The surgical treatment of gastro-esophageal reflux in neonates and infants

Gastro-esophageal reflux (GER) is a physiological process characterized by the involuntary passage of gastric contents into the lower esophagus not induced by noxious stimuli. It represents a common condition in preterm infants and may occur in healthy neonates. The phenomenon is only considered as GER disease when it causes the patient to be symptomatic or results in pathological complications. Fundoplication is recommended in symptomatic neonates and infants with GER that does not respond to medical treatment. The presence of respiratory symptoms related to GER is the primary indication for fundoplication in this selected population. The Nissen fundoplication is the antireflux procedure of choice and the experience concerning other procedures, including laparoscopic techniques, is limited in this age group. The best results are achieved in newborn infants with isolated GER, as the recurrence rate of GER in infants with associated anomalies is high. Further studies are necessary to evaluate the benefit of laparoscopic fundoplication in this age group.     

Five-year study of medical or surgical treatment in children with severe vesico-ureteral reflux dimercaptosuccinic acid findings

 The results of serial dimercaptosuccinic acid (DMSA) imaging over 5 years are reported in 287 children with severe vesico-ureteral reflux entered into the European Branch of the International Reflux Study in Children. The children were randomly allocated to medical (n=147) or surgical (n=140) management and DMSA studies were performed during the follow up period at least 6 months after any urinary tract infection. Abnormal images were classified into four types: (1) large polar hypodensity with normal renal outline; (2) peripheral photon deficient defect(s) in a non-deformed kidney; (3) small renal image with normal contour; and (4) peripheral defect(s) with resultant irregularity of the renal outline. The DMSA findings were abnormal at entry in 235 (82%) with no difference in incidence or severity between the two treatment groups. During follow up, deterioration was observed in 25 medically and 23 surgically treated patients and comprised image deterioration alone in 17, image deterioration with corresponding reduction in differential function in 16 and reduction in relative function without image change in 15, with similar distribution between the two treatment groups. Deterioration was more frequent in children entering the study under the age of 2 years and in those with grade IV rather than grade III reflux. These findings, showing no difference in outcome between children managed surgically or medically, are consistent with the radiological results already published. Conclusion In the International Reflux Study the DMSA scintigraphic data showed no difference in outcome between children managed surgically or medically. Received: 11 April 1997 / Accepted: 25 June 1997     

Esophageal motor activity in children with gastro-esophageal reflux disease and esophagitis

OBJECTIVE: To evaluate esophageal body motor contractions occurring during esophageal reflux in pediatric patients with gastro-esophageal reflux disease (GERD). METHODS: Patients referred for the evaluation of GERD who were evaluated with combined 24-hour pH probe and esophageal manometry test (MP24) were included. Patients were separated into the following groups: Group C -- normal pH probe and normal EGD; Group 1 -- abnormal pH probe and normal EGD; and Group 2 -- abnormal pH probe and EGD with histologic esophagitis. Esophageal motor function during reflux episodes was analyzed. RESULTS: Twenty-five patients were included. All had a normal stationary esophageal manometry. Patients in Groups 1 and 2 had significantly more gastroesophageal reflux by pH probe than Group C (P < 0.01). During the MP24, patients in Group 1 and 2 had significantly fewer contractions per minute pre-, during, and post-GER (P < 0.05). There were significant differences in the number of isolated and prolonged contractions (>7 sec) during prolonged GERD episodes >5 minutes (P < 0.05). CONCLUSION: Children with GERD have a decreased number and abnormal esophageal body contractions with esophageal reflux. This suggests that children with GERD with and without esophagitis have impaired esophageal body acid clearance.     

小儿重症哮喘的机械通气治疗

病情极危重的哮喘常被称为“致死型哮喘”或“危及生命的哮喘”,表现为严重的低氧血症、呼吸性酸中毒、呼吸肌疲劳、肺性脑病等。这些症状可危及生命且药物治疗通常不能缓解。1961年Leonhardt首先用机械通气治疗危重型哮喘,现已成为治疗这类疾病的重要手段。哮喘的机械通气治疗     

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

Background

Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

Aims

To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

Methods

We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients’ Visick score assessed parents’ perspective.

Results

Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents’ perspectives were excellent or good in 85 %.

Conclusions

A significant positive impact of redo Nissen intervention on the patient’s outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

     

Familial forms of gastro-esophageal reflux

Gastroesophageal reflux is a common disorder that can be responsible for respiratory disease and is not considered as an inherited condition. We report five families with several affected members. Other familial cases have been published and some authors have suggested that transmission occurs on an autosomal dominant basis. Only prospective studies could determine whether GER is an inherited disorder, but at present their feasibility is limited since currently available diagnostic investigations are not suitable for screening.     

Pharmacologic control of gastro-esophageal reflux in infants with cisapride

Autonomic receptors in the upper gastro-intestinal tract permit pharmacologic manipulation of esophageal and gastric function. A new non-anti-dopaminergic, non-cholinergic, prokinetic agent, cisapride, was evaluated to determine it's efficacy in controlling gastro-esophageal reflux (GER) in infancy. Forty infants, mean age 6.5 months, were studied and their response to therapy determined by continuous measurement of lower esophageal pH over a 36-hour period. Five parameters were assessed in the erect, supine, and prone positions, both before and during short-term cisapride therapy. The drug was effective in reducing GER in 86% of the infants studied. Those infants who had a poor overall response to therapy could be identified retrospectively by the lack of improvement in esophageal acid clearance and frequency of reflux episodes; anatomic abnormalities were present in the majority of this subgroup. Cisapride is considered to be effective in the short-term treatment of primary GER of infancy, and a more prolonged assessment is indicated. Offprint requests to: H. Rode     

机械通气在儿童危重哮喘治疗中的应用

目的 探讨危重哮喘患儿应用机械通气治疗的临床疗效.方法 回顾性总结10年间28例危重哮喘患儿应用气管插管机械通气的临床资料,分析其通气方式、好转率、病死率、机械通气治疗前后血气分析指标的变化.结果 在通气模式上,采用容量辅助/控制模式12例,同步间歇指令通气联合压力支持16例.撤机模式均为同步间歇指令通气联合压力支持,此外根据病情还适当应用肺保护性通气、低呼气末正压通气、肺开放等通气策略.患儿病情好转出院率96.4%,病死率5.6%.结论 机械通气是危重哮喘患儿十分重要的抢救治疗手段.把握适应证、采用正确的通气策略、配合及时有效的呼吸管理和综合治疗是治疗成功的关键.     

Pharmacologic efficacy of sodium alginate suspension on gastro-esophageal reflux in infants and children

Eighty-three children presenting with symptomatic gastro-esophageal reflux (GER) (48 males, 35 females, aged 15 days to 57 months (mean = 7 months) were assessed by pH monitoring. All showed acid pathological GER on the 3 hours post-prandial esophageal pH measurement (% of time at pH less than 4 greater than 4.2) and all had a second pH measurement within the following 3 hours after intake of a single (5 ml) dose of sodium alginate (AGS). AGS administration was followed by a highly significant reduction (p less than 0.00001) of all pH measurement variables: a) Percentage of time spent at pH less than 4 returned to normal with a mean 11.7% to 4.8%; that is a 52.5% improvement (median); b) Total number of reflux reduced on average from 8.9 to 5.0: that is a 35% improvement (median); c) Mean duration of reflux reduced on average for 4 to 2 min; that is a 60% improvement (median). In 76 patients hourly monitoring of % of time spent at pH less than 4 shows that hourly improvement persists.     

Psychomotor adaptation in children with severe chronic asthma

Acute effects of steroid medications or hypoxic-induced brain damage have been hypothesized to cause neuropsychologic impairment in children with severe asthma. The present investigation included neuromotor, cognitive, psychosocial, and medical evaluations of 67 hospitalized asthmatic children from 9 to 14 years of age, at risk for motor dysfunction. Mean scores from the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) were similar to test norm means and were not indicative of neuromotor impairment. Scores of the BOTMP correlated significantly (P less than .01) with measures of child and family psychosocial adaptation but not with measures of cognitive ability, steroid dose at admission, or severity of asthma. Thirteen children had battery composite scores more than 1 SD below age means but did not demonstrate decreased IQ or increased steroid use, respiratory failure, seizures, or abnormal neurologic signs compared with the other 55 children. These results indicate that most severely asthmatic children, including many with histories of hypoxia and high-dose steroid use, do not demonstrate psychomotor impairments indicative of brain damage. It is concluded that neuromotor development in asthmatic children is associated with psychologic characteristics that influence adaptation to illness and activity level.     

儿童重症哮喘气道中性粒细胞凋亡的研究

Objective To investigate the changes of neutrophils in airway inflammation in children with severe asthma. Method Children with mild to moderate asthma (n=23), severe asthma (n=16) and healthy control subjects (n=16) underwent lung function tests and sputum induction. The sputum specimens were assayed for cellular differential count, the supematant and peripheral blood were assayed for the concentrations of IL-8 by "sandwich" enzyme linked immunosorbent assay (ELISA). Sputum supernatant, IL-8 and mifepristone were assessed for their abilities to prolong the in vitro survival of blood-derived neutrophils. Result The percentage of sputum neutrophils was significantly higher in severe asthmatics [59.54 (41.99-74.65) %] than mild-moderate asthmatics [30.03 (15.94-47.71)%] and healthy control subjects [29.72 (16.53-45.74)%] (P<0.01) ; the level of IL-8 in sputum was significantly higher in severe asthmatics [2907.78 (331.67-3457.93) ng/L] than mild-moderate asthmatics [287.58 (130.75-656.84) ng/L] and healthy control subjects [179.2 (58.55-346.59) ng/L] (P<0.01) ; the percentages of neutrophilic apoptosis respectively cultured with LPS [(10.57±1.97) % ], severe asthmatics supematant [ (11.82±2.96) % ], IL-8 [(10.47±1.93) % ], dexamethasone [(9.93±1.95)% ] ,severe asthma supernatant + mifepristone [(12.15±2.86)% ] in vitro were lower than that cultured with PBS [(17.98±2.27) % ], healthy control supernatant [(17.37±2.50) % ], mild-moderate asthmatics supematant [ (16.35±3.26) % ], mifepristone [(17.89±2.38) % ], and dexamethasone + mifepristone [ ( 17.06±2.59) % ] ( P<0.01 ). Conclusion Suppression of neutrophilic apoptosis seems to play a potential role in airway neutrophilic inflammation in severe asthmatics, and the level of IL-8 in sputum was significantly higher in patients with severe asthmatics.     

Management of severe asthma in children

The majority of children with asthma are classified as mild/moderate and can be successfully managed with regular inhaled corticosteroids and bronchodilators. However, more than 5% of asthmatic children continue to have sub-optimal control despite apparently appropriate therapy. These children suffer significant morbidity including poor school attendance, adverse effects on family life and consume disproportionate health care resources. True therapy resistant asthma is rare in children and paediatricians should focus on ensuring the correct diagnosis, identifying and managing modifiable risk factors for difficult to control asthma before using the label severe asthma. Management of severe asthma requires a multidisciplinary approach. Symptomatic children on Step 4 (less than 5 years) or Step 5 (more than 5 years) of British Thoracic Society/SIGN Asthma Guideline or in children with diagnostic uncertainty should be referred to the local tertiary paediatric respiratory service.