Gastroesophageal Reflux: Contemporary Management Pediatric Surgery Update...
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Multiple-channel intraluminal impedance probes are the best test for quantifying the presence and severity of non-acid reflux over time.
Impedance probes are not readily available to all practitioners, particularly outside major centers, and even within the United States not all pediatric gastroenterologists perform them.
pH probes are more readily available and more commonly used than impedance probes for reflux evaluation.
Gastroenterologists report they can perform impedance studies in neonates, although they are rarely requested.
Surgical decisions to operate for reflux are typically based on clinical symptoms rather than objective testing.
Collis gastroplasty is not necessary for routine fundoplication with hiatal hernia repair in pediatric patients.
Pyloroplasty is not routinely performed at the time of fundoplication.
For patients who tolerate nasogastric tube feeds without vomiting, gastrostomy tube alone may be sufficient without fundoplication.
For patients who continue to vomit despite nasogastric tube feeds, fundoplication (Nissen) is indicated.
For a 3-year-old child who is eating orally, gastrostomy tube placement is not routinely indicated at the time of fundoplication.
In a study from the speaker's institution examining fundoplications and correlating upper GI studies with pH studies, the upper GI influenced management in 4% of cases.
Of the 4% of cases where upper GI influenced management, 80% were due to detection of malrotation.
The 4% rate of upper GI studies influencing management can be interpreted two ways: either 4% is significant enough to warrant routine pre-operative upper GI, or 4% is low enough that malrotation can be evaluated intraoperatively during fundoplication.
If pre-operative upper GI demonstrates malrotation in a patient being evaluated for fundoplication, management changes from fundoplication to Ladd procedure with proton pump inhibitors instead.
Upper GI studies can also detect duodenal web or duodenal stenosis in addition to malrotation, though malrotation was the most common reason for management change.
In 2013, laparoscopic approach should be the default for fundoplication rather than open approach.
For type 2 (paraesophageal) hiatal hernias in children, fundoplication and hiatal hernia repair alone is adequate without gastropexy or gastrostomy tube.
Once a paraesophageal hernia is reduced and fundoplication performed, gastropexy does not appear necessary based on available data.
In gastroschisis patients being re-operated at 6 months of age, there are often not many adhesions present, making laparoscopic approach feasible.
For gastroschisis patients requiring fundoplication, left upper quadrant initial port placement via mini cut-down is preferred over umbilical access to avoid adhesions.
In neurologically normal 6-month-old infants with reflux, there may be justification to wait longer before proceeding to fundoplication since they may still outgrow reflux.
Laparoscopic approach can be successfully attempted even in patients with previous abdominal operations, as adequate visualization can usually be achieved with patience.
For redo fundoplication after prior laparoscopic Nissen, laparoscopic approach is preferred as visualization is often better than with open technique, even in the upper abdomen.
Laparoscopic anti-reflux operations are well-tolerated by infants with cardiac anomalies.
Wrap herniation above the diaphragm is NOT more common in the open group compared to laparoscopic (contrary to what might be expected).
Postoperative bowel obstruction rates are significantly lower with laparoscopic fundoplication compared to open approach.
Traditional rates of postoperative bowel obstruction after open fundoplication were quoted as 5-10%.
Current estimated rate of postoperative bowel obstruction after laparoscopic fundoplication is approximately 1-2%.
For laparoscopic fundoplication, ports are placed higher in the abdomen, which may contribute to even lower bowel obstruction rates than general laparoscopic surgery.
Neurologically impaired children who develop adhesive bowel obstruction after fundoplication may present late and very ill because they have a closed-loop obstruction with inability to vomit.
Nasogastric tube trial is a useful diagnostic test: if a vomiting patient does well with NG feeds, they may only need a gastrostomy tube; if they continue to vomit with NG feeds, they will need fundoplication.
Nasojejunal tube trial is even more diagnostic than nasogastric tube, as tolerance of NJ feeds strongly predicts success with fundoplication.
For infants with hypoplastic left heart status-post stage 1 repair who have documented aspiration and recurrent desaturation events that cease with NJ feeds, fundoplication is indicated.
Indications for fundoplication in cardiac patients include recurrent aspirations, apnea-bradycardia-desaturation events, or failure to thrive, not simply the presence of cardiac anomaly alone.
In cardiac patients who are failing to thrive and need gastrostomy tube, performing fundoplication at the same time prevents creating an aspiration risk with G-tube alone.
PEG tubes that stick straight out are particularly cumbersome in cardiac patients who have sternal wires and atrial leads.
PEG tubes are not very appropriate for babies in general.
Cardiologists and pulmonologists are aggressive about recommending fundoplication for children with pulmonary hypertension or cardiac anomalies who are borderline feeders.
For cardiac patients too sick for fundoplication, primary GJ tube placement is an alternative, allowing jejunal feeding in hospitalized patients.
Fundoplication alone typically improves gastric emptying in most patients, eliminating the need for routine pyloroplasty.
There is still a segment of patients with poor gastric emptying despite fundoplication who may benefit from additional interventions.
Gastric electrical stimulation can effectively stop retching in neurologically impaired children with severe gastroparesis after fundoplication, with immediate cessation of retching.
Retching after fundoplication in patients with severe gastroparesis can loosen or undo the fundoplication wrap.
In the past when performing open fundoplications, gastric emptying studies were routinely checked and pyloroplasties were performed on neurologically impaired patients.
After switching to laparoscopic fundoplication and based on data showing it helps gastric emptying, routine pyloroplasty is no longer performed.
For gastric pull-up procedures (for lye stricture or esophageal atresia), pyloroplasty is performed.
For reverse gastric tube procedures performed in the neonatal period for esophageal atresia, pyloroplasty has not been performed.
When pyloroplasty is not performed during gastric pull-up, there is a lower rate of stricture at the esophagogastric anastomosis, possibly because bile is seen in the stomach on endoscopy indicating the pylorus is functioning.
For asymptomatic type 1 (sliding) hiatal hernias, operative intervention is not indicated.
For asymptomatic paraesophageal hernias (types 2-4), operative intervention is indicated.
In developmentally delayed children who develop small hiatal hernias after fundoplication, if they are asymptomatic, observation is appropriate given the high operative risk.
Adult thoracic surgeons performing gastric pull-ups for esophageal cancer stopped doing pyloromyotomies or pyloroplasties, and if patients had emptying trouble they performed Botox injections.
Adult thoracic surgeons found more problems with reflux and stricture at the esophagogastric anastomosis when they performed pyloroplasty during gastric pull-up.
Over time, even though vagus nerves are divided during gastric pull-up, the stomach will eventually empty without pyloroplasty.
Some surgeons perform a mucosal-sparing pyloroplasty (essentially a pyloromyotomy closed transversely) rather than full-thickness pyloroplasty.
Operative intervention for hiatal hernias is indicated in symptomatic patients with type 1 or other paraesophageal hernias.