Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children.

Operative correction of symptomatic gastroesophageal reflux (GER) was undertaken in 530 children during a 21-year period. Gastroesophageal fundoplication (GEF) alone was performed in 415 children; 83 had simultaneous GEF and pyloroplasty; 13 had pyloroplasty alone; and 19 had GEF with later pyloroplasty. Of the last 355 children with reflux, 110 (31%) had pyloroplasty. Pyloroplasty was performed for persistent symptoms despite medical therapy when more than 60% of the isotope meal was retained in the stomach at 90 minutes. Children with central nervous system disorders and GER often had delayed gastric emptying (DGE). A modified Heineke-Mikulicz pyloroplasty was used for the first 59 children; the last 56 patients had a more simplified antroplasty with a 2.5- to 3.5-cm vertical incision through the antral muscularis down to the duodenum without mucosal incision; the muscularis was reapproximated in a transverse direction with sutures. With a mean follow-up of 5.8 years, only three patients experienced mild transient dumping. None had pyloroplasty leak or clinical evidence of alkaline reflux. Antroplasty is a helpful, simple adjunct to GEF with low morbidity in children with GER and DGE.     

Gastric emptying in children with gastroesophageal reflux. I. An estimate of effective gastric emptying

The association of gastroesophageal reflux (GER) and gastric emptying has been observed, but its importance is poorly understood. We compared 18- to 24-hour esophageal pH recordings with gastric emptying of radionuclide in apple juice in 109 children (2 weeks to 16 years old) referred for an evaluation of GER. A pH score and the pattern of GER (type I, II, and III) were obtained by esophageal pH monitoring. Gastric emptying was measured at 30 minutes (%GE30) and at 60 minutes (%GE60). The measured gastric emptying of apple juice was similar for the normal child and for those with GER regardless of pattern type. An inverse linear correlation between postcibal reflex and measured gastric emptying was demonstrated only by the eight asymptomatic children with a normal pH score (%GE30, r = -.9603, P less than .001; and %GE60, r = -.8263, P less than .05). If the contribution of postcibal reflux on gastric emptying was eliminated, then the effective gastric emptying was increased in many children with the type I (44%, P less than .05), type II (46%, P less than .05), or type III (60%, P less than .05) pattern of GER as compared with children with a normal reflux pattern (7%). In conclusion, measured gastric emptying of clear liquids is not necessarily decreased in most children with GER. Furthermore, many children with GER demonstrate an increased effective gastric emptying even though measured gastric emptying may not appear increased.     

Does delayed gastric emptying contribute to gastroesophageal reflux disease?

We studied 76 patients with symptoms of heartburn, regurgitation, or both and 38 asymptomatic control subjects by measuring the gastric emptying of technetium-99m-labeled oatmeal. In addition, we performed 24-hour esophageal pH monitoring and manometric studies of the esophagus on all study participants. Endoscopy was performed on all patients. Patients with proved reflux on 24-hour pH monitoring, in comparison to those without reflux and the control subjects, had a shorter lower esophageal segment with a lower pressure and more esophagitis. Delayed gastric emptying occurred with equal frequency in patients with and without reflux. Esophageal reflux was not associated with delayed gastric emptying. Delayed emptying was associated with less esophagitis than found in those with normal gastric emptying, suggesting that the prolonged presence of food in the stomach may have a buffering effect on gastric acidity. We concluded that delayed emptying is not a major factor in the pathophysiology of gastro-esophageal reflux disease and that therapy aimed at speeding gastric emptying cannot be supported by our results.     

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.     

Balloon pyloroplasty in children with delayed gastric emptying

Objective

To evaluate initial experience with balloon pyloroplasty for delayed gastric emptying in children.

Design

A retrospective review.

Setting

A tertiary care pediatric hospital.

Patients

Seven children with scintiscan-proven delayed gastric emptying that was refractory to maximal medical therapy.

Interventions

Balloon pyloroplasty under fluoroscopic guidance, mostly on an outpatient basis. For 1 child, the procedure was endoscopically monitored also.

Outcome measures

Postoperative symptoms and physical findings, gastric emptying and complications.

Results

Of the 7 children who underwent balloon pyloroplasty, 3 were rendered asymptomatic and 2 more were symptomatically improved. Four of the original 7 patients underwent postdilation scintigraphy, and all 4 showed normalization of the gastric emptying time. There were no complications.

Conclusions

Initial experience with fluoroscopically-guided balloon pyloroplasty indicates that it is a safe and easily tolerated procedure, worthy of further study.     

Gastric emptying in children with gastroesophageal reflux. II. The relationship to retching symptoms following antireflux surgery

Following antireflux surgery, children with persistent retching symptoms are presumably more likely to have delayed gastric emptying. We report 66 children between 2 weeks and 16 years of age who had an operation to control gastroesophageal reflux (GER). All patients had GER confirmed by 18- to 24-hour esophageal pH monitoring. Preoperative gastric emptying studies were performed in each patient with 99m-Tc sulfur colloid in apple juice. In addition to the percent gastric emptying (%GE), an effective gastric emptying was estimated by correcting the %GE for postcibal reflux (corrected %GE). Repeat 18- to 24-hour esophageal pH monitoring was performed postoperatively in all patients, and a repeat gastric emptying study was performed in 32 patients. After an average postoperative follow up of 6 months (range of 1 to 18 months), persistent retching was present in 12 (18%) patients. The retching was associated with dumping symptoms in six patients. Retching was seen in patients with a preoperative increase in effective gastric emptying (10/34, 29%, P less than .05) or a decrease in effective gastric emptying (2/15, 13%, NS), and not in patients with an effective gastric emptying within the control range (0/17, 0%). Postoperatively, retching with dumping symptoms was associated with an increased effective gastric emptying, and retching without dumping symptoms with a decreased effective gastric emptying. In conclusion, persistent retching followed anti-reflux surgery in children is related to extremes in effective gastric emptying. The preoperative measurement of corrected %GE identifies children at increased risk for this postoperative problem.     

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.     

Outcomes of pyloroplasty and pyloric dilatation in children diagnosed with nonobstructive delayed gastric emptying

Background

Pyloroplasty and pyloric dilatation are methods used to ameliorate the symptoms of nonobstructive delayed gastric emptying in children. Our purpose was to review the results of these methods with respect to symptomatic improvements.

Methods

We retrospectively reviewed the records of children who, exclusive of fundoplications, in the 11-year period before December 31, 2005, had undergone at our institution a Heineke-Mikulicz pyloroplasty (HMP) and/or a fluoroscopically guided balloon pyloric dilatation (FGBD). We recorded evidence of either short- or long-term subjective improvement of symptoms.

Results

Twenty-three children underwent HMP. Five had no prior medical treatment. Of the 23, 3 had no subjective improvement in symptoms. Of the 20 who had subjective evidence of improvement recorded, 13 (56.5%) proved to be long-term and 7 short-term improvement. Eight children had FGBD. All 8 had prior medical treatment that had failed. There were 3 who displayed no subjective evidence of improvement, whereas 5 had subjective evidence of improvement—3 (37.5%) long term and 2 short term.

Conclusions

Heineke-Mikulicz pyloroplasty and FGBD in this study demonstrated only in limited numbers long-term improvement of symptoms. Efforts to understand more fully gastric emptying and to define those children who should undergo FGBD or HMP are needed.     

Nissen fundoplication improves gastric motility in patients with delayed gastric emptying

apd: 6 February 2001     

Laparoscopic gastroesophageal dissociation in neurologically impaired children with gastroesophageal reflux disease

Purpose

Neurologically impaired children with severe gastroesophageal reflux disease (GERD) are a challenging group of patients. We theorized that a laparoscopic gastroesophageal dissociation (LGED) may decrease reflux-related readmissions and healthcare visits, and improve quality of life (QOL) for them and their caregivers.

A prospective evaluation of dietary status and symptoms after near-total esophagectomy without gastric emptying procedure.

BACKGROUND: After esophagectomy, the stomach is the most commonly utilized reconstructive conduit. There remains debate among surgeons regarding the requirements for pyloroplasty/pyloromyotomy following reconstruction. We present a series of patients having undergone near total esophagectomy and reconstruction with gastric tube without gastric emptying procedure to analyze critically these patients' ability to reestablish a subjectively acceptable and nutritionally adequate eating pattern without significant side effects of early satiety, dumping, or diarrhea. METHODS: Between 1991 and 1998, 48 patients underwent esophagectomy utilizing this technique and were available for long-term follow-up and nutritional assessment. Patient weights were recorded at 2 weeks, 6 months, and 1 year and a telephone interview conducted at a mean of 36 months postoperatively for the evaluation of eating patterns and symptoms. A subgroup of these patients (32 of 48) completed a 3-day dietary record that was assessed by a certified nutritionist. This patient group included 10 patients (21%) who had received perioperative chemoradiotherapy. RESULTS: Dietary intake was characterized as normal or minimally limited in 41 patients (85%). Those who had received perioperative chemoradiotherapy needed no significant increased time to return to a normal dietary baseline (6.1 versus 5.9 months). Mean weight loss prior to surgery was 3 kg. Weight loss continued for the first 6 months (mean 10 kg); however, 63% were able to gain weight from 6 months to 1 year following surgery (mean 3 kg). Most patients were overweight prior to operation (mean 115% of ideal body weight) and achieved a new postoperative baseline (mean 104% of ideal body weight) at 1 year. Patients demonstrated a mean daily caloric intake of 2,179 kilocalories per day, which was 98% of recommended according to their ideal body weight. Postoperative symptoms of short-term nausea (19%), occasional dysphagia with certain foods (38%), mild increased stool frequency (15%), and occasional regurgitation (25%) were noted. CONCLUSIONS: Near-total esophagectomy with verticalized gastric tube without a gastric emptying procedure is well tolerated and allows a return to subjectively acceptable and nutritionally appropriate dietary eating pattern without significant associated side effects.     

Preoperative evaluation of patients with gastroesophageal reflux disease

All patients who are candidates for laparoscopic fundoplication for the treatment of gastroesophageal reflux disease (GERD) should have a symptom review, barium swallow imaging, endoscopy, esophageal manometry, and ambulatory pH monitoring. The presence of a typical primary symptom, an abnormal 24-hour pH score, and a good response to acid-suppression therapy are predictive of a successful surgical outcome. The surgeon should be particularly wary of the following types of patients who may be referred for fundoplication but not have GERD: those who do not respond to proton pump inhibitors, those without esophagitis, those with only atypical symptoms, those in whom pH monitoring was done without previous manometry, and those with a borderline reflux score, severe vomiting, severe dysphagia and heartburn, unusual symptoms, severe depression, or morbid obesity.