Gastro-oesophageal reflux in children: surgical management

Gastro-oesophageal reflux occurring infrequently and without symptoms or occurring without damage to the oesophagus is not considered pathological, otherwise the reflux and the pathology are referred to as gastro-oesophageal reflux disease (GORD). Factors predisposing to GORD include: impairments to the physiological antireflux barrier and anatomical abnormalities of the oesophagus or diaphragm. Non-operative and medical management result in resolution of symptoms in the majority of children. Surgery is indicated in the event of failure of medical management or severe complications and in neurologically normal children this would usually be a laparoscopic or open fundoplication. In severely neurologically impaired children other options are sometimes considered and these include: fundoplication with or without vagotomy and pyloroplasty; surgical feeding jejunostomy and oesophago-gastric dissociation.     

Gastro-oesophageal reflux in children: surgical management

Gastro-oesophageal reflux disease (GORD) is symptomatic reflux of gastric contents into the oesophagus. Factors predisposing to GORD are loss of the physiological antireflux barrier and anatomic abnormalities of the oesophagus or diaphragm. Conservative measures and medical management results in resolution of symptoms in a majority of children. Surgery is indicated in the event of failure of medical management or severe complications. Surgical procedures include open or laparoscopic fundoplication in children with normal neurology; fundoplication with or without vagotomy and pyloroplasty; surgical feeding jejunostomy and oesophago-gastric dissociation in the severely neurologically impaired children.     

Laparoscopic treatment of intestinal malrotation in children

Background: Laparoscopic treatment of intestinal malrotation in children is difficult, and most of our pediatric surgeon colleagues active in the field of laparoscopic surgery tell us that more often than not they must convert to an open procedure. Initially, we experienced much difficulty too, but after modification we were able to master the technique, and now we feel confident. We here describe the actual technique we use. Methods: Our experience encompasses nine children treated during the past 18 months. Five of the children presented in the newborn period and four later. During laparoscopic surgery, it is of paramount importance to concentrate not on the loops of bowel, but on the duodenum. By starting to identify the duodenum, mobilizing it, and carrying on the mobilization of the small bowel down until the whole small bowel has been seen, the pathologic anatomy is easily unraveled. Moreover, an existing volvulus is automatically reduced and the bowel automatically put in a nonrotation position in the abdomen. Results: All patients have done well, and no complications have been noted. Operative time has been reduced to about 1 hour. Conclusions: Laparoscopic treatment of intestinal malrotation in children is not so difficult provided certain rules, as described, are followed.     

Management of gastroesophageal reflux associated with malrotation in children

Aim

Children being investigated for gastroesophageal reflux (GOR) have a high incidence of malrotation. Current literature suggests these patients should be managed with a combined antireflux and Ladd's procedure. We review our experience, the largest series to date, of performing an elective Ladd's procedure as the first-line intervention.

Method

Retrospective case note review of 20 children with significant symptoms of GOR and an incidental finding of malrotation. Children presenting immediately with bilious vomiting were excluded. All patients underwent a Ladd's procedure as their sole primary operative intervention.

Results

Median age at operation was 7 months (21 days-12 years). Fifteen patients (75%) had evidence of reflux on barium contrast study. All children were followed up for at least 6 months. Eighteen (90%) had resolution or significant improvement of their symptoms postsurgery. Only 3 have not managed to tolerate a full oral diet, all unrelated to GOR. None of our series required an antireflux procedure.

Conclusion

In children with debilitating vomiting necessitating surgical management, a contrast study is imperative in the work up. The high incidence of GOR and the significant improvement after correction of malrotation show the relationship between delayed gastric emptying and GOR. We suggest that when an abnormally placed duodenojejunal flexure is found, a Ladd's procedure alone is sufficient and may obviate the need for a more invasive antireflux procedure.     

腹腔镜Ladd手术治疗小儿肠旋转不良

目的 探讨腹腔镜Ladd手术的可行性以及治疗肠旋转不良合并中肠扭转的适合条件。方法 2002年7月～2006年3月施行腹腔镜Ladd手术15例。采用三孔技术,腹腔镜下牵拉肠管纠正中肠扭转复位,切断Ladd带、游离十二指肠及全部小肠,最后经腹壁戳孔提出阑尾切除。结果 15例在腹腔镜下顺利完成Ladd手术,1例合并十二指肠隔膜、1例合并十二指肠旁疝和1例合并空肠异位胰腺同时完成手术。手术时间45～150min,平均75min。术后1～3d进食,无手术并发症发生,术后住院4～6d,平均5d。12例随访1～42个月,平均21个月,生长发育良好,症状消失。结论 腹腔镜Ladd手术是一种安全有效的技术,可以在新生儿期完成,适用于并发亚急性中肠扭转的病儿,对于急性扭转并有腹胀者可能会很困难且危险。     

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.     

Gastro-oesophageal reflux in pregnancy at term and after delivery

Gastro-oesophageal reflux during a 40-minute reflux provocation test was assessed by lower oesophageal pH monitoring in 25 pregnant women at term, and again on about the second day after delivery. At term 17 women refluxed a total of 29 times; after delivery five women refluxed once each. There was a significant decrease in gastro-oesophageal reflux by the second day after delivery (p less than 0.05). Gastro-oesophageal reflux is, however, only one of the factors that predisposes to acid aspiration pneumonitis.     

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。     

Gastro-oesophageal reflux and respiratory disorders treated by Hill's procedure

A retrospective review of 132 patients with respiratory disorders associated with gastrooesophageal reflux is presented. The patients were operated upon according to Hill's technique. In 66 infants and children, recurrent lung infection was the most frequent indication for surgery. The mean duration of respiratory symptoms was 17 months. In 66 adults, asthma was the most frequent indication for surgery. The mean duration of respiratory symptoms was 9.7 years. Suppression of reflux was obtained by operation in 95% of infants and children, with disappearance of respiratory disorders in 78.6% and clinical improvement of symptoms in 16.4%. Suppression of reflux was confirmed in 94% of adults, with disappearance of respiratory disorders in 36% and improvement of symptoms in 28%. The correlation between disappearance of reflux after surgery and cure of respiratory disorders in infants and children must be seen in the light of the natural history of lower oesophageal sphincter maturation. Nevertheless, surgery shortens the period of risk in life-threatening situations. In adults, one patient out of two benefited from operation. Failures were more frequent in asthma and there was no characteristic type of asthma associated with reflux.