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.     

The Durability of Laparoscopic Nissen Fundoplication: 11-Year Outcomes

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1–13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of −4.9 (range −12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results. Presented at the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 22, 2006, Los Angeles, CA     

胆道闭锁手术空肠胆支造瘘与防返流瓣的比较研究

目的为对肝门空肠吻合加空肠胆支造瘘术与加胆支防返流瓣成形术,这两种术式的优缺点进行比较.方法48例胆道闭锁分为两组.A组24例胆道闭锁行肝门空肠Roux-Y吻合,空肠胆支造瘘术.B组为另外24例行肝门空肠Roux-Y吻合,空肠胆支防返流瓣成形术.对这两组术后情况进行回顾性分析.结果A组9例存活,均无黄疸,最长的已9年,1例出现肝脾肿大、食道静脉曲张.现已8岁.B组存活10例,其中无黄疸存活8例.结论两组病例术后排胆汁(或排黄绿色大便)时间、胆管炎发生次数等临床表现进行比较.排胆汁时间相似,无显著差异.术后胆管炎发生率也无显著差异.     

Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy. Received: 29 June 1998/Accepted: 2 July 1999     

胃腔食管化手术在返流性食管炎治疗中的应用

目的:探寻胃腔食管化手术防治返流性食管炎的疗效.方法:选择中下段食管癌、食管裂孔疝病人共40例,随机分为A、B两组,每组20例.在外科治疗原发病的基础上,A组采用胃腔食管化术式、B组采用传统手术方式行抗返流治疗.观察两组病人的临床疗效(包括问卷调查、内窥镜检查、食管粘膜病理学检查)并进行比较.结果:两组病人均顺利完成手术,无手术死亡,无吻合口瘘.随访0.5～3 a,A组有返流性食管炎临床症状1例(5%),胃镜检查证实有食管粘膜糜烂1例(5%);B组有返流性食管炎的临床症状7例(35%),胃镜检查有食管糜烂4例(22%),食管下段粘膜溃疡2例(11%),食管裂孔疝复发1例(5%);两组比较差异有统计学意义(P＜0.05).结论:胃腔食管化术式用于部分外科疾病所引起的返流性食管炎的预防和治疗,其效果好,操作简单,安全可靠.     

Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results

OBJECTIVE: Preoperative 24-hour pH testing is controversial in surgical patients who have symptomatic gastroesophageal reflux disease (GERD) and endoscopic evidence of esophagitis. The objective of this study was to compare the clinical outcomes of Nissen fundoplication for symptomatic reflux between patients with normal and abnormal preoperative pH testing. METHODS: Patients were selected from a prospective database of patients who underwent laparoscopic esophageal procedures between January 1997 and December 2001 at our institution. Only patients having typical symptoms of GERD (heartburn and/or reflux), preoperative pH testing, manometry, and endoscopy and who had at least 6 months of post-operative follow-up were included in the study. Fifteen patients had normal preoperative DeMeester scores (DMS) (median 11.4, range 3.3 to 14.7). These were compared with 208 consecutive patients having abnormal preoperative DMS (median 49.6, range 15.2 to 250). Logistic regression modeling was performed to identify variables significant for poor outcome. Differences between means were tested using appropriate parametric or nonparametric tests. RESULTS: There were no statistically significant differences in demographics, preoperative symptom score (mean 2.9 +/- 1.1 vs. 3.1 +/- 0.68, P = 0.30), or preoperative grade of esophagitis (P = 0.37) between the 2 groups. After a median follow-up of 8.8 months (range 6 to 36), 6 (40%) of the patients having normal preoperative DMS and 17 (8.1%) of the patients having abnormal preoperative DMS continued to have typical GERD symptoms (P <0.01, B error = 0.02). The most significant factor for poor outcome in the regression model was normal preoperative pH (odds ratio 9.02, P <0.01). CONCLUSIONS: Symptomatic GERD patients with normal preoperative 24-hour pH test results have significantly worse subjective outcomes after Nissen fundoplication compared with patients having abnormal preoperative pH test results. To minimize poor symptomatic outcomes after antireflux surgery, a policy of routine preoperative pH testing is advised.     

Postrenal acute renal failure during pregnancy 20 years after antireflux surgery

We report that a 27-year-old woman with bilateral severe hydronephorosis during pregnancy 20 years after antireflux surgery. The patient developed postrenal acute renal failure due to obstruction of the lower ureter. This patient could safely give birth after bilateral percutaneous nephrostomy through joint management with the obstetrics and gynecology staff. We describe that stenosis of the lower ureter is a late complication of antireflux surgery.     

94. Oesophagitis — Hiatushernie — Indikation und Verfahrenswahl: Alternative Techniken

Zusammenfassung Alternativ zur Fundoplicatio nach Nissen-Rossetti darf aufgrund der derzeit vorliegenden experimentellen und klinischen Ergebnisse lediglich die Silicon-Antirefluxprothese nach Angelchik als etabliertes Antirefluxverfahren gelten. Da sowohl für die alleinige Hernienkorrektur als auch für Verfahren, die die anatomische Rekonstruktion der Mageneingangsregion zum Ziel haben, nach wie vor weder pränoch postoperativ reproduzierbare klinische Daten zur Erfolgsbeurteilung vorliegen, diese Verfahren auf der anderen Seite mit Refluxrezidivraten bis zu 66% belastet sind, ist die Anwendung dieser Operätionsmethoden heute als kontraindiziert zu betrachten.     

抗反流药物治疗对支气管哮喘伴胃食管反流患者哮喘症状影响的荟萃分析

目的 荟萃分析抗反流药物治疗对支气管哮喘(简称哮喘)伴胃食管反流患者哮喘症状的影响.方法纳入对合并胃食管反流的哮喘患者行抗反流治疗的前瞻性随机对照试验,抗反流治疗干预要求使用双肓法,样本量大小、匹配方式不限,研究对象为年龄＞13岁的伴胃食管反流病的哮喘患者.检索PubMed数据库、Embase数据库、Cochrane图书馆临床对照试验数据库、OVID数据库、中国生物医学文献数据库、中国知网全文数据库、万方科技期刊全文数据库.手工检索<中华结核和呼吸杂志>、<中华消化杂志>、<中华内科杂志>、CHEST及纳入文献的参考文献.所有检索均截至2009年11月.排除研究对象在进入研究前3 d内服用过抗反流药物、重复或多重发表、方法学质量评价为B级以下的文献.运用Cochrane荟萃分析的方法,由2名评价员独立对试验进行筛选、质量评价、数据提取和交叉核对.使用Revman 4.3.2软件对数据合并进行统计分析,评价抗反流药物治疗对哮喘伴胃食管反流患者哮喘的疗效.结果共纳入14项临床随机对照试验,包括1555例患者.抗反流治疗组与安慰剂组相比,FEV1增加[加权均数差(WMD)为0.11 L;95%可信区间(95%CI)为0.02～0.20;Z=2.49,P=0.010];日间最大呼气流速(PEF)增加(WMD为42.33 L/min;95%CI为3.39～81.28;Z=2.13,P=0.030);早晨PEF增加(WMD为16.16 L/min;95%CI为5.91～26.41;Z=3.09,P=0.002);夜间PEF增加(WMD为18.35 L/min;95%CI为6.77～29.92;Z=3.11,P=0.002).抗反流治疗与安慰剂治疗后比较,FEV1较基础对照值降低达20%时的吸入乙酰胆碱浓度(PC20-FEV1)减低(WMD为-0.07 mg/L;95%CI为-0.33～0.19),但差异无统计学意义(Z=0.55,P=0.590).14项研究中有8项研究在抗反流治疗后观察到哮喘症状改善,但荟萃分析显示哮喘日间症状和夜间症状的改善均无统计学意义.结论抗反流治疗可改善合并胃食管反流病哮喘患者的肺通气功能,但对气道高反应性和哮喘症状无显著影响.