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.pratan.2012.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Gastroesophageal reflux (GER) is a common presenting complaint in children and adults, and is a frequent reason for physician consultation. GER disease (GERD), whilst benign in the majority of cases, is frequently a chronic condition that has been shown to result in significantly reduced quality of life in children and adolescents. Furthermore, there is emerging evidence that the prevalence of GERD is rising and may have links to adult obesity and other morbidities. Consequently, accurate diagnosis, appropriate management strategies, and timely referral to specialist services are important principles in the effective management of GERD. Acid-suppressive drugs are effective therapies but are one of the most costly classes of drugs prescribed. Therefore, not only is an accurate diagnosis important to the patient, but it is also of significant interest from a public health and resource utilization standpoint.
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Affiliation(s)
- Matthew W Carroll
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Childrens Hospital, Vancouver, BC, Canada
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Driessen C, Paulus GF, Robben SG, Tjon a Ten WE, Van den Neucker A, Verhoeven BH, Van Heurn LWE. Splenic size after division of the short gastric vessels in Nissen fundoplication in children. Pediatr Surg Int 2012; 28:235-8. [PMID: 22127485 PMCID: PMC3284667 DOI: 10.1007/s00383-011-3027-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE Nissen fundoplication is an effective treatment for gastro-esophageal reflux disease (GERD). Mobilization of the gastric fundus during fundoplication requires division of short gastric vessels of the spleen, which may cause splenic ischemia. The aim of this study was to determine if Nissen fundoplication results in hypotrophy of the spleen. METHODS We performed pre-operative and post-operative ultrasound measurements of the spleen in children undergoing Nissen fundoplication. During operation, the surgeon estimated the compromised blood flow by assessment of the percentage of discoloration of the spleen. RESULTS Twenty-four consecutive children were analyzed. Discoloration of the upper pole of the spleen was observed in 11 patients (48%) of a median estimated splenic surface of 20% (range 5-50%). The median ratio for pre-operative and post-operative length, width, and area of the spleen was 0.97, 1.03, and 0.96, respectively. The percentage of the estimated perfusion defect during surgery was not correlated with the ratios. In three patients, the area ratio was smaller than 0.8 (0.67-0.75), meaning that the area decreased with at least 20% after surgery. In none of these patients a discoloration was observed. CONCLUSION Discoloration of the spleen after Nissen fundoplication is not associated with post-operative splenic atrophy.
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Affiliation(s)
- C. Driessen
- Department of General Surgery, Maastricht University Medical Centre, P.Debyelaan 25, 6202 Maastricht, The Netherlands
| | - G. F. Paulus
- Department of General Surgery, Maastricht University Medical Centre, P.Debyelaan 25, 6202 Maastricht, The Netherlands
| | - S. G. Robben
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - W. E. Tjon a Ten
- Department of Pediatric Gastroenterology, Maastricht University Medical Centre, Maastricht, The Netherlands ,Department of Pediatrics, Maxima Medical Center, Veldhoven, The Netherlands
| | - A. Van den Neucker
- Department of Pediatric Gastroenterology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - B. H. Verhoeven
- Department of General Surgery, Maastricht University Medical Centre, P.Debyelaan 25, 6202 Maastricht, The Netherlands
| | - L. W. E. Van Heurn
- Department of General Surgery, Maastricht University Medical Centre, P.Debyelaan 25, 6202 Maastricht, The Netherlands
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Hassall E. Over-prescription of acid-suppressing medications in infants: how it came about, why it's wrong, and what to do about it. J Pediatr 2012; 160:193-8. [PMID: 22018908 DOI: 10.1016/j.jpeds.2011.08.067] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/21/2011] [Accepted: 08/30/2011] [Indexed: 12/12/2022]
Affiliation(s)
- Eric Hassall
- Sutter Pacific Medical Foundation, San Francisco, CA 94118, USA.
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Lee SL. Short- and long-term antireflux and asthma medication use in children after nissen fundoplication. Perm J 2011; 13:4-11. [PMID: 21373224 DOI: 10.7812/tpp/08-061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE We sought to determine antireflux and asthma medication use after Nissen fundoplication (NF). METHODS We performed a retrospective study using hospital discharge and pharmacy data from 1996 through 2005. A total of 342 pediatric patients had ≥1 NF; 336 of those had complete medication data. Use of antireflux medications and asthma medications were reviewed before and after NF. RESULTS Short-term (one year after NF) use of antireflux medications decreased (odds ratio [OR] = 0.35; 95% confidence interval [CI], 0.26-0.45). During the entire study period, the decrease in antireflux medication use after NF remained in place (233 to 197 patients; OR = 0.63; 95% CI, 0.47-0.84). Use of antireflux medications decreased in neurologically healthy patients (n = 186) after NF but remained the same in neurologically impaired patients. Short-term use of inhaled and systemic asthma medications did not change (OR = 1.16 [95% CI, 0.89-1.51] and 0.90 [95% CI, 0.69-1.18]), respectively. During the entire study period, inhaled and systemic asthma medication use increased after NF (OR = 2.11 [95% CI, 1.63-2.74] and 1.85 [95% CI, 1.43-2.41]), respectively. Inhaled and systemic asthma medication use increased in both neurologically healthy and impaired children. In older children (age >5 years), short-term use of inhaled and systemic asthma medications decreased after NF (OR = 0.39 [95% CI, 0.25-0.60] and 0.31 [95% CI, 0.19-0.53]), respectively. However, during the entire study period, inhaled and systemic asthma medication use in older children remained the same. CONCLUSION NF decreased antireflux medication use in the short and long term, particularly in neurologically healthy children. Inhaled and systemic asthma medication use increased after NF in neurologically healthy and impaired children. NF provided a short-term decrease in inhaled and systemic asthma medication use in older children but showed no change in the long term.
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Esophagitis and Barrett esophagus: unifying the definitions and diagnostic approaches, with special reference to esophageal atresia. J Pediatr Gastroenterol Nutr 2011; 52 Suppl 1:S23-6. [PMID: 21499040 DOI: 10.1097/mpg.0b013e3182133143] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Affiliation(s)
- Ioana Bratu
- University of Alberta, Edmonton, Alberta, Canada.
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Kawahara H, Mitani Y, Nose K, Nakai H, Yoneda A, Kubota A, Fukuzawa M. Should fundoplication be added at the time of gastrostomy placement in patients who are neurologically impaired? J Pediatr Surg 2010; 45:2373-6. [PMID: 21129548 DOI: 10.1016/j.jpedsurg.2010.08.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 08/12/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Patients who have advanced neurologic impairment (NI) and require gastrostomy placement (GP) frequently have symptomatic gastroesophageal reflux. We investigated the outcomes of GP without fundoplication in patients who had NI. METHODS This was a retrospective review of 54 patients with NI (median, 7 years; range, 1-18 years) undergoing GP alone. The operative criteria included medically controllable or no reflux symptoms. The patients were divided into 2 groups based on the percentage of total esophageal time with a pH less than 4.0 (reflux index, or RI): group I (GI, n = 33), RI less than 5.0% (median age, 6 years; range, 2-15 years); group II (GII, n = 21), RI 5.0% or greater (median age, 10 years; range, 1-18 years). Data are expressed as medians and ranges. RESULTS Nutritional management was successfully conducted after GP with or without the administration of lansoprazole, famotidine, or rikkunshito in all but 2 patients. One GI patient with alpha-thalassemia required fundoplication, and one GII patient with Cockayne syndrome required gastrojejunal tube feeding. The RI increased significantly in GI patients (2.1% [0%-4.8%] vs 4.5% [0.2%-11.4%], P = .004), whereas it decreased significantly in GII patients (11.2% [5.9%-41.6%] vs 9.8% [1.05-26.6%], P = .04). CONCLUSION Gastroesophageal reflux and related symptoms rarely deteriorate to require additional treatment after GP in patients with NI. Gastrostomy placement is a less invasive and effective procedure for improving the quality of life in those patients.
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Affiliation(s)
- Hisayoshi Kawahara
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodo-cho Izumi, Osaka 594-1101, Japan.
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Does laparoscopy lower the threshold for the surgical treatment of gastroesophageal reflux disease in children? J Pediatr Gastroenterol Nutr 2010; 51:599-602. [PMID: 20706151 DOI: 10.1097/mpg.0b013e3181ddc014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess whether laparoscopic surgery lowers the threshold for surgical intervention, we examined whether the introduction of the laparoscopic technique at our institution in 1997 has resulted in an increase in antireflux surgery in children at our clinic. PATIENTS AND METHODS The number of annual fundoplications between 1997 and 2008 at a single institution was assessed in children younger than 18 years. The number of fundoplications was compared with the number of pyloromyotomies and appendicectomies per year in the same period of time to prove or exclude a general increase in the referral of children. RESULTS Since 1997, the proportion of laparoscopic fundoplications increased from 60% in 1997 to 100% in 2008. During this period, 109 laparoscopic fundoplications were performed: 31 in the period from 1997 to 2002 and 78 from 2003 to 2008. Regression analysis shows a significant increase in the number of performed fundoplications (slope: 1.03 ± 0.28, P = 0.0043), whereas both the number of pyloromyotomies and appendicectomies remained stable (slopes: -0.14 ± 0.40, P = 0.73, and -0.75 ± 0.47, P = 0.14, respectively). CONCLUSIONS Since the introduction of minimally invasive surgery at our tertiary referral center in 1997, the number of patients referred for an antireflux operation has increased. This cannot be explained by an increase of referrals from outside the region or a change in the indication for surgery. We conclude that laparoscopy lowers the threshold for the surgical treatment of gastroesophageal reflux disease in children.
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Zaidi T, Sudall C, Kauffmann L, Folaranmi S, Khalil B, Morabito A. Physical outcome and quality of life after total esophagogastric dissociation in children with severe neurodisability and gastroesophageal reflux, from the caregiver's perspective. J Pediatr Surg 2010; 45:1772-6. [PMID: 20850619 DOI: 10.1016/j.jpedsurg.2010.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 04/29/2010] [Accepted: 04/30/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE The objective of this study is to retrospectively assess the surgical outcome and the quality of life (QOL) from the caregiver's perspective after total esophagogastric dissociation in neurologically impaired (NI) children with gastroesophageal reflux (GOR). METHODS Based on O'Neill questionnaire, a QOL questionnaire was designed, which was completed by the caregivers recording the child's well being and caregiver's satisfaction preprocedure, immediately (6 months), and long-term postprocedure (median, 21 months; range, 4-38). Statistical analysis was done using Kruskal-Wallis Test and Dunn's multiple comparisons test. RESULTS Twenty-three children underwent surgery between 2003 and 2008; 19 families participated. Ease of feeding improved significantly both immediately and long term. Statistically significant improvements were also seen in comfort and ability of the child to enjoy life, frequency of medical visits, vomiting, retching, and choking. Postoperatively, caring for the child became easier, and the caregiver's frustration in caring improved statistically, but the caregiver's overall QOL did not improve significantly. CONCLUSIONS Total esophagogastric dissociation has huge positive impact on the physical well being of the NI children experiencing GOR. The overall view of the procedure is one of success surpassing all expectations. Therefore, it should be considered alongside other antireflux procedures in NI children.
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Affiliation(s)
- Taqi Zaidi
- Department of Paediatric Surgery, Royal Manchester Children Hospital, Manchester M13 9WL, United Kingdom.
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Development of a quality of life instrument for pediatric gastroesophageal reflux disease: qualitative interviews. J Pediatr Gastroenterol Nutr 2010; 50:486-92. [PMID: 20639705 DOI: 10.1097/mpg.0b013e3181b99ca6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Antireflux procedures (ARP) are commonly performed in children and there is no disease-specific quality of life (QOL) instrument for gastroesophageal reflux (GERD) in children. The aim of this study was to identify the relevant domains for developing such an instrument. These domains will be validated in a future study. PATIENTS AND METHODS Parents of 19 patients (age 2 months-18 years) clinically diagnosed with GERD were recruited to complete semistructured interviews. Seven patients with adequate verbal skills were also interviewed. Patients were treated medically (13 patients) or with an ARP (6 patients). The interviews were analyzed using grounded theory. RESULTS GERD affects QOL through the following domains: symptom severity, feeding quality, sleep quality, hygiene, growth and development, social quality, self-image, coping skills, family QOL, health care usage, and impact of ARP. A greater-than-expected effect on parental QOL and remarkable use of accommodation were identified. CONCLUSIONS A pediatric GERD-specific instrument cannot rely on QOL perception alone, but must address broadly the impact of the disease and the effect of coping skills on the child and his or her family in their activities of daily living and interaction with society. We have identified reproducible domains that will serve as the foundation for such an instrument.
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Marlais M, Fishman JR, Köglmeier J, Fell JME, Rawat DJ. Reduced quality of life in children with gastro-oesophageal reflux disease. Acta Paediatr 2010; 99:418-21. [PMID: 19930192 DOI: 10.1111/j.1651-2227.2009.01613.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To assess self-reported Quality of life (QoL) in children with Gastro-oesophageal reflux disease (GORD) aged 5-18 and compare this with both disease and healthy control children in a prospective consecutive sample. METHODS All children attending a tertiary paediatric gastroenterology clinic from February 2009 to May 2009 with GORD, chronic constipation and inflammatory bowel disease (IBD) were asked to complete the validated PedsQL generic QoL assessment (self-report) at their clinic appointment. The PedsQL considers physical, emotional, social and school domains and is scored from 0 to 100. Healthy children were also recruited from the same site. Groups were compared using the independent samples Student's t-test. RESULTS A total of 184 children completed the assessment [103 (56%) male, mean age 10.7 years +/- 3.3] including 40 children with GORD, 44 with chronic constipation, 59 with IBD and 41 healthy children. QoL was significantly lower in the GORD group compared with both children with IBD (74 vs. 82) and healthy children (74 vs. 84), and was comparable to that of children with chronic constipation (74 vs. 74). CONCLUSIONS Self-reported QoL in children with GORD attending a tertiary paediatric gastroenterology clinic is significantly reduced compared with both healthy children and children with IBD.
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Affiliation(s)
- M Marlais
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK.
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Tounian P. Traitement du reflux gastro-œsophagien : de l’abstention thérapeutique à la chirurgie. Arch Pediatr 2009; 16:1424-8. [DOI: 10.1016/j.arcped.2009.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 04/03/2009] [Accepted: 06/11/2009] [Indexed: 10/20/2022]
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Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547. [PMID: 19745761 DOI: 10.1097/mpg.0b013e3181b7f563] [Citation(s) in RCA: 473] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.
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Tighe MP, Afzal NA, Bevan A, Beattie RM. Current pharmacological management of gastro-esophageal reflux in children: an evidence-based systematic review. Paediatr Drugs 2009; 11:185-202. [PMID: 19445547 DOI: 10.2165/00148581-200911030-00004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Gastro-esophageal reflux (GER) is a common phenomenon, characterized by the regurgitation of the gastric contents into the esophagus. Gastro-esophageal reflux disease (GERD) is the term applied when GER is associated with sequelae or faltering growth. The main aims of treatment are to alleviate symptoms, promote normal growth, and prevent complications. Medical treatments for children include (i) altering the viscosity of the feeds with alginates; (ii) altering the gastric pH with antacids, histamine H(2) receptor antagonists, and proton pump inhibitors; and (iii) altering the motility of the gut with prokinetics, such as metoclopramide and domperidone. Our aim was to systematically review the evidence base for the medical treatment of gastro-oesophageal reflux in children. We searched PubMed, AdisOnline, MEDLINE, and EMBASE, and then manually searched reviews from the past 5 years using the key words 'gastro-esophageal' (or 'gastroesophageal'), 'reflux', 'esophagitis', and 'child$' (or 'infant') and 'drug$' or 'therapy'. Articles included were in English and had an abstract. We used the levels of evidence adopted by the Centre for Evidence-Based Medicine in Oxford to assess the studies for all reported outcomes that were meaningful to clinicians making decisions about treatment. This included the impact of clinical symptoms, pH study profile, and esophageal appearance at endoscopy. Five hundred and eight articles were reviewed, of which 56 papers were original, relevant clinical trials. These were assessed further. Many of the studies considered had significant methodological flaws, although based on available evidence the following statements can be made. For infant GERD, ranitidine and omeprazole and probably lansoprazole are safe and effective medications, which promote symptomatic relief, and endoscopic and histological healing of esophagitis. Gaviscon(R) Infant sachets are safe and can improve symptoms of reflux. There is less evidence to support the use of domperidone or metoclopramide. More evidence is needed before other anti-reflux medications can be recommended. For older children, acid suppression is the mainstay of treatment. The largest evidence base supports the early use of H(2) receptor antagonists or proton pump inhibitors.
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Affiliation(s)
- Mark P Tighe
- Paediatric Medical Unit, Southampton General Hospital, Southampton, UK
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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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Pensabene L, Miele E, Del Giudice E, Strisciuglio C, Staiano A. Mechanisms of gastroesophageal reflux in children with sequelae of birth asphyxia. Brain Dev 2008; 30:563-71. [PMID: 18328656 DOI: 10.1016/j.braindev.2008.01.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 01/21/2008] [Accepted: 01/30/2008] [Indexed: 11/17/2022]
Abstract
UNLABELLED Patterns of childhood gastroesophageal reflux (GER) have been studied extensively; however, the mechanisms underlying its occurrence in neurologically impaired children (NIC) are poorly understood. Concurrent esophageal manometry and pH monitoring was conducted in 10 un-operated children (7 male; mean age: 59.5 months) with sequelae birth asphyxia and esophagitis. Reflux episodes were scored when esophageal pH decreased to <4 for at least 5 s. When the rate of decrease of lower esophageal sphincter (LES) pressure was >1 mmHg/s, the decrease of LES pressure was defined as LES relaxation. The time relationship of the pharyngeal manometric swallowing signal to LES relaxation onset was then evaluated in order to distinguish between LES relaxations associated with swallowing (type II or III, associated with one or more swallows, respectively) and those that occurred independently of swallowing (type I). RESULTS Esophageal manometry and pH monitoring were conducted for a mean duration of 91.5 min. Basal LES pressure averaged (+/-SD) 9.2+/-4.8 mmHg; in 4 of 10 patients (40%) the LES pressure was largely undetectable, varying between 0 and 2 mmHg. Mean LES pressure was inversely correlated with age (r=0.7, P=0.02). The total number of reflux episodes/h averaged 32.1+/-12.1 LES pressure reached 0 mmHg in 98% of reflux episodes. Type I LES relaxations were present in 3.15+/-1.1 reflux episodes/h, whereas type II LES relaxation occurred in 2.3+/-2.4 episodes/h. Acid reflux episodes appeared during absent basal LES tone periods, without phasic LES relaxations, in 74%. CONCLUSIONS Absent basal LES tone is the main mechanism of GER in a subgroup of NIC, especially in older children. Transient LES relaxation, the most common known event associated with acid reflux in neurologically normal children, seems to precede a minority of reflux events in NIC.
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Affiliation(s)
- Licia Pensabene
- Department of Pediatrics, University Magna Graecia of Catanzaro, Italy
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Tannuri ACA, Tannuri U, Mathias AL, Velhote MCP, Romão RLP, Gonçalves MEP, Cardoso S. Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center. Dis Esophagus 2008; 21:746-50. [PMID: 18847453 DOI: 10.1111/j.1442-2050.2008.00860.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.
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Affiliation(s)
- A C A Tannuri
- Pediatric Surgery Division, University of São Paulo Medical School, São Paulo, Brazil.
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Hassall E. Step-up and step-down approaches to treatment of gastroesophageal reflux disease in children. Curr Gastroenterol Rep 2008; 10:324-331. [PMID: 18625145 DOI: 10.1007/s11894-008-0063-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The single biggest change in the approach to treating pediatric gastroesophageal reflux disease (GERD) in recent years has been the empiric use of proton pump inhibitors (PPIs) for symptoms suspected to be those of GERD. In other words, PPIs have been used increasingly as a first-line concurrent diagnostic test and treatment before any investigation. Although this approach is useful for some patients, there are a number of caveats about its application to children. In general, these caveats are related to age per se (eg, infancy) and to age-related symptoms and severity of GERD itself. The most important caveats relate to the prescription of empiric PPI therapy in infants--which generally is to be avoided--and to how PPIs are used in older children--specifically, the advisability of empiric trials being of limited duration. Even in children with proven reflux esophagitis, GERD is not chronic and relapsing in all; thus, trials of therapy withdrawal are warranted. In light of many factors, including the burgeoning literature on potential risks of infections in acid-suppressed children and adults, caution with dose and duration of acid-suppressive drugs in children is urged. The role of antireflux surgery is also mentioned.
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Affiliation(s)
- Eric Hassall
- Division of Gastroenterology, British Columbia Children's Hospital, 4480 Oak Street, Vancouver, British Columbia V6H3V4, Canada.
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Hassall E. Talk is cheap, often effective: symptoms in infants often respond to non-pharmacologic measures. J Pediatr 2008; 152:301-3. [PMID: 18280829 DOI: 10.1016/j.jpeds.2007.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/16/2007] [Indexed: 01/05/2023]
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Chueh H, Kim MJ, Jung JA. A case of acute respiratory distress syndrome associated with congenital H-type tracheoesophageal fistula and gastroesophageal reflux. KOREAN JOURNAL OF PEDIATRICS 2008. [DOI: 10.3345/kjp.2008.51.8.892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Heewon Chueh
- Department of Pediatrics, College of Medicine Dong-A University, Busan, Korea
| | - Myo Jing Kim
- Department of Pediatrics, College of Medicine Dong-A University, Busan, Korea
| | - Jin-A Jung
- Department of Pediatrics, College of Medicine Dong-A University, Busan, Korea
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Long-term outcome of laparoscopic Nissen-Rossetti fundoplication for neurologically impaired and normal children. Surg Endosc 2007; 22:875-80. [PMID: 17963001 DOI: 10.1007/s00464-007-9603-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 06/20/2007] [Accepted: 07/26/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study aimed to assess the long-term effects of laparoscopic Nissen-Rossetti fundoplication (LNF) on clinical and pH evaluations of children with gastroesophageal reflux disease (GERD) according to neurologic status. METHODS The study examined 127 children (73 neurologically impaired and 54 neurologically normal with primary GERD) who consecutively underwent LNF from 1992 to 2003. The follow-up protocol included evaluations at 3, 15, and more than 36 months (long-term evaluation) postoperatively, which consisted of physical examination and 24-h pH monitoring. Recurrences were defined as abnormal pH-metry exhibited by symptomatic children. RESULTS The long-term follow-up period averaged 5.5 years. Of the 73 neurologically impaired children, 9 (12%) had GERD recurrences, which occurred during the evaluation period and required redo surgery in four cases, including two Bianchi procedures. In the neurologically normal group, one recurrence (2%) occurred 3 months after surgery. The long-term complications in this group included dyspepsia (n = 3), occasional dysphagia (n = 2), gas bloat syndrome (n = 1), and alimentary disorders (n = 2). CONCLUSIONS For children with primary GERD, LNF is a long-term efficient procedure. For the neurologically impaired children, the results were good, with more than 85% of the children symptom free after 5 years, although repeated evaluations are required to diagnose late recurrences related to evolving dysmotility disorders.
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