Antireflux Surgery: New Era's, New Results

Abstract

INTRODUCTION In the past, surgical treatment for gastroesophageal reflux disease has known its ups and downs. Substantial morbidity in Nissen fundoplication made many pediatricians and also some pediatric surgeons reluctant to propose surgery in GERD.When alternative techniques with less complications, but with the same effect, became available, a number of pediatric surgeons became less restrained to offer surgery as a means of therapy for GERD (1). The advent of in particular protonpump inhibitors (PPIs) has revolutionized the approach to acid-related disorders, reducing the indications for surgery again (2). However, putting children on lifelong PPIs is a dilemma for both doctor and parents. The safety of long-term administration of acid blocking medication needs to be considered in relation to potential consequences of prolonged acid suppression, such as hypergastrinemia, proliferation of gastric flora, enterochromaffin-like cell hyperplasia theoretically leading to gastric cancer (3), and nosocomial infections. As almost half of the pediatric population with GERD is mentally handicapped, nosocomial infections are a non-neglectable thread. When the laparoscopic surgical approach to GERD was introduced in pediatric surgery in the nineties of the last century, it became apparent that this approach was beneficial for the pediatric patient (4). In particular the group of mentally handicapped children, which in the past had always been a complication prone population in regard to postoperative morbidity, duration of hospitalization, and cure of GERD, seemed to benefit from the laparoscopic approach and showed no increase in postoperative morbidity, had a reduced hospital stay and showed an equal cure of GERD as did children in the not-mentally handicapped group (5). In a group of 149 children, operated between 1993 and 2002 laparoscopically according to Thal for GERD, 49% was mentally handicapped. Follow-up ranged from 6 months to 9 years (median 4.5y). Nineteen children died. All but one were not related with the antireflux procedure. Immediate relief of symptoms occurred in 120 children (80,5%). In 29 children the results were less than optimal. Eight patients underwent a laparoscopic redo-procedure (5,4%). However, none of the children with a follow-up of more than five years showed any symptoms anymore. It was concluded from this study that the laparoscopic Thal fundoplication was a safe procedure and that results in the long run were favorable, irrespective of the nature of the cause, i.e. mental retardation (5). Close examination of the subgroup that did not do well directly after the operation, showed that in particular children with motility disorders of the esophagus or gastroduodenal motility disorder continued to have problems. It is therefore of great importance to identify these children during preoperative work-up for GERD. Alternative therapeutic strategies for these patient groups are warranted.