Postfundoplication retching: Strategies for management
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Read the article on jpedsurg.org ↗Article · May 2020 · 1 min read
In brief
In brief
Retching after fundoplication is common in children with neurodisability and is a leading cause of wrap failure. Management includes feed modifications, antiemetics, and motility agents, while high-risk patients should avoid fundoplication altogether as it may worsen symptoms without addressing the underlying emetic reflex.
Written by the GCMD Library team from the article.
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