Gastric emptying in children with gastroesophageal reflux and in healthy children

Purpose

The aim of this report is to examine whether children with gastroesophageal reflux (GER) have delayed gastric emptying compared to healthy children.

Methods

All patients had GER verified by 24-hour pH monitoring. Gastric emptying of cow’s milk was examined by radionuclide scintigraphy in 51 patients with GER and in 24 controls. Gastric emptying rate was expressed as exponential half time (T_1/2).

Results

Median age was 4.4 years [range 0.1–15.4] in patients and 6.1 years [range 2.5–10.0] in controls (p = .10). A wide range of gastric emptying rates was observed both in GER patients [range 16–121] and controls [range 29–94]. One GER patient (2%) had slower gastric emptying (T_1/2 = 121 min) than the healthy child with the longest T_1/2 (94 min). Mean T_1/2 was 49 minutes (SD 20.1) and 46 minutes (SD 14.2) in GER patients and controls, respectively (p = .51).

Conclusions

Gastric emptying rate of milk was not significantly different between children with GER and healthy children. A wide range of gastric emptying rates was observed in both groups.     

开腹和腹腔镜手术治疗小儿肠旋转不良的临床对比研究

【摘要】〓目的〓比较开腹手术和腹腔镜手术治疗小儿肠旋转不良的治疗效果。方法〓收集2012年至2014年的肠旋转不良患儿资料,传统开腹手术68例,腹腔镜手术30例,分别比较两组间的手术时间、术后进食时间和术后并发症等的差别。结果〓开腹手术时间较腹腔镜手术时间短,但术后开始进食时间及全量进食时间较腹腔镜手术组的时间长,两组之间比较有统计学意义;开腹手术术后并发症8例,腹腔镜手术术后并发症4例,两组间比较无统计学意义。结论〓腹腔镜Ladd?蒺s手术术后肠功能恢复快,可早期恢复进食,术后并发症无增加,用于治疗小儿肠旋转不良是安全而有效的。     

Evaluation of gastroesophageal function and mechanisms underlying gastroesophageal reflux in infants and adults born with esophageal atresia

Purpose

To evaluate the mechanisms underlying gastroesophageal reflux (GER) following esophageal atresia (EA) repair and gastroesophageal function in infants and adults born with EA.

Methods

Ten consecutive infants born with EA as well as 10 randomly selected adult EA patients were studied during their first postoperative follow-up visit and a purposely planned visit, respectively. A ¹³C-octanoate breath test and esophageal pH–impedance–manometry study were performed. Mechanisms underlying GER and esophageal function were evaluated.

Results

Transient lower esophageal sphincter relaxation (TLESR) was the most common mechanism underlying GER in infants and adults (66% and 62%, respectively). In 66% of all GER episodes, no clearing mechanism was initiated. On EFT, normal motility patterns were seen in six patients (four infants, two adults). One of these adults had normal motility overall (> 80% of swallows). Most swallows (78.8%) were accompanied by abnormal motility patterns. Despite this observation, impedance showed normal bolus transit in 40.9% of swallows. Gastric emptying was delayed in 57.1% of infants and 22.2% of adults.

Conclusions

TLESR is the main mechanism underlying GER events in patients with EA. Most infants and adults have impaired motility, delayed bolus clearance, and delayed gastric emptying. However, normal motility patterns were seen in a minority of patients.     

Value of tests for evaluation of gastroesophageal reflux in children

The accuracy of five tests for the diagnosis of gastroesophageal reflux in children was performed in 93 symptomatic children with gastroesophageal reflux and 16 nonreflux patients. These tests include the barium esophagram, the Tuttle test, extended esophageal pH monitoring, esophagoscopy, and esophageal biopsy. Esophagoscopy was less sensitive in detecting reflux in patients than any other test (P = less than 0.001), and biopsy was more likely to identify reflux patients than the barium swallow (P = less than 0.02), but there was no test superior to others. The severity of esophagitis noted at endoscopy or the presence of eosinophils or neutrophils in the mucosa was not associated with a decreased possibility that one other test would be normal or that surgical repair of the reflux would be performed. Patients with extended esophageal pH test scores markedly elevated were less likely to have another negative test (P = less than 0.01) and more likely to have surgical repair of gastroesophageal reflux (P = less than 0.001). Obtaining two tests of esophageal function that agree increases the certainty of diagnosis, and use of several tests are indicated if the results of a single test do not support the clinical impression.     

抗胃食管反流外科治疗的远期疗效观察

目的探讨胃食管反流外科治疗的远期疗效。方法1988年11月至2004年1月手术治疗129例胃食管反流病(GERD),分别采用N issen手术(65例)、贲门斜行套叠术(39例)、Belsey4号手术(17例)、Toupet手术(3例)、Thal手术(1例)、Dor手术(4例)等6种方法治疗。116例得到随访,计算临床症状评分,并与术前比较。手术前后分别有95例及51例行食管压力测定检查,56例及35例行24 h食管pH值监测及DeM eester评分;术前常规行内镜检查,术后48例行内镜检查,对结果进行比较。结果在随访的116例患者中,临床症状评分由术前的(4.1±0.4)分降为术后的(1.1±1.0)分,较术前显著降低(t=27.21,P<0.01)。手术疗效优42例(36.2%),良60例(51.7%),可7例(6.0%),差7例(6.0%),手术远期优良率87.9%(102/116)。N issen、Belsey 4号和贲门斜行套叠术三者间疗效无差异。结论外科手术是治疗GERD的有效方法,N issen手术、贲门斜行套叠术和Belsey 4号手术疗效相近。     

Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease

The use of the laparoscopic approach to perform antireflux procedures has increased dramatically since its introduction in 1991. To date, no prospective randomized studies comparing open surgery to the minimal invasive approach in children have been reported. Many retrospective reviews and case series have demonstrated that laparoscopic antireflux procedures are safe and effective once the learning curve is achieved. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize the available evidence to identify the risks and benefits of laparoscopic antireflux procedures.     

抗胃食管反流手术对大鼠胃排空功能影响的实验研究

目的 观察不同抗胃食管反流手术对大鼠胃排空功能的影响。方法 将大鼠随机分为5组，A组为贲门肌层切开组，B组为贲门肌层切开后行Nissen手术，C组为贲门肌层切开后行Nissen手术并加行幽门肌层切开，D组为贲门肌层切开加贲门斜行套叠术，E组为对照组。于第4周行放射性核素胃排空功能检查，观察手术对大鼠胃排空功能的影响。结果 （1）半胃排空时间C组较B、D组快（P＜0．05），B、C、D组较E组快（P＜0．05），A组与E组无差别（P＞0．05）。（2）2h胃内放考元素潴留率测定表明，A组与E组无差别（P＞0．05），B、C、D组较E组少（P＜0．05），B、C、D组间无差别（P＞0．05）。结论 （1）抗反流手术（Nissen手术、贲门斜行套叠术）可以使半胃排空时间增快，2h胃内放射性元素潴留率减少。（2）Nissen手术加做幽门肌层切开可使半胃排空时间增快，但2h胃内放射性元素潴留率较单纯Nissen术无变化，综合考虑，行抗反流手术不必同时加行幽门肌层切开术。     

胃食管反流胃底折叠术中支气管痉挛的处理

目的 探讨胃食管反流病(GERD)胃底折叠术中支气管痉挛的发生与处理措施.方法 总结GERD胃底折叠术中发生支气管痉挛的34例资料.结果 34例中剖腹手术6例,腹腔镜手术28例.支气管痉挛有8例在气管插管后即刻发生,10例在气管插管后1～10 min手术开始前发生,14例在术中不同时间不明原因发生,1例在术后气管拔管送回监护病房后发生,1例气管插管后的顽固支气管痉挛未行手术.处理措施均为静注糖皮质激素和氨茶碱,吸入七氟醚,呼吸机正压通气.以上措施无效者加用肾上腺素.结论 GERD胃底折叠术患者多有支气管痉挛的呼吸道症状,为麻醉的危险凶素之一,麻醉医师应高度重视,妥善处理.     

Laparoscopic treatment of intestinal malrotation in adults.

BACKGROUND: Congenital midgut malrotation is rarely encountered outside the pediatric population. The Ladd's procedure is the standard corrective measure for intestinal malrotation in children and consists of division of peritoneal bands (Ladd's bands) traversing the posterior abdomen, reduction of volvulus, appendectomy, and functional postioning of the intestine with or without fixation. Clinical manifestations of malrotation and results of Ladd's procedure have been described in adults, but laparoscopic treatment remains to be established as adequate treatment. METHODS: Records were reviewed of 7 patients, ages 17 to 45, all with a history of abdominal discomfort dating from childhood or early adolescence. The diagnosis of malrotation was made by barium small bowel examination in all cases. Symptoms consisted of recurrent bouts of abdominal pain that were most often postprandial, with bloating and, less frequently, constipation. Surgical treatment consisted of laparoscopic exploration via 4 ports. Peritoneal bands were completely divided, and an appendectomy performed in all patients. Three patients required reduction of nonstrangulated chronic midgut volvulus. RESULTS: No early complications occurred, and all patients were discharged on postoperative days 1 through 3. At 2 months to 48 months after surgery, 1 patient had been lost to follow-up. Five patients (71%) reported substantial improvement in abdominal discomfort, with only occasional mild symptoms. Constipation continued in 1 patient, but required less aggressive treatment. One patient reported only slight improvement in postprandial abdominal pain. CONCLUSIONS: Although rarely encountered, intestinal malrotation after childhood can produce significant clinical symptoms that respond to surgical treatment. The results of the present series indicate that laparoscopic Ladd's procedure is an acceptable alternative to the open technique in treating symptoms of intestinal malrotation in adults.     

The significance of gastric emptying in children with intestinal malrotation

Persistent gastrointestinal symptoms are common postoperatively in children with intestinal malrotation. We investigated this problem in 14 children with intestinal malrotation who had a Ladd procedure (3 patients), gastroschisis repaired (6 patients), or omphalocele repaired (5 patients) between one month and 15 years prior to study. In 13 patients, gastric emptying was measured at 30 minutes (%GE30) and at 60 minutes (%GE60) following ingestion of 99m-Tc sulfur colloid in apple juice. We estimated the degree of gastric peristalsis using the %GE corrected for immediate postcibal gastroesophageal reflux (corrected %GE). Patients with vomiting exhibited slow gastric emptying compared to patients without vomiting (%GE30: 14.0 +/- 5.5 v 32.5 +/- 4.2, P less than .005). The slow gastric emptying was related to slow gastric peristalsis (corrected %GE30: 20.3 +/- 5.0 v 47.1 +/- 6.0, P less than .005). In all 5 patients with persistent bloating and diarrhea, gastric peristalsis was rapid at 30 minutes (corrected %GE30 = 56.7 +/- 4.2) and at 60 minutes (corrected %GE60 = 69.5 +/- 5.3). To assess the role of gastroesophageal reflux (GER) in persisting symptoms, all children had extended (18 to 24 hours) esophageal pH monitoring. Eleven (79%) of the 14 patients demonstrated GER by esophageal pH monitoring, including four of six patients without reflux symptoms. All ten children under two years of age demonstrated GER regardless of symptoms or congenital anatomic abnormality. In conclusion, GER is common in patients under two years of age with intestinal malrotation, but clinical symptoms seem related more to extreme variations in gastric peristalsis than to GER.     

Hypopharyngeal and distal esophageal pH monitoring in children with gastroesophageal reflux and respiratory symptoms

Purpose

Fundoplication is frequently required for gastroesophageal reflux (GER)-related respiratory disease. Correlation between esophageal pH data and respiratory symptoms is poor but may be improved by monitoring hypopharyngeal pH. Reflux to the hypopharynx is underestimated by salivary bicarbonate. The aim of this study was to determine if hypopharyngeal pH monitoring using pH 4 and pH 5 as reflux thresholds could predict children with reflux-related respiratory disease.

Methods

One hundred five children aged 4 months to 12 years underwent esophageal and hypopharyngeal pH monitoring. Hypopharyngeal pH data were analyzed using pH 4 and pH 5 as reflux thresholds. pH data from 4 groups were compared: group A, control group, no GER, no respiratory symptoms (n = 20); group B, respiratory symptoms, no GER (n = 16); group C, GER, no respiratory symptoms (n = 26); and group D, both GER and respiratory symptoms (n = 37).

Results

Comparing groups C and D, there was no significant difference in hypopharyngeal pH data. Using pH 5 as the reflux threshold, children in group B refluxed to the hypopharynx significantly more frequently than controls. This was most evident in children with wheeze.

Conclusion

Hypopharyngeal pH monitoring does not differentiate children with GER and respiratory symptoms from those with GER alone and is therefore of doubtful value in diagnosing recurrent aspiration.     

Long-term follow-up study of the Stretta procedure for the treatment of gastroesophageal reflux disease

Background The endoscopic delivery of temperature-controlled radiofrequency energy to the gastroesophageal junction (Stretta procedure) recently has been shown effective for patients with gastroesophageal reflux disease (GERD). However, its effectiveness has been assessed mainly over short periods (6–12 months). This study aimed to evaluate long-term results of the Stretta procedure.Methods All patients undergoing the Stretta procedure since August 2000 were prospectively evaluated under an institutional review board–approved protocol. All patients with a follow-up period longer than 18 months were recruited for a 24-h pH study and mailed a follow-up survey, which included the following: Short Form 12 (SF-12) health status questionnaire, GERD-specific quality-of-life questionnaire (QOLRAD), and queries regarding long-term satisfaction and medication use.Results The Stretta procedure was performed on 82 patients, and 41 patients with a follow-up period longer than 18 months qualified for the study. Follow-up surveys were completed by 36 patients (88%) during a mean follow-up period of 27.1 ± 3.7 months. Of these 36 patients, 30 (83%) were highly satisfied with the procedure and would have it performed again. More than half of the Fifty Stretta patients (56%) had completely discontinued their use of proton pump inhibitors (PPIs), and an additional 31% had reduced their dose significantly. The mean PPI equivalent doses were 37.8 ± 22.2 mg/day before the Stretta procedure and 11.6 ± 14.6 mg/day at 27-month follow-up assessment (p = 0.001). According to the patient outcomes for daily PPI use (yes/no), the patients were divided into two groups: responders (n = 20) and nonresponders (n = 16). The responder group scored higher in QOLRAD score (p = 0.0001), SF-12 physical score (p = 0.038), and SF-12 mental score (p = 0.003). In the 24-hour pH study, the responder group demonstrated a significant decrease in distal esophageal acid exposure time (6.4% ± 1.5% to 3.1% ± 1.4%; p = 0.0001).Conclusion The Stretta procedure results in a statistical significant long-term decrease in GERD symptoms and PPI use. The treatment effect is durable beyond 2 years, and 56% of patients had discontinued their user of all antisecretory drugs.Presented at the European Association for Endoscopic Surgery (EAES) Glasgow 2003, 15–18 June 2003     

Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease

Background Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures. Methods This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created. Results The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann–Whitney U test are not statistically significant. Conclusions For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon’s experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.     

Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: An anti-reflux procedure is required

Background Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed.Methods A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy.Results Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux).Conclusion Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.