AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Persistent gastroesophageal reflux disease (GERD) is one of the two most frequent disorders for which infants and children undergo abdominal surgery.¹ However, most children with GERD may be treated nonsurgically. Appropriate therapy for GERD is based on the underlying pathophysiology, clinical presentation, and accurate interpretation of diagnostic test results.

History of the Procedure

As in many other fields, surgical therapy for gastroesophageal reflux (GER) has evolved a great deal. A few historical procedures of note include the Allison crural repair, the Boerema anterior gastropexy, and the Angelchik prosthesis. Both the Allison and the Boerema repairs have high failure rates and are rarely, if ever, used.^{2, 3} The Angelchik prosthesis is a silicone ring that is positioned at the gastroesophageal (GE) junction and prevents reflux. The Angelchik prosthesis was rarely used in children and has been largely abandoned because of a high rate of complications.⁴

Today, both transthoracic and transabdominal fundoplications are performed, including partial (anterior or posterior) and circumferential wraps. The most commonly performed operation today in both children and adults is the Nissen fundoplication, which is a 360° transabdominal fundoplication (see Media file 3).^{5, 6} First reported in 1991, laparoscopic fundoplication is well studied in adult populations. Laparoscopic fundoplication has quickly gained acceptance for use in children as well.^{7, 8, 9, 10, 11, 12}

Frequency

The prevalence of GER varies by age. In a study of parent reporting and symptom scores, 67% of healthy infants aged 4 months had GER;¹³ the prevalence decreased to 21% by age 7 months. A one-year follow-up study by the same author demonstrated that vomiting spontaneously resolved in nearly all of these cases.¹⁴ In pH probe studies, 8% of healthy infants younger than 1 year had abnormal reflux.¹⁵ An estimated 85% of premature infants have GER; the vast majority of cases resolve without treatment.¹⁶ Children with neurologic disorders also have an increased prevalence of GER. In one referral center, the rate of GER was higher in patients older than 1 year with CNS disease than in healthy children (69% vs 47%).¹⁷ In another report, 65% of patients who underwent antireflux surgery had neurological impairment.¹⁸

Pathophysiology

Nearly all infants have some degree of GER. This reflux is transient and does not cause any morbidity. However, in some children, the reflux is pathologic and persistent, causing feeding difficulties, failure to thrive, aspiration or respiratory complications, esophagitis, and esophageal stricture. GERD occurs on a continuum from mild physiologic reflux to a severe debilitating problem.

The passage of food from the esophagus to the stomach is facilitated by a transient relaxation of the distal esophagus, which is initiated by swallowing-induced peristaltic waves. The resting tone of the distal esophagus is important in preventing the reflux of gastric contents into the thoracic portion of the esophagus. The anatomic area integral to the prevention of reflux is the abdominal esophagus, where the high-pressure zone (HPZ) is located.

The HPZ depends on many factors, including an adequate length of intra-abdominal esophagus, an intact phrenoesophageal ligament, a normal diaphragm, and sufficient gastric emptying. Symptoms of reflux tend to occur when the sphincter pressure is 0-5 mm Hg.¹⁹ About 81% of patients in whom the intra-abdominal esophagus is 1 cm or shorter have reflux, whereas 38% of those with an intra-abdominal segment longer than 3 cm have reflux.²⁰

Several factors contribute to GER in children. The most important factor is probably transient relaxation of the lower esophageal sphincter (LES), although this is somewhat controversial. Transient LES relaxation occurs normally and is a mechanism to vent air from the distended stomach.²¹ However, in some children, LES relaxation is frequent and prolonged, leading to pathologic reflux. Unlike physiologic LES relaxation, GER is primarily observed during episodes of sphincter relaxation unassociated with swallowing.²² Some children, such as those with neurologic disorders, may be predisposed to frequent LES relaxation, which leads to irritation of the esophageal mucosa by hydrochloric acid. Esophagitis causes further dysfunction of the LES, creating a cycle of continuing injury.

In addition to LES relaxation, esophageal dysmotility may also play a role in pediatric GER. In an evaluation of 25 pediatric patients with GERD, esophageal manometry and 24-hour pH probes were used to correlate esophageal contractions with acid-reflux episodes.²³ The investigators demonstrated that patients with GERD had significantly fewer and less sustained esophageal contractions than patients without reflux. This may be an important distinction because the presence of esophageal dysmotility in a subset of pediatric patients with GERD could be a relative contraindication to operative management.

Children who are at risk for GERD include otherwise healthy infants without illness or disability, preterm infants, children with neurologic impairment, and children with a history of esophageal atresia/tracheoesophageal fistula (EA/TEF). In healthy term and preterm infants, the mechanism of GER is primarily frequent, transient relaxation of the LES and otherwise normal esophageal motor function.²⁴

Children with neurologic impairment, including those with mental-motor retardation, seizure disorders, and hydrocephalus, appear to have a higher prevalence of GER than that observed in other children after 1 year of age. Several reasons are postulated for this phenomenon, including a reduction in LES pressure with elevations in intracranial pressure and abnormal esophageal peristalsis secondary to CNS dysfunction.¹⁷ Children with a history of EA/TEF also have a high prevalence of GER, which often lasts into adulthood.^{25, 26, 27} This prevalence is likely due to a shortened esophagus and/or superior displacement of the GE junction, abnormal peristalsis in the esophagus, and delayed gastric emptying (DGE).²⁸

Other factors implicated in the genesis of GER include abnormal or altered anatomy, such as hiatal hernia, short esophagus, and gastrostomy. Medications that decrease LES pressure and may hence exacerbate GER include methylxanthines and calcium channel blockers.

Clinical

Many healthy infants have physiologic reflux. Approximately 40% of healthy infants have at least one episode of emesis a day, with more than 5 mL of nonbilious emesis per episode.^{29, 30} These minor reflux episodes (ie, spitting up) usually resolve by the time the patient is aged 6 months and do not cause any serious sequelae. However, in some children, GER is pathologic. GERD may cause irritability, apnea, recurrent pneumonia, respiratory dysfunction, esophagitis, and failure to thrive.

Importantly, the presenting symptoms of GERD in infants and children are likely different than those seen in adults, and vary according to the age of the patient. Anorexia and feeding difficulty correlate with erosive esophagitis on endoscopy. This correlation is particularly noticeable in patients aged 1-5 years.³¹ Furthermore, in a study of 27 infants with pathologic GER, feeding difficulties and frequent regurgitation were significantly associated with the disease, whereas crying duration demonstrated no correlation.³²

Feeding difficulties in infants have been further evaluated in a recent study investigating the clinical outcomes of GERD treatment.³³ In a retrospective review of 28 infants with feeding difficulty prior to GERD treatment, a posttreatment evaluation with both endoscopy and a videofluoroscopy demonstrated marked functional improvement in infant swallowing.

GERD has been closely linked to respiratory problems due to recurrent aspiration of gastric contents.³⁴ Reflux should be ruled out in children with recurrent pneumonias or chronic nocturnal coughs. Considerable controversy remains regarding whether GERD is associated with sudden infant death syndrome (SIDS) in a temporal or causative manner.^{35, 36} The relationship of GERD with childhood asthma is more defined, and the prevalence is thought to be 40-60%.^{37, 38} In a prospective evaluation of pediatric patients with GER and asthma, investigators demonstrated a significant reduction in the use of bronchodilators and inhaled steroids after treatment for reflux disease. This effect was not seen in control patients with asthma and no diagnosis of GER.³⁹  

Some authors dispute the association between reflux and lung disease.⁴⁰ However, the use of multichannel intraluminal impedance has allowed for the investigation of nonacid reflux in the pathogenesis of GER–related respiratory disease. An examination of 28 children with persistent respiratory symptoms despite antacid therapy demonstrated that symptoms occurred more frequently in association with nonacidic reflux.⁴¹ A follow-up study of 24 children with asthma demonstrated a higher correlation between asthma and reflux detected by impendence (acid and nonacid) compared with pH probe alone (acid).⁴²

Esophageal mucosal damage from gastric acid exposure is common in patients with GERD and leads to complications such as esophagitis. Esophageal strictures are another frequent complication that results from scarring. Barrett esophagus, a premalignant process that involves cellular changes, has also been linked to chronic reflux in older children. Some have surmised that the constant acid exposure during times of healing may lead to this epithelial transformation.⁴³ Serial follow-up with endoscopy and biopsy are warranted for these precancerous lesions.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The primary indication for antireflux surgery in children with gastroesophageal reflux (GER) is the failure of medical therapy. Other indications include the complications described above, including a history of recurrent aspiration events with or without pneumonia, apnea or near-miss SIDS, reactive airway disease, refractory emesis, failure to thrive, esophagitis, esophageal stricture, Barrett esophagus, and associated anatomic anomalies (eg, a large hiatal hernia).⁴⁴

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The anatomy of the esophagus, stomach, and esophagogastric junction is critical to their function and to the development of reflux.

The proximal esophagus contains the upper esophageal sphincter (UES), which comprises the cricopharyngeus and thyropharyngeus muscles. The body of the esophagus is made up of inner circular and outer longitudinal muscular layers with the proximal third being smooth muscle, which transitions to striated muscle in the distal two thirds. The LES is the distal-most segment of the esophagus, approximately 3-5 cm in adults, and its ability to prevent reflux depends on a number of anatomic factors.

As the esophagus passes through the diaphragmatic hiatus, it becomes the abdominal esophagus. The right crus of the diaphragm forms a sling around the esophagus so that the esophagus narrows when the diaphragm contracts.^{45, 46, 21} At this level, the phrenoesophageal ligament also encircles it. This membrane is the reflection of the subdiaphragmatic fascia onto the transversalis fascia of the anterior abdominal wall. The esophagus meets the stomach intra-abdominally, forming the angle of His. The acute angle of the angle of His and the length of the abdominal esophagus both contribute to closing the esophagus when intragastric and intra-abdominal pressures are high.

The blood supply of the esophagus is segmental (see Media file 2). The inferior thyroid artery supplies the cervical esophagus. Branches of the bronchial arteries and branches directly off of the aorta supply the proximal and distal thoracic esophagus, respectively. Finally, branches of the left gastric and inferior phrenic artery supply the abdominal esophagus. A relatively constant branch connects the left gastric and inferior phrenic arteries, called the Belsey artery.

The blood supply of the stomach is rich, with overlap among the vessels. The lesser curve is supplied by the left and right gastric arteries, branches of the celiac trunk and proper hepatic artery, respectively. The greater curve is supplied by the right gastroepiploic from the gastroduodenal artery and the left gastroepiploic and the short gastric arteries from the splenic artery. This excellent collateral blood supply of the stomach allows the surgeon to ligate much of the arterial supply (ie, the short gastric arteries during fundoplication) without risk of ischemia (see Media file 1).

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

In some children, reflux is caused by gastric or intestinal motility disorders or by gastric outlet obstruction. Antireflux surgery would not be helpful and, in fact, may be contraindicated in these patients, especially without a gastric emptying procedure. These patients may be identified with contrast scintigraphy (milk scan) or, occasionally, with an upper GI barium study. A second group of patients in whom antireflux surgery may be contraindicated are those with esophageal dysmotility disorders. Children with weak or uncoordinated peristalsis of the esophagus do not benefit from fundoplication because it may slow passage of food from the esophagus even further.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Imaging Studies

• Although an upper GI barium study is no longer the primary diagnostic study of choice, it may be useful in the evaluation of gastroesophageal reflux disease (GERD), if it is performed by an experienced pediatric radiologist. Esophageal motility and anatomic abnormalities, such as hiatal hernia, stricture, or malrotation, may be noted. The sensitivity of this study in diagnosing the occurrence of reflux and the presence of esophagitis is low.⁴⁷
• GE scintigraphy, also known as the milk scan, is also occasionally used. The patient is given a radiolabeled meal (historically, children have been given radiolabeled milk), and serial images are recorded up to 60 minutes after ingestion. This study may be used to diagnose and quantitate reflux. It may also be used to assess gastric emptying and identify children with DGE. Finally, late images may demonstrate isotope in the lungs, indicating pulmonary aspiration.
• Both of these studies may be helpful but are not sensitive. The primary diagnostic tool for GER today is the pH probe study. Impedance/pH monitoring is currently under investigation as a potentially improved diagnostic modality.

Other Tests

• The 24-hour pH probe monitor is the criterion standard diagnostic test for GER.
• • Originally described by Johnson and De Meester in 1974, a catheter at the LES measures episodes of reflux over a 24-hour period.
  • An esophageal intraluminal pH of less than 4 for at least 15 seconds defines an episode of reflux.
  • The values recorded include the total time with pH below 4.0, upright time with pH less than 4.0, supine time with pH less than 4.0, episodes longer than 5 minutes, and the longest episode.
  • A composite score is calculated based on these results.
  • This test has since been evaluated and validated in children.^{48, 49}
  • This test is more sensitive and specific for acid reflux than barium esophagraphy.⁴⁷
  • Although the pH probe helps in the diagnosis of acid reflux, it is not helpful in diagnosing bile reflux.
  • This test may be difficult to perform in some children and cannot be used to determine the presence or severity of esophagitis.
• Esophageal manometry is used to assess the contractility of the esophageal body and sphincters (UES and LES).
• • The result is not diagnostic for GER, but the findings may reveal LES hypotension in the setting of reflux or abnormal peristalsis in patients with esophageal dysmotility or severe esophagitis.
  • Esophageal manometry can also be used to identify children with motility disorders in whom antireflux surgery is contraindicated (see Contraindications).
  • Some have found no correlation between motility pattern and outcome and do not advocate routine use of this study.⁵⁰
• Esophageal impedance/pH monitoring is a novel technique used to detect acid and nonacid reflux.
• • This test uses a probe similar to that used in standard pH monitoring.
  • The impendence probe measures the change in electrical resistance that occurs across its sensors with the passage of intraluminal material.
  • The test has the benefit of identifying the content, direction, and localization of any reflux.¹⁵
  • The diagnostic sensitivity of the probe appears to be superior to the pH probe in patients treated with antacids.
  • The use of the test is limited by a lack of standardized pediatric normal ranges⁵¹ and increased cost relative to standard pH manometry.¹⁵

Diagnostic Procedures

• Endoscopy is used to visualize and obtain a biopsy sample from the esophageal mucosa and to diagnose esophagitis, strictures, and Barrett esophagus.
• Although no validated grading system for children is available, erosions or ulceration indicates esophagitis.
• Biopsy should be performed in most cases, even if the mucosa appears relatively normal.

Histologic Findings

Results of biopsy obtained during endoscopy may confirm esophagitis or be diagnostic of Barrett esophagus.

Infiltration of neutrophils and eosinophils, papillary hyperplasia, and basal-zone thickening have been linked to the diagnosis of GERD.⁵² Barrett esophagus is characterized by intestinal metaplasia of the esophageal mucosa; columnar intestinal epithelium and goblet cells replace the normal squamous epithelial lining of the esophagus. In children with chronic aspiration, lipid-laden macrophages are visible in bronchoalveolar-lavage specimens.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

The North American Society of Pediatric Gastroenterology and Nutrition issued clinical guidelines for the management of gastroesophageal reflux disease (GERD).⁵³ For additional information, see the eMedicine pediatric topic, Esophagitis.

First-line treatment is generally medical, and surgery is reserved for complications of GERD or failure of medical therapy. Teaching parents the optimal feeding technique with upright positioning of the infant, frequent low-volume feedings, and (occasionally) thickening of the food is usually successful. Medical management is appropriate in children with confirmed symptoms and confirmed GERD.

Prokinetic agents improve esophageal peristalsis and gastric emptying and increase LES tone. Cisapride is effective in decreasing reflux. However, it has been removed from the market because of its cardiotoxicity (which is lethal in rare instances) and is only available in a limited-use protocol.^{54, 55, 56}

Metoclopramide, an antidopaminergic and cholinomimetic drug, is a prokinetic agent and has again become the mainstay of medical management of GERD. However, both reversible and irreversible neurologic adverse effects (eg, tardive dyskinesia) may occur with this medication.  The adverse effects of metoclopramide are independent of dose and duration of use.^{57, 58, 59} Two other drugs that increase peristalsis of the esophagus and stomach are bethanechol (Urecholine) and domperidone.

Acid suppressants are useful in treating esophagitis induced by acid reflux and should be used either alone or concomitantly with prokinetic agents.⁶⁰ Histamine-2 receptor antagonists (H2RAs), such as ranitidine, cimetidine, famotidine, and nizatidine, and proton pump inhibitors (PPIs), such as omeprazole, esomeprazole and lansoprazole, have been shown to be effective. Numerous studies demonstrate the effectiveness of H2RAs in adults with reflux, and 3 randomized controlled trials with children showed H2RAs to be effective in both relieving symptoms and healing the esophagitis.^{61, 62}

Numerous randomized controlled trials have indicated that PPI therapy is superior to H2RAs in adults with GERD.⁶³ PPIs are also used in children, although they are not as well studied in children as they are in adults. No randomized placebo controlled studies have been conducted in children. Several papers report that PPIs are an effective treatment of reflux esophagitis, but none has demonstrated superiority over high-dose H2RA.^{64, 65, 66, 67, 68}

When medical therapy fails (ie, when patients have continued symptoms, refractory esophagitis, or complications of GERD), antireflux surgery should be considered. Of note, children with neurologic impairment are more refractory to medical therapy than otherwise healthy children.⁶⁹

Surgical therapy

Surgery is usually reserved for patients with continued reflux and complications of reflux esophagitis despite medical therapy. In the pediatric population, more than 50% of antireflux operations are performed in those younger than 1 year.⁷⁰ Improvement in esophagitis, pulmonary infections, and failure to thrive is apparent in more than 95% of those undergoing antireflux surgery, with an associated morbidity rate of less than 7% and a mortality rate of less than 1%.^{71, 12}

The principles of surgical therapy for GERD include lengthening of the intra-abdominal esophagus, accentuation of the angle of His, increasing the pressure barrier at the esophagogastric junction, and approximation of the crura.⁷² The Nissen fundoplication is the most common operation performed today (see Media file 3). It involves wrapping the gastric fundus 360° around the distal esophagus. Alternatives to the Nissen fundoplication include the Thal procedure (anterior 180° fundoplication), Toupet procedure (posterior 270° fundoplication), Boix-Ochoa procedure (restoration of intra-abdominal esophagus and recreation of the angle of His), and Watson fundoplication (anterior 120° fundoplication). Comparisons between these various operations have demonstrated an equivalent rate for complications, revisions and long term satisfaction.^{73, 74}

The Nissen procedure and other related procedures may be performed laparoscopically. Laparoscopic fundoplication has been well studied and accepted as equivalent to open procedures in adults.^{8, 75, 9} Findings from early follow-up studies suggest that laparoscopic fundoplication in children is also comparable with open surgery and is associated with a shorter hospital stay.^{76, 77, 10, 11, 12} The safety of laparoscopic as compared with open fundoplications has been evaluated in children as young as one year.⁷⁸ Some have found the reoperation rate to be higher after the laparoscopic procedure.⁷⁹ Laparoscopic antireflux operations have also been reported to be safe and effective in children after the repair of esophageal atresia.⁸⁰

DGE may occur in patients with symptomatic GERD and appears to be more common in children with neurologic impairment.⁸¹ In addition, DGE prior to surgery is thought to be a risk factor for recurrent reflux.⁸² A gastric-emptying operation with a fundoplication is sometimes indicated, although its routine use is controversial.^{83, 84} Dumping syndrome is a potential complication of all gastric-emptying procedures.

Preoperative details

The preoperative planning for antireflux surgery in children is critical. Many children have malnutrition, chronic aspiration, pneumonia, or pulmonary dysfunction. Therefore, assess and optimize the patient's nutritional and pulmonary status preoperatively. In a study of 56 children with neurologic impairment who underwent fundoplication, a low preoperative albumin level (<3.5 g/dL) and the nutritional risk index (NRI) proved to be predictive of prolonged hospitalization, ICU stay, and time using a ventilator.⁸⁸ Therefore, in malnourished children, consider preoperative supplemental nutrition to improve these indices. In addition, any ongoing pulmonary infection or pneumonia should be adequately treated.

In terms of other preoperative planning, the surgeon must choose between the open and laparoscopic approach. Although data in children are limited, laparoscopic antireflux surgery is probably equivalent to the open procedure and may have some advantages. In patients with previous abdominal surgery, the laparoscopic approach is more technically demanding, and a less experienced surgeon is likely to choose an open procedure. However, in experienced centers, laparoscopic reoperation is reportedly safe and effective in otherwise normal children as well as those with neurologic impairment.^{89, 12, 90, 91}

Intraoperative details

As mentioned above, whether laparoscopic or open, numerous procedures are available, including complete and partial fundoplication. Although the Nissen 360º fundoplication is most commonly used, a partial wrap is sometimes preferred in children with esophageal dysmotility disorders who are undergoing surgery because this is less likely to cause esophageal obstruction in the context of abnormal esophageal peristalsis.⁹²

In addition, each type of fundoplication may be tailored to the patient and to the surgeon's preference. For example, most surgeons approximate the crura of the diaphragm. Many also divide the short gastric vessels, believing that this allows a looser wrap and leads to less postoperative dysphagia. However, some suggest that this is an unnecessary and time-consuming step.⁹³

Two other procedures that are often performed concomitantly with antireflux surgery in children include a gastric emptying procedure and placement of a gastrostomy tube (G-tube). DGE is reported in approximately 50% of children with GER.⁹⁴ Some have recommended that all children have contrast scintigraphy preoperatively. Those with slow gastric emptying (ie, >60% of isotope retained in the stomach after 90 min) should then have a gastric emptying procedure, such as antroplasty or pyloroplasty.^{82, 81, 95} However, this point is controversial.

Finally, some children who have antireflux surgery also benefit from a G-tube. Many surgeons place G-tubes in children with neurologic impairment at the time of fundoplication.⁹⁶ In addition, a G-tube may be indicated in children with failure to thrive or malnutrition preoperatively. In addition to enabling postoperative feeding, it allows drainage or venting of the stomach postoperatively, as needed.

Postoperative details

Although some surgeons believe a nasogastric tube should be left in place or believe that the G-tube should be left to drain to gravity until evidence of normal bowel function (eg, return of bowel sounds) is observed, this is not always done, particularly if a laparoscopic approach is used. The patient should be fed a clear liquid diet by mouth and the appropriate diet should be reinstated, as tolerated. If the patient is to be fed through a G-tube, the chosen liquid diet should be started slowly and progressively change to the goal diet, as tolerated. Although little evidence supports the practice in children, many believe that postoperative return of bowel function is faster after laparoscopic surgery and advance the diet more quickly than after open surgery. Fundoplication usually provides instant symptom relief. However, it can be associated with complications.

Follow-up

After bowel function returns, be vigilant for the development of complications (see Complications), which occur more commonly in children with neurologic impairment than in otherwise healthy children.¹⁸

For excellent patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education article Spitting Up in Infants.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Postoperative complications may occur early or late. Early complications include retching, gas bloat (patients with this complication are usually unable to vomit), dysphagia, atelectasis, pneumonia, wound infection or dehiscence, small-bowel obstruction due to adhesions, and DGE. Retching most often occurs in children with neurologic impairment and those who retch preoperatively. It probably indicates an underlying gastric dysrhythmia and loss of central inhibition of the gastric emetic reflex that is exacerbated by the operation.^{97, 98} This problem may be managed by using prokinetic agents, nasogastric tube placement (temporary), or G-tube decompression or venting, or it may require a gastric emptying procedure if not already performed. Small-bowel obstruction from adhesive disease may be managed with a brief trial of nasogastric tube decompression and watchful waiting, but failure to resolve requires abdominal exploration and lysis of adhesions.

Late complications include bowel obstruction and wrap failure, which may include a wrap disruption, a slipped wrap, herniation of the wrap into the chest, or an excessively tight wrap. Typically, patients with wrap failure present with symptoms such as dysphagia or recurrent reflux symptoms. These patients should have an upper GI barium study to evaluate the integrity and anatomy of the repair. In addition, many should undergo repeat endoscopy to diagnose recurrent or persistent esophagitis.

Often, dysphagia may be due to postoperative edema, and it resolves. In patients whose dysphagia does not resolve and who have esophageal narrowing on upper GI study or endoscopy, pneumatic dilation is often successful.^{99, 100} Postoperative slipped Nissen or hiatal hernia may require repeat operation and repair if recurrent gastroesophageal reflux (GER) cannot be controlled medically.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Although long-term data in children are sparse, the long-term success of antireflux surgery is generally thought to be good. A series of more than 1000 laparoscopic Nissen fundoplications in 10 years revealed good outcomes, with a 4% wrap-failure rate.¹² 

A few groups report objective postoperative testing, and some have questioned the benefit of surgery.¹⁰² One report demonstrated a beneficial effect of surgery on the rate of reflux-related hospitalizations in children aged 1-4 years. However, this effect was not noted in older children. In fact, after multivariate analysis, the study demonstrated that older children with developmental delay actually experienced an increased rate of reflux-related hospitalizations after surgery.¹⁰³

The 24-hour pH study has also been used to objectively evaluate outcomes after antireflux surgery. In a prospective review of 53 pediatric patients treated with the laparoscopic Thal procedure, 25% were found to have pathologic reflux at follow-up. Of note, the follow-up evaluation also found that 90% of patients reported they were symptom-free, perhaps underscoring the need for more objective outcomes data.

Children with neurologic impairment tend to have a high failure rate.¹⁸ In addition, many of these children have serious coexisting morbidity and relatively short life expectancy. In a study of 46 infants examined 5 years after Nissen fundoplication, 24% died as a result of other medical problems.¹⁰⁴ Of the survivors, 74% had no recurrent symptoms, and 12% required repeat operation or fundoplication. However, 45% of the patients had at least one postoperative complication.

In another report of 109 children who received either Nissen or Boix-Ochoa antireflux procedures, with up to 10-year follow-up, 20% had recurrent reflux; 91% of these cases occurred in the Boix-Ochoa group.¹⁰⁵

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The future of gastroesophageal reflux (GER) therapy includes several endoscopic therapies that are currently gaining favor in adult populations and that may replace surgery in some patients. The therapies include radiofrequency ablation (Stretta procedure), the injection of inert substances at the LES, and endoscopic gastroplication.

In the Stretta procedure, a catheter is used to deliver radiofrequency energy and to create thermal lesions deep to the mucosa at the GE junction. An open-label trial of 112 adult patients with 12-month follow-up showed an improvement in GERD scores and mental health, as well as a decrease in acid exposure and requirement for PPIs.¹⁰⁶ No serious complications occurred. Another group compared the Stretta procedure with laparoscopic fundoplication in 140 adults with favorable results.¹⁰⁷ This procedure has also been reported in small numbers of children with some short-term success.¹⁰⁸

Other described procedures include endoscopic injection of inert substances into the mucosa or muscle of the GE junction and endoscopic plication, which involves the placement of mucosal or transmural sutures at the LES-GE junction. A report on this gastroplication with an EndoCinch device in 22 adults and 1-year follow-up showed that patients had improved reflux scores and health-related quality of life, as well as decreased acid exposure and PPI requirements.¹⁰⁹ Long-term data on these techniques are not available. In addition, the safety and efficacy of this technique in children is not known.¹¹⁰ However, one report describes successful gastroplication in 17 children (mean age, 12.4 y).¹¹¹

Finally, some are performing robot-assisted laparoscopic fundoplication in children with good results.¹¹² Operative time is a purported benefit of the robot-assisted approach. However, a recent prospective study compared the operative times for the performance of a robotically assisted Thal semifundoplication in children with the conventional laparoscopic technique.¹¹³ The study found that, although the time dedicated to the most challenging steps of the procedure were decreased when using the robot, the lengthy set up it required negated any overall effect.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
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Media file 2:  Arterial blood supply and lymphatic drainage of the esophagus.
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Media file 3:  Nissen fundoplication.
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Media file 4:  Toupet partial fundoplication.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
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• References

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