Gastoesophageal Reflux: Update Course 2015

OK, we're back. We're gonna get head in right into session two. I'm sorry we're running a little over. Let me introduce the next panel here. Uh, we have Doctor uh Mack Harmon, who's from, uh, Women and Children's Hospital of Buffalo, and we have Doctor Whitt Holcomb, who is from Mercy Children's Hospital of Kansas City. Uh, we have Dan von Almen sitting here as part of the, uh, discussion panel, and we also, and Dan von Almen is from Cincinnati Children's Hospital. And by way of uh virtuality, we have Doctor Andrea Hayes Jordan, who is uh uh uh coming to us through the, through the web soon. We'll see her in a minute. She'll be coming to us at the, at the end. Um, so, uh, I think we're going to start off. Matt, you have a core topic. Gastroesophageal reflux, another non-controversial subject for us. We'll start with a case presentation. A 20 day old, uh, female infant is referred to you after seeing an ENT surgeon because she's vomiting out her nose and choking with every feed. The parents stay up all night long holding her upright and trying to keep her from choking. She's gaining weight fairly well due to the parental diligence. So you obtained this study. Why do you obtain that study? Why do you obtain that study? Uh, I have a question coming up after this. Let me get there, OK? Someone obtained this study. And they show it to you and you have two views, and that one is all contrast going up rather than down. At this point you recommend, and this, Todd, I guess is something people can vote on a PH or impedance study, start a PPI or medical therapy, fundoplication, some sort of transgastric jainnostomy tube for feeding, or something else. We're going to let that, that poll go. So, so in the meantime, with now what would, what would you, what would you do at this point with? So, so Matt, can I come back to you for a second? Yeah. Um, you know, you said it jokingly said, why do that study? This is a 3 week old, am I correct? You know, I, I think in a 3 week old it's worthwhile doing this study. There's so many other things that it could be. Uh, just the other day we found a, a, a right aberrant subclavian arch obstructing the esophagus. Uh, so you know there is debate of, of what you should do now. Maybe in an older child, you probably don't need to do anything, but there's the 3 week old, there's pyloric stenosis, I guess we could have done an ultrasound first. There's, there's a series of other phenomena. All right, any other comments about what people would do now? So, uh, we're, Mark, do we have that poll? Yes. Well, we'll work on that, Mac. Sorry. Well, I'm not, Mac, I'm not sure, you know, 3 week old who's gaining weight, all being, albeit with parental diligence, I'm not sure I would do anything. So it's, it's the, it's the vomiting out the nose and choking and the parents staying up all night trying to take care of the child. Maybe if that's the problem, stay up all night and feed the child, they wouldn't vomit out the nose. OK, we'll do parental counseling. All right, let's decide you want to do a fundoplication on a neonate. Never done that? What would you do? Another quiz for the audience? Dan, what would I do if it were a given, I would do a lap Neen. OK, if, if appropriate, you'd do a lap Nessen. Yes, if appropriate. Mark Wilkin laparoscopically, of course. Is there another way to do it, right? I don't know. All right. Do we get votes from the audience? Is that, uh, hey that that audience. I said a lapnising. OK, the polls are, uh, we'll need a few more minutes for the polls, so no polls right now. Anyone do an openness and fund application in our group here? OK, so are we skipping? Are we done with the workup? We're done with that part, or are you going back to it later? No, go, go ahead. You want, I just want to address that more. I think that's the hardest part of this whole thing. Yeah, I'm very reluctant to do a fund in a newborn in the first month of life. In fact, I extend that to about 6 months of life. Of course, if I was gonna do it, I'd do it laparoscopically. But how do you, how do you take care of this child? These, these are desperate parents. It will not work for you to say don't feed them at night. This is they are exhausted. They stay up every night. They don't feed the baby every night. The Baby just throws up all night long. So it's choking. So you're convinced is the child losing alty? Is the child losing weight? Is the child truly having alties? Is the child having obsoclonus and extension like a sandifer? Is the child? Behaving otherwise normal. If it's just to placate the parents, maybe they should get the fund of placation. If it's not to placate the parents, but it's affecting the child's well-being, then I would let's say the child is losing weight for the sake of our discussion to move forward. That's a big difference though, to me that's a very significant and the dramatic vomiting, all right. So gastroesophageal reflux disease, let's pause for a second in our case and talk about how the pediatricians view it. So this is a recent review. Gastroesophageal reflux occurs in more than 2/3 of otherwise healthy infants and is the topic of discussion with pediatricians at 1 25% of all 6 month visits. Differentiating between gastroesophageal reflux and gastroesophageal reflux disease lies at the crux of the matter. And in 2009, NAS began. And Espagan, the European equivalent, published guidelines for reflux in children, and there are many papers in the pediatric literature right now talking about our institutions adopting these guidelines. Is everybody getting on the same page with how we diagnose these diseases and treat them? They also say finally if surgical approaches should be reserved for children who have intractable symptoms unresponsive to medical therapy and who are at risk for life threatening complications of reflux disease, so those are the two indications for surgical therapy according to the pediatricians. If anti-reflux surgery is pursued, the new guidelines stress the importance of providing the families with adequate counseling and education. Before procedure and so that they have a realistic understanding of the potential complications including symptomatic recurrence. How, how do we as surgeons respond to that? We on, on board with the pediatricians? Is this controversial, straightforward? No, I do think it's important to have a thorough preoperative conversation with the families, uh, about the potential, uh, complications afterwards, uh, and it's also important to, to figure out if the child's having significant wretching symptoms preoperatively because at least in my experience, the most frustrating part of the postoperative, uh, follow up is in the child who is wretching. And if the child is wretching preoperatively, there's a high likelihood they're gonna wretch postoperatively, uh, and so you need to try to figure that out early on if there's gonna be a likelihood of postoperative wretching and counsel the families appropriately, but also counsel the families appropriately to what they can expect and what do you counsel your families on for recurrent symptoms? Well, uh, I tell them that, that it's not likely, excuse me, I tell them that there's a 95% chance that the operation will be done successfully and that, and that they won't have another, they won't need another operation. I tell them that there's about a 5% chance that they might need to have another operation and I tell them that there's a, uh, a 90%, 95% chance that the fund application will, um. Help resolve or resolve their symptoms. I think one thing that we get caught up sometimes is if we do a fundoplication and the patient still needs some antacid therapy afterwards that that's a failure. To me it's an adjunctive therapy and so the fundallication has helped the child with the reflux and then they need a little medicine, uh, and so I don't necessarily consider that a failure. 95% others around the room. 95% success. I tell what I tell the families is that clinically it's 95% successful, but if they look in the literature, which many of these parents are all over the internet, they will see numbers that are much higher than that. And then it just depends on what you, how you assess the recurrence as to whether what the numbers are that you're going to find. So there is a difference how you assess the recurrence, or do we as surgeons do this operation differently? It, it's some some of us have, I'm sure it's some of both. I think it's different varies. It depends on the patient population. There are a lot of variables in that, and I, I tell the parents that there's a 5 to 10% chance that they might need another operation, or I guess I could send them to Kansas City where, you know, because what may do a better job than we do. But overall, the, the real question though is what about, you know, they'll ask, you know, what about when he's an adult or she's an adult, and how, what about the lifetime risk? And if you look at the adult literature for fund application, after about 15 years, almost all of them are, are, are undone. And so I don't know why we think that ours is going to be any different. We just don't follow our patients past 18. So I, I, I tell the parents that there's a, that there is a chance. Although, you know, it doesn't, again, to Witt's point, going on medications is not a failure, and sometimes these kids need the fund to get over their, their acute phase and their hump and get growing and everything, and if they end up on PPIs down the line, that may not be a terrible thing. Great, we're gonna move ahead. So AAP has some guidelines about how to treat reflux. They point out that H2 agonists or PPIs may have the risk factors for pneumonia, gastroenteritis, candidaemia, and NEC in a preterm infant, but fundoplications are associated with significant morbidity. Before surgery, other ideologies should be, uh, considered, and again, please counsel your parents carefully. So Max, do they, do they have data to support that statement, the significant morbidity? I'm telling you because pediatrician's guidelines. I know, because, because we have, because we have, there's lots of articles that many in this room have authored that show that the immediate morbidity and mortality of a fundoplication, of a laparoscopic fundoplication, even in infants is very low. It's a safe operation. I think they're talking about long term issues, not short term issues. So the burden is on us to figure out how to define these two indications for surgery because I think it's muddy right now. Anyone who attended the American College of Surgeons meeting a few weeks ago, there was a panel session on reflux. I think you were there, Witt, and most of the discussion was about, do we know who to operate on. So we need to figure out how to define what is, what are intractable symptoms and who is at life risk, risk of life for reflux disease. So Mac, just as a follow up for you, because I think this is where I think I would like to folk to better understand your poll questions. There's so much variability in your first one. 80% do lapnocence, OK, but regarding what you do with the patient, Fondo, that's where there's a disagreement, and, and I'm, I have a lot of questions for you. So, well, we're going to end this session not knowing the answer to your questions. Oh no, we'll get in. All right, so here's, here's the case that we already presented a little bit. This child received a short, loose, minimally mobilized laparoscopic missing and a gastrostomy tube. Mom hugged the surgeon and cried with joy. No more staying up at night. No more vomit coming out the nose. However, 3 months later, some vomiting started again, and now mom is crying again. It's not coming out the nose. Patient's not losing weight, but we were having no vomiting and now we're having vomiting. Weight gain's OK. G tube's OK. What do you do now? Start him on a little medication. X-ray redonising transgastric J tube that's popular these days. I would try the medication something else. So we got medication. I would get an upper GI so that you can see what the anatomy, I think an upper GI. And let's say, let me ask you, so you get the upper GI and let's say they say it looks a little loose. Your Nissan's, I don't think you can tell anything about how loose or tight it is unless there's wide open, right? I would look, right. The question that I would want to answer is the anatomic question, not the physiologic question. The reason the upper GI is just. Make sure there's not a hiatal hernia. And hopefully if you do minimally minimal dissection, there's less of a chance of that, but it's not zero. But if there's not a hiatal hernia, and even if the kid has a little bit of reflux on the upper GI, but the Nissan looks mostly intact and the kid's otherwise fine, I think you reassure the mom, all babies vomit. And, you know, and again, if it's just some occasional vomiting, it doesn't mean that it even needs to be treated with medication as long as everything else is OK. Every baby's vomiting. I see that Steve's on the chat. I wonder if he'll make a comment. Rothenberg, I know that he's on one extreme. He says that upper GI just cannot tell you anything, that it may look perfect on the upper GI, but going in to redo the wrap often has uh. An improvement in their symptoms. Well, even if their upper GI looks great. So this child got a post-op upper GI, and here you can see it looks like the fundallication. Can we show the image, Mark, can we show this image, the the slides image. Thanks. Maybe you can respond. Do people always do a G tube in these little babies? No, no. This kid, there was some ENT issues about swallowing function, and so the G tube was put in hoping to be temporary. I'm curious, Mike, would you have the patient be seen for undergo an endoscopy to rule out EE, rule out some motility disorder of the esophagus? I think that's, that's a good discussion point. Who would get a routine endoscopy on an infant that you felt like you needed to do a fundo on for some good reason? Would you get endoscopy? No, no. I think it's unusual that we do that. It may be the right thing to do, but I think it's unusual that we do it unrecognized component of motility disorders. An infant less likely to have EE since they are so early in the feeding process, but I think that's an unrecognized component of the challenges that people actually see, which is they think it's a rat or they've gone to a wrap this early. And it actually is more of a functional motility issue that is actually exacerbated by the rap, and then you actually can create a more difficult situation where you've already created a functional obstruction downstream. So, so Greg, I, I want, can you spend, uh, eosinophilic esophagitis, definitely a newer hot topic now. It's really sexy right now. It's the new thing that we've underrecognized for all this time. You've mentioned that it's not something you see in the infant. When do we start seeing EE? So clearly this is not my area of expertise. We have a lot of people in this room who focus more on, on, on I don't disorders, although we do all of us in Cincinnati work with our motility team fairly consistently for this population. They have seen kids really early with EE, and this is where, you know, again, maybe it's center specific. Where we have the opportunity to interact with people who focus on it. EE is not new for us because really a lot of the originating ideas came from Cincinnati and so we're working with people who've been doing it for the last 1015 years. And again, those are those patients are the ones they're very careful about sending to us for consideration. This case aside. It is a little bit less likely given how early the symptoms began, but our team would be pretty aggressive about scoping, biopsying, making sure we're not missing EE, because in this day and age with the prevalence of allergies, it's becoming an issue across the board. The frequency of food allergies is skyrocketing in the PES population. Good points. So this child did get a post-op upper GI and it looks like the fundoplication is still intact to some degree, but there is some reflux back up the esophagus. I think we've already perhaps gone through this at this point. It sounds like, uh, let's pull the audience though. Jenny, can we put up that poll? Uh-huh. OK, so we're doing that. Can I ask you a question about the PPIs? We always say the child's vomiting, so start him on PPIs. Do PPIs stop vomiting? No. I, I never understood that acid reflux less acidic, right? Yeah, so we said start on him a little medication so maybe he could tell us what, what else would he pick. No, OK, you'd pick that. No, I would, I, is if the child is feeding well, I mean, is, is, is gaining weight, I wouldn't do anything on this child. Nothing. All right. Uh, so, contra, since we're doing an update, I want to take a few seconds to talk about some recent publications that are controversial in our world about this topic. Uh, these are isolated studies that have been published recently. Funddoplication and gastrostomy versus percutaneous gastro gastrojainnostomy tube for reflux in children. A meta-analysis looking at 400 fundos, 125 GJ tubes, and there's no difference in the rate of pneumonia, no difference in mortality, more major complications in the fundo group, up to 29% compared to a GJ tube, more minor complications in the GJ tube, 70%, uh, compared to the fundoplication. So this is the sort of thing that the pediatricians are looking at that are, that, that our patients are learning about and that we're learning about. A randomized controlled trial looking at laparoscopic versus openness and fundoplication published this year. You have only 44 in the laparoscopic group, 43 in the open group. 23 in each group have neurologic impairment. Median age was 4.7 years. Only experienced laparoscopic surgeons did the laparoscopic fundo. The authors point that out. No novices. Recurrence of gastroesophageal reflux was 37% in the laparoscopic group and only 7% in the open fundo group. Risk of reoccurrence was 5.2% higher. In the laparoscopic group. Let me do one more and then we'll discuss this. Another randomized trial looking at laparoscopic versus openness and fundallication in children under the age of 2. Over the course of 7 years, 4 surgeons at a single institution, still only 21 open and 18 laparoscopic in the randomized trial. No difference in length of postoperative stay, time of advanced to full feeds, or analgesic requirements. The laparoscopic group had a longer op time. And higher surgical charges. Post-discharge complications did not differ significantly between the two groups. So this paper concludes there's no advantage of a laparoscopic missing. Thoughts about open versus laparoscopicness. Mark, you were very committed to laparoscopic Nissan's a little while ago. Are we doing, we're doing the wrong thing. So what they're not addressing here is What what they're not addressing are the long term the long term complications of a laparotomy. And for those of us that are old enough to remember, or at least maybe when we were training, when there were a lot of open Nissans that had gone on before us, so you always had one or two kids on every pediatric surgery service with a bowel obstruction that was several years out from their open Nissan, and the morbidity and even mortality from a bowel obstruction is underreported. Related to a laparotomy. So even if it's equivalent. Even if it's equivalent, and I don't know, I mean, these studies are very small numbers, and there are large studies with Much better results than those, uh, I think the laparoscopic is the way to go. Prospective and randomized whip. Well, the, the last study, that's the only one I can remember, but, uh, it's a small study I just slide, it's a small study, uh, I believe it was 40 patients over 7 years, and so that averages out to 5 or 6 patients a year, so. I would not say that that's the surgeons have enough experience with either technique really over 7 years, 5 patients a year to come to valid conclusions. Any other comments about this? Yeah, I would agree there's this selective bias by the fact that you've got institutions still doing open fundoplication. I know that our institution hasn't done an open fundoplication. Many years, so you know, I'm, I'm somewhat skeptical by the numbers presented as well as the fact that you still have open fund applications. The laparoscopic fundoplication should be the same operation that you do openly. You just do it laparoscopically. So in my opinion, the results should be the same, and then there should be other advantages or disadvantages of one approach versus the other. I think there's significant to Mark's earlier point about patient population, there's significant potential patient bias or, you know, why did the patients who got open get open versus those who got laparoscopic. Laparoscopic? Was it purely surgeon choice, or was there some referral pattern that changes the patient population, because clearly neurologically impaired patients do worse than neurologically normal, or at least that's the historical data is that there's a significant difference in the way those Populations, uh, what their long term outcomes are from a fundal placation. Couple of more points real quick. Partial versus complete wrap. Everybody do a Nissan in this room. Raise your hand if you could pick a Nissan. Who does partial? No hands. So here's a meta-analysis and to jump to the conclusion, um. They're, uh. Showed improved outcomes following complete fundoplication barely. I think that if. Whichever one you do the best you ought to do. If you do a partial one better than a Nissan, you ought to do a partial one. I think the, the results are probably equivalent, but it's whatever you do best. It's another thing I don't, it's sort of like the PPIs that I don't understand that if, if a Nissan, uh, fails by coming apart a little bit and the recurred reflex, but, but yet it's OK to do a partial wrap, and that prevents reflux. It just doesn't. I struggle with that. Good point. And, uh. I'm going to, I think, uh, skip to this topic about minimal mobilization versus maximum mobilization. Again, Kansas City and Birmingham did a prospective randomized trial trying to compare the left picture is, uh, aggressive mobilization, taking down the frontoesophageal ligament, creating a larger retroesophageal window than we really see here versus not doing much mobilization and found that minimal mobilization resulted in, uh, less, um. Uh, incidents of, uh, uh, transmigration of the rap, uh, over time and recently Kansas City has published a follow-up story, uh, paper looking at following their patients, uh, over 6.5 years. And I think this is the punchline, the aggressive mobilization. Had a 23% incidence, went from 23 to 37% incidence of transmigration where the minimal mobilization did increase over those six years but went from 3% to 12% at the end of 6.5 years. So time to diagnosis hernia was significant, significantly longer in the minimal mobilization group compared to the maximum mobilization group. Uh, and there was no significant difference, uh, in reflux symptoms or medication use in the group. So again, I think the minimal mobilization approach has been shown to be, uh, the better operation laparoscopically, right? So that study was mainly looking at transmigration being the cause of recurrent reflux and the need for recurrent operations. If you don't have transmigration as a problem in your practice, I wouldn't change anything, but in our practices in Birmingham and in Kansas City, it seemed like transmigration was the 90% of the reasons why we were having to redo them, and that's really what led to this study is trying to find a way to reduce transmigration and minimal mobilization, uh, seems to do that. Um, Mac, before we move on to wit, and actually, um, we're gonna load up Witt's slides here. Um, oh, perfect, um, I, I wanna go back for one minute and, and take a NICU baby that they're having trouble feeding, the baby's refluxing, aspirating. Um, actually, we're, they're feeding the baby and they're aspirating. The question is, do they have, do they need a G tube or a Nissan? And that question comes up, do they need a G tube alone or Nissan in a G tube? And I know that people talk about, uh, uh, using pH impedance to see if this is a, so let's say you do a swallow study and it shows that they aspirate when they, they eat. And they want you to do a G tube. How do you assess them to make sure they don't need a Nissan? Do you do pH impedance? Do you go by history alone? Um, I know what I started doing is I put an NG tube down, and if they do well with an NG tube, I just do a G tube. If they don't, I do a Nissan. That's as simple as I make it. I think bolus gastric feeding trial is the way to go. I think that's the, I, I found that to be the most helpful as well, Todd. I agree. Um, does anyone disagree with that? Do it differently. An algorithm for determining when they call you for a G tube to see if they also need a Nissan. Does anyone do something different? I, I think that like Max said, the trial of bolus G tube feedings with the baby does fine. I think that's a really good test because it's a functional test. You know, if you start going down the, the rabbit hole of pH impedance probes and things like that, and sometimes some of our medical colleagues will want to do that, it, it to me it doesn't inform you what you need to do ultimately for that baby. What about a, uh, an older child, um. 8 months old, they're having failure to thrive. And do you work them up for reflux, doing anything different? I mean it depends on what their symptoms are. If they're still completely, I mean, they're not and they're NG fed, No, they're orally fed, orally fed. So then what's the question? No, I guess my question, so then you're asked for a failure to thrive 8 month old that needs a G tube, and they're not vomiting. No, no, just do a G tube. So vomiting is your, whether they're vomiting or not. Well, yeah, whether they're symptomatic, you know, one of the real interesting questions that we struggle with is, do you need an upper GI on every single one of those beforehand, because that's our, you know, surgical dictum is that you need an upper GI beforehand. Who gets an upper GI prior to a G tube? Oh, to a G tube, G tube alone. You decide you're gonna do a G tube, do you get an upper GI to see if they're malrotated. We did a study. We, we wrote our group wrote a paper on this, and there was a 4% incidence of changes on the on the upper GI, and as I recall, 80% of that 4% was due to malrotation. So let me ask you, if you select, if you take that and divide those patients up to those who are vomiting versus those who just didn't want to take anything by mouth, it's just oral version or they just wouldn't eat, do you? I wonder if any of those had any change if you select out that group. I don't, I don't know that precise data, but, but I agree with what's been said so far, and it's really a lot easier, I think, in an 8 month old, 1 year, 1.5 year old child if they have failed to thrive, poor oral intake, but they don't have any reflux symptoms, you just do a gastrostomy on those children. To me, the harder question is the. The 2 month old who's in the NICU's been on a ventilator all their life. They can't get him off the ventilator. They're trying to feed the baby's not feeding well, and generally speaking, we end up doing a fundo on those particular kids. But if, if you've got some history. That they are not vomiting and don't have reflux symptoms, whether they're neurologically impaired or not, then you ought to just do a gastrostomy. OK. What about an 8 month old that is vomiting, but the mom says, yeah, they spit up, they spit up. Well, I, I just saw a child last week that, that was having some reflux symptoms, similar scenario. They were 8 months old. They were on some medications. The sy the vomiting was getting better. Mom wasn't interested in a fundo, so we just did a gastroscopy. Is it reasonable to do a G tube, see how they do, and then go back and do a Nissan? Absolutely, yeah, that's perfectly fine. The, the papers will show you there's probably a 10 to 15% instance, maybe a 20%. We did that paper together. We wrote that paper. We looked at all the GP. Somebody wrote a paper. It was 15%, as I recall. It was less than that. I'll look it up. I think it was a little less, but it was, but a small percentage might need to fund those subsequently, right. Uh, what about the patient who was sent to you to the ENT office? I had to look in the back of the, I don't know, I make it up, and, and they have their cords are really erythemous needs a fundo shows up in your office. Have they've been on PPIs? It shows up. OK, yes or no. I don't know. I would start PPIs first because that's something that PPIs would help with. So they can have reflux all they want, but that, that will take the acid away and they probably won't have the cord inflammation. Now the question is, you're saying it's going in their airway, so do they need a Nissan? No, the ENT is asking. I'm not asking. I think in that case, I, I think that might be a good case for an impedance, um, uh, an objective measurement of, do the, is the, is the erythema that they're seeing actually due to reflux or not.