Control Of Gastroesophageal Reflux Research Articles

Effects of Anterior Fundoplication on Postoperative Dysphagia and Reflux After Laparoscopic Esophagocardiomyotomy for Pediatric Achalasia.

Introduction: Achalasia among children often fails endoscopic management (e.g., dilation, botulinum toxin). Laparoscopic esophagocardiomyotomy (L-ECM) is a standard intervention to relieve obstruction but can induce gastroesophageal reflux (GER). Concurrent anterior fundoplication (A-fundo) has been evaluated in randomized trials among adults, demonstrating mixed results on controlling postoperative GER without exacerbating dysphagia. Furthermore, evidence for the best approach among children remains sparse. We hypothesized that, among children undergoing L-ECM without mucosal violation, routine A-fundo would not improve postoperative GER control while exacerbating dysphagia. Materials and Methods: Observational data of 47 consecutive achalasia patients ≤18 years who received L-ECM (2002-2023) at a single academic institution were collected. Patient records were culled for demographics, achalasia characteristics, and outcomes. Two L-ECM groups were identified: with or without A-fundo. Patients were screened for postoperative dysphagia (additional procedures) and GER (new antireflux medications). Univariate independence testing was conducted to identify statistically significant variables. Results: Among 47 patients undergoing L-ECM, 28 (59.6%) received concurrent A-fundo. Compared with patients undergoing L-ECM alone, patients with L-ECM/A-fundo had significantly longer hospital stays (P < .01) without statistically different rates of postoperative dysphagia (P = .81) or GER (P = .51). Five children (10.6%) experienced mucosal injury with L-ECM: 4 recognized intraoperatively received A-Fundo without subsequent leak; 1 mucosal injury was missed and did not receive A-Fundo, which subsequently leaked. Conclusion: In this largest observation of pediatric achalasia patients, A-fundo appeared clinically insignificant when determining contributors to control GER or exacerbate postoperative dysphagia. A-fundo should not be routinely adopted in children having L-ECM for achalasia without further multicenter analysis but appears beneficial in cases having inadvertent mucosal violation.

Reinke Edema: Factors that Interfere with Vocal Recovery after Surgery.

Introduction Dysphonia and lower pitch after surgery of Reinke edema are common. They are caused especially due to chronic smoking but, probably, other factors should be associated. Objectives To evaluate the results of laryngeal microsurgery in patients with Reinke edema, following a standardized postoperative guidance protocol in our service. Methods Retrospective study. Thirty patients (3 males; 27 females) were included, 70% between 41 and 60 years old. The parameters analyzed in the pre- and postoperative (between 4 and 6 months) of patients undergoing laryngeal microsurgery for Reinke edema were: smoking, vocal symptoms, videolaryngostroboscopy, voice therapy, perceptual and acoustic vocal evaluation, histopathological report. Results Smoking was reported by 100% of the patients and maintained in the postoperative period by 80%. Complete improvement of symptoms in the postoperative period was reported by 43% of them, partial improvement by 40%, and maintenance by 17%. There was low adherence to voice therapy in the pre- and postsurgery. Postoperative videolaryngoscopy indicated congestion (19), atrophy and bowed vocal fold (1), subepithelial edema (2), and normal findings (8). The histological findings were subepithelial edema, enlargement of vessels, inflammation, epithelial hyperplasia, and thickening of the basement membrane. The perceptual and acoustic vocal analyzes indicated improvement of the analyzed parameters. Conclusions The maintenance of some vocal symptoms and laryngeal alterations in videolaryngoscopy after microsurgery of Reinke edema is frequent, even in patients who follow the recommendations of vocal rest and control of gastroesophageal reflux. Vocal symptoms are attributed to changes in the laryngeal mucosa caused by chronic smoking, aggravated by the maintenance of addiction in the postoperative period.

Impact of gastroesophageal reflux in the pathogenesis of tracheal stenosis.

Benign airway stenosis is a multifactorial and heterogeneous disease often occurring after tracheal intubation. Despite the frequent finding of pathological gastroesophageal reflux (GER) in benign tracheal stenosis, the cause-and-effect relationship between these two entities and its impact on the outcome of the stenosis itself have not been established. The altered ventilatory dynamics caused by an increased thoracoabdominal pressure gradient in such patients has been proposed as a central cause. The presence of GER in a setting of microaspiration can also induce changes in the local collagen proliferation response, as well as in the local microbiome of the tracheal stenosis site, which may potentially cause and enhance the harm imposed to the already diseased tracheal wall. Diagnosis of GER remains underestimated in the general population, thus making its accurate detection and treatment in central airway stenosis a matter of investigation. The high prevalence of GER in tracheal stenosis patients often occurs in the absence of typical upper digestive signs and symptoms, therefore requiring an objective assessment using a 24-hour ambulatory esophageal pH/impedance study that has shown abnormal results in more than half the patients. The impact of the treatment of GER in patients with benign tracheal has been scarcely reported. Our group showed recently that the surgical control of GER through laparoscopic fundoplication in selected patients with tracheal stenosis can improve substantially the chance of resolution of the tracheal stenosis as opposed to the medical management with high dose proton pump inhibitors. This chapter describes the impact of GER in the pathogenesis of tracheal stenosis with a focus on its mechanisms, diagnosis and treatment strategy.

A Prospective Study of the Effect of Gastroesophageal Reflux Disease Treatment on Children With Otitis Media

To demonstrate improvements in validated quality-of-life measures for otitis media and gastroesophageal reflux disease (GERD) and an objective score for pediatric reflux obtained by fiberoptic laryngoscopy after treatment with antireflux precautions and therapy in children diagnosed as having either recurrent acute otitis media or otitis media with effusion and GERD. Prospective, before-and-after intervention study. Hospital-based pediatric otolaryngology practice. Population-based sample of 47 patients (mean age, 19.5 months). Standard antireflux therapy for 2 consecutive 12-week periods. Otitis Media 6-Item quality-of-life survey, Infant GERD Questionnaire-Revised, GERD Symptom Questionnaire for Young Children, Pediatric Reflux Finding Score, and speech awareness threshold. Follow-up data were available for 37 patients. Mean (SD) change scores for Otitis Media 6-Item quality-of-life survey were 1.6 (1.1) at visit 2 and 1.5 (1.1) at visit 3 (P < .001 and P = .004, respectively). Change scores were significantly improved for Infant GERD Questionnaire-Revised and GERD Symptom Questionnaire for Young Children at visit 2 and for Infant GERD Questionnaire-Revised at visit 3. Mean (SD) change scores for the Pediatric Reflux Finding Score were 6.4 (4.9) at visit 2 and 8.0 (7.2) at visit 3 (P < .001 and P = .03, respectively). Hearing loss was significantly improved following therapy, as were laryngeal findings of reflux on fiberoptic laryngoscopy. Otitis media was considered by the examining physician to be clinically improved in 28 of 37 children (76%; 95% confidence interval, 60%-87%) at visit 2 and in 6 of 10 children (60%; 95% confidence interval, 31%-83%) at visit 3. Nine children (19.1%) required myringotomy tube placement. Children with otitis media with effusion or recurrent acute otitis media and GERD have improved quality of life following treatment with antireflux therapy. Control of gastroesophageal reflux may play a role in the management of otitis media and avoidance of tympanostomy.

Laparoscopic Cardioplasty to Avoid Esophageal Resection in Patient Not Responsive to Heller Myotomy

Some achalasia patients do not ameliorate dysphagia after Heller myotomy. If stenosis does not respond to endoscopic dilatations and persists after a second extended myotomy, an esophageal resection is considered unavoidable. This article describes an original technique of treating this type of persistent stenosis with an esophageal stricturoplasty. The procedure was completed under laparoscopy. The postoperative course was uneventful. Resolution of all preoperative symptoms was achieved at the first year follow-up. Control of gastroesophageal reflux was documented by 24-hour pH-impedance. If confirmed by further cases, laparoscopic esophageal stricturoplasty could become a valid option for a conservative treatment of these patients.

Photodynamic Therapy for High-Grade Dysplasia in Barrett’s Esophagus

Photodynamic therapy followed by acid suppression with a proton pump inhibitor offers the potential of eradicating high-grade dysplasia in Barrett’s esophagus, and the possible prevention of subsequent degeneration to invasive esophageal cancer. Areas of dysplasia are very heterogeneous and are often completely invisible to standard white light endoscopy. High-grade dysplasia may also be a multi-focal change and if so carries a greater chance of malignant degeneration. Therefore, treatment and eradication of the whole Barrett’s segment is important. This remains a major advantage for photodynamic therapy. The principles that guide treatment are becoming clear. All the abnormal and Barrett’s epithelium should be destroyed. Following photodynamic therapy, complete control of gastro-esophageal reflux, usually with proton pump inhibitors, is essential. The endpoint of treatment is re-epithelialization of the complete Barrett’s segment with neo-squamous epithelium. Nevertheless, continued surveillance is still necessary since the phenotype expressed may still have malignant potential and cancer has occurred some time after apparently successful ablation. There is now the clear randomized evidence that Photofrin photodynamic therapy can eradicate high-grade dysplasia and prevent progression to invasive cancer.

Gastroesophageal reflux in asthmatic children not responding to asthma medication: A scintigraphic study in 126 patients with correlation between scintigraphic and clinical findings of reflux

Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I ( n=100) consisted of children with asthma but no clinical symptoms of GER. Group II ( n=26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100–200 μCi (3.7–7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.

Feeding Management of Children with Severe Cerebral Palsy and Eating Impairment

Some children with cerebral palsy and severe feeding impairment experience pulmonary complications from aspiration and gastroesophageal reflux. This exploratory study examined whether pulmonary function would improve following one year of intervention with optimal positioning for feeding, control of gastroesophageal reflux and use of food textures that would minimize aspiration from swallowing. Two children showed a 28% and 45% improvement, respectively, in functional residual capacity. One child experienced a 37% improvement in total respiratory resistance and a 284% improvement in respiratory compliance. All children gained sufficient weight to maintain their growth trajectories but only one who was changed from oral to tube feeding due to aspiration showed catch-up growth in length. One child showed pathological gastroesophageal reflux that was controlled medically throughout the study period. Although all children experienced pulmonary illnesses during the one year of follow up, control of aspiration permitted a clinically significant improvement of their pulmonary obstructive syndrome. Further study is needed to more fully determine the effect of this treatment approach on pulmonary function.

Potential control of gastroesophageal reflux by local modulation of transient lower esophageal sphincter relaxations

Transient lower esophageal sphincter relaxations (TLESRs) are neurally mediated abrupt reductions in lower esophageal sphincter (LES) pressure. TLESRs are not usually associated with deglutition or secondary peristalsis but are thought to be necessary for venting swallowed air from the stomach. Their central role in acid reflux, however, makes them a compelling therapeutic target for patients with gastroesophageal reflux disease. Pharmacologic approaches for reducing TLESR frequency are being studied, but theoretically more promising are endoscopic approaches that interfere with mechanoreceptor function. Further study into the mechanisms of action of these approaches is needed, as are controlled clinical trials to define the true utility of these techniques and identify patients who will receive the most benefit.

Acid suppression therapy in Barrett's esophagus: the importance of pH monitoring.

It is generally accepted that intestinal metaplasia of the esophageal mucosa results from chronic injuries caused by acid gastroesophageal reflux (GER). It would seem to follow, therefore, that appropriate therapy of Barrett’s esophagus, once recognized, should attempt to eliminate any continuing esophageal acid exposure. Indeed, the usual standard of care in this disease includes the use of potent acid-suppressing medications (or surgery) in an attempt to accomplish this goal. Such therapies have been well documented to result in resolution of the patient’s reflux symptoms and healing of associated esophagitis. There is, however, no present evidence that either of these therapeutic approaches results in regression of the metaplastic epithelium or elimination of the malignant potential in this disease. The observation that patients with Barrett’s esophagus have a decreased sensitivity to esophageal acid exposure indicates that control of heartburn in these patients does not ensure the absence of continuing acid reflux [1]. This possibility was initially documented by the study from our laboratory using ambulatory intra-esophageal pH monitoring, which showed that Barrett’s patients rendered asymptomatic on omeprazole frequently were having continued abnormal GER [2]. Subsequently, this phenomenon was better clarified by the observation that recovery of gastric acidity overnight, so-called “nocturnal acid breakthrough” occurs with high frequency even with twice-daily dosing of omeprazole [3]. These observations form the basis for the suggestion that long-term control of GER in patients with Barrett’s esophagus requires monitoring of intragastric and distal esophageal pH during the time when the patient is undergoing therapy. This concept has gained acceptance by many clinical investigators in this field. Does continuing acid reflux, even in diminished amount, constitute a threat to the patient with Barrett’s esophagus? The first suggestion that this might be true was provided by cell culture studies from esophageal biopsies of patients with Barrett’s esophagus showing that in vitro exposure to pulses of acid resulted in greater proliferation and less differentiation of the metaplastic epithelium [4]. A subsequent study by the same investigators provided the clinical link to the in vitro experiments. Using ambulatory pH monitoring during therapy with proton pump inhibitors (PPI) to establish the presence or absence of control of GER, these investigators documented that patients with continuing abnormal GER showed greater evidence of proliferation activity and less differentiation from their endoscopic biopsies than did patients with well-controlled GER [5]. Thus, experimental evidence both at the basic and clinical level supports the need for ambulatory pH monitoring to establish adequacy of acid suppression therapy and to guide titration of medication dosing in these patients. Does dose adjustment based on pH monitoring result in evidence of regression of the abnormal metaplastic epithelium in Barrett’s esophagus patients? Two recent clinical observations suggest an affirmative answer to this question. Our approach to patients with Barrett’s esophagus has been to use pH monitoring to adjust

Fundoplication provides effective and durable symptom relief in patients with Barrett’s esophagus

Background: Columnar-lined esophagus with intestinal metaplasia (IM), also called Barrett’s esophagus, is a manifestation of severe gastroesophageal reflux (GER) and may predict poor symptom relief and high failure rate after fundoplication. We compared symptom scores and reoperation rates in GER patients with and without Barrett’s esophagus. Methods: Between July 1992 and July 1997, 646 patients underwent fundoplication (626 laparoscopic). Of 150 endoscopic biopsies of suspected columnar-lined esophagus, 80 confirmed IM, 50 identified cardiac or fundic epithelium, and 20 revealed only esophagitis. Typical GER symptoms were scored by patients preoperatively and postoperatively (0 to 4 scale). We compared symptom response (Wilcoxon rank sum test) and failure rates ( t test) in patients with IM and GER controls without IM. Preoperative data were available for 74 IM patients and 496 controls. One-year follow-up was available in 45 IM patients and 301 controls. Intermediate follow-up (2 to 5 years) was available in 20 IM patients and 99 controls. Results: Preoperatively and postoperatively, patients with IM reported heartburn, regurgitation, and dysphagia scores similar to controls. Procedure failure, requiring redo fundoplication, appeared more likely in IM patients than controls (6.3% versus 2.5%), but this difference did not reach statistical significance ( P = 0.061) Conclusion: Fundoplication provides equivalent symptom relief for patients with and without IM.

Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation.

Barrett's esophagus is associated with significantly increased risk of development of esophageal adenocarcinoma. Replacing columnar epithelium with the normal squamous lining in this condition offers the possibility of decreasing the risk of degeneration to invasive adenocarcinoma. This study aimed to establish the feasibility of argon beam plasma coagulation (ABPC), in conjunction with control of gastroesophageal reflux, to restore the squamous lining. Thirty patients with Barrett's esophagus (four low-grade dysplasia, three high-grade) were recruited from our surveillance program, and underwent endoscopic ABPC. Twenty-seven patients completed treatment, with macroscopic replacement of their columnar lining by squamous epithelium, histologically confirmed in all 27, and followed up for a median of 9 months (range, 6-18 months). Two patterns of squamous replacement were identified: 70% of patients showed squamous epithelium with no persistent intestinal metaplasia, and in 30% the new squamous epithelium covered areas of underlying intestinal metaplasia. One patient has withdrawn from the study. Two esophageal perforations, with one death, occurred early in the study. ABPC, in conjunction with control of gastroesophageal reflux, allows squamous regrowth in both benign and dysplastic Barrett's esophagus. Despite the theoretical safety advantages of ABPC over techniques such as laser, esophageal perforation may occur with this technique. It is too soon to recommend ABPC for dysplastic or nondysplastic Barrett's because follow-up is too short to show a decreased incidence of and mortality from adenocarcinoma.

Restoration of the normal squamous lining in Barrett’s esophagus by argon beam plasma coagulation

Objective: Barrett’s esophagus is associated with significantly increased risk of development of esophageal adenocarcinoma. Replacing columnar epithelium with the normal squamous lining in this condition offers the possibility of decreasing the risk of degeneration to invasive adenocarcinoma. This study aimed to establish the feasibility of argon beam plasma coagulation (ABPC), in conjunction with control of gastroesophageal reflux, to restore the squamous lining. Methods: Thirty patients with Barrett’s esophagus (four low-grade dysplasia, three high-grade) were recruited from our surveillance program, and underwent endoscopic ABPC. Results: Twenty-seven patients completed treatment, with macroscopic replacement of their columnar lining by squamous epithelium, histologically confirmed in all 27, and followed up for a median of 9 months (range, 6–18 months). Two patterns of squamous replacement were identified: 70% of patients showed squamous epithelium with no persistent intestinal metaplasia, and in 30% the new squamous epithelium covered areas of underlying intestinal metaplasia. One patient has withdrawn from the study. Two esophageal perforations, with one death, occurred early in the study. Conclusion: ABPC, in conjunction with control of gastroesophageal reflux, allows squamous regrowth in both benign and dysplastic Barrett’s esophagus. Despite the theoretical safety advantages of ABPC over techniques such as laser, esophageal perforation may occur with this technique. It is too soon to recommend ABPC for dysplastic or nondysplastic Barrett’s because follow-up is too short to show a decreased incidence of and mortality from adenocarcinoma.

Modified Toupet wrap for gastroesophageal reflux in childhood.

It was the aim of our study to follow up our clientele of infants and children who had undergone a partial (posterior) Toupet wrap or modified Toupet wrap. All 22 children who had undergone a posterior partial wrap within a 4-year period were followed up for 4.0 years (0.6-5.7 years). 36.4% of children had associated anomalies such as operated esophageal atresia, operated congenital diaphragmatic hernia, Gregg's syndrome or arthrogryposis multiplex congenita. 14% of children suffered from some form of neurological impairment. Prior to operation the 4 main examinations for detection and documentation of gastroesophageal reflux (GER) disease were carried out where possible. Five children underwent Toupet fundoplication and in 17 children a modified Toupet fundoplication with reinforcement of the wrap fixation using a Vicryl-mesh was applied. A pH-metric study and upper gastrointestinal series with reflux testing were done in all 22 children at least 6 months postoperatively. Successful control of GER was documented in 21 of 22 children (95.5%). In the remaining child a reoperation was necessary to correct recurrence of a sliding hiatal hernia and GER. In three children (13.6%) postoperative complications occurred within the first 2 weeks following fundoplication and were managed medically. Following the postoperative 24-hour pH-metric study and the upper gastrointestinal series with reflux testing, one child with normal results at these investigations was lost to follow-up. The remaining 21 children were followed up for another 10 months to 5 years. Four children (18.2%) were found to suffer from functional complications (mild dumping syndrome, retrosternal pain, vomiting during episodes of asthma, dysphagia). No gas bloat syndrome occurred within the follow-up interval and all children were able to belch and vomit. There was no mortality in our limited series. Our series indicates that the partial (posterior) Toupet wrap and the modified Toupet fundoplication are safe and effective procedures for surgical correction of GER in children which preserve the ability of infants and children to belch and vomit.

The uncut Collis-Nissen fundoplication: Results for 79 consecutively treated high-risk children

Purpose: The Nissen fundoplication fails to control gastroesophageal reflux (GER) in up to 25% of children with neurological impairment or chronic lung disease. The uncut Collis modification lengthens the intraabdominal esophagus, improving the antireflux function without opening the stomach. This study reviews the results of the uncut Collis-Nissen fundoplication in a pediatric series. Methods: Seventy-nine children had an uncut Collis-Nissen fundoplication performed over a 5-year period. The median age was 1.4 years. Associated problems included neurological impairment (77%), chronic lung disease (38%), and esophageal atresia (3%). Surgery was undertaken only in children with objective documentation of pathological GER, who had GER complications unresponsive to medical treatment. The usual complications that led to surgery were pulmonary (73%), esophagitis (67%), or failure to thrive (35%). Liquid gastric emptying was assessed routinely preoperatively, and was delayed in 42% patients who then had concomitant pyloroplasty. Results: GER was controlled in 97% of patients after a median follow-up of 1.8 years. All children with recurrent symptoms were restudied, and only two children had documented recurrent GER. One of these required a repeat fundoplication. Thirty-three percent were on promotility medication for feeding difficulties, gagging, or retching. There were postoperative complications in 26% (minor 23%, major 3%) and one postoperative mortality. Eleven late deaths were unrelated to surgery or GER. Conclusion: The uncut Collis-Nissen fundoplication provides excellent control of GER in children and is associated with acceptable morbidity and low mortality. It should be particularly considered in children with neurological impairment or chronic lung disease.

Recognition of recurrent gastroesophageal reflux following antireflux surgery in the neurologically disabled child: High index of suspicion and definitive evaluation

Multiple symptoms suggestive of gastroesophageal reflux (GER) developed in 181 of 240 children (75%) with profound neurological impairment (NI) following operative management of GER. Diagnostic testing was performed in 102 children, 56% of patients with symptoms. Recurrent GER was evident on one or more diagnostic studies in 46% of children evaluated. Significant differences ( P < .05) were found in the testing protocols of children with studies positive for GER and those individuals with negative tests. Children with study-documented recurrent GER: (1) had testing conducted at a more remote time postoperatively; (2) received a greater number of total tests; (3) were evaluated by more than one type of diagnostic test; and (4) underwent upper endoscopy and pH monitoring more frequently. No single clinical symptom was predictive of study-documented recurrent GER. These results suggest that recognition of recurrent GER after an antireflux operation in a child with profound NI requires a high index of suspicion. Definitive evaluation of children with postoperative symptoms demands repeated testing over time and the use of more than one type of diagnostic test. A contrast study should be used to evaluate the mechanical properties of the fundoplication and esophagoscopy and/or esophageal pH monitoring to assess the physiological control of GER.

Predicting preoperatively the outcome of respiratory symptoms of gastroesophageal reflux

The fact that bronchopulmonary symptoms remain unchanged in about 15% of patients after successful operation for gastroesophageal reflux (GER) with respiratory tract disease (RTD) makes surgical indications uncertain and warrants further research into preoperative prognostic predictors. This problem has been adressed in infants by demonstrating that those most likely to be cured by antireflux procedures have long nocturnal episodes of GER and/or temporal coincidence between drops in pH levels and respiratory episodes. In an attempt to validate these predictors and, at the same time, to search for other reliable ones, we have retrospectively studied the charts, manometric studies, pH tracings, and pathology reports of 55 patients aged 48 ± 36 months (range, 2 to 170) who had Nissen funduplication for GER with RTD in the last 10 years. Forty-five children were cured or improved of their RTD symptoms after operation, but in 10 (18%) they were unchanged in spite of the control of GER. Patients with a former history of vomiting (n = 38) had better results than those (n = 17) without it (95% of RTD cure v 53%, P < .001). The success rate in children with recurrent obstructive airway disease (n = 20) was definitely lower than in those without it (n = 35) (70% v 89%, P < .05). Neither esophageal manometry nor mucosal biopsy provided any predictive clue, but pH studies confirmed that the mean duration of nocturnal episodes of reflux (ZMD) was definitely longer in patients responding favourably to surgical cure of GER than in those in whom this failed (12.2 ± 9.6 v 3.9 ± 2.8 minutes, P < .01). Patients with ZMD longer than 4.5 minutes had 95% chances of cure after funduplication. In addition, all cases in whom a temporal coincidence between GER and respiratory episodes could be documented were cured after surgery. Our results suggest that a thorough study of both the clinical history and the extended pH metering tracings may predict preoperatively which patients (infants and children of any age) are more likely to be relieved of their RTD by funduplication.

The mean duration of gastroesophageal reflux during sleep as an indicator of respiratory symptoms from gastroesophageal reflux in children

The coexistence of gastroesophageal reflux (GER) and respiratory symptoms has been reported in children, but identifying a reliable indicator of reflux-induced respiratory symptoms has been difficult. The mean duration of reflux episodes during sleep (ZMD), extracted from a 18- to 24-hour esophageal pH recording, has been presented previously as a reliable correlate of respiratory symptoms caused by GER in infants. To reexamine the accuracy of the ZMD we report 519 consecutive children with respiratory symptoms (aged 1 week to 15 years) who were referred for documentation of GER by 18- to 24-hour esophageal pH monitoring. Follow-up information was obtained on 388 patients 1 to 115 months later (mean, 23 months). From the follow-up information, 259 children could be reliably classified; 128 as having reflux-related and 131 as having reflux-unrelated respiratory symptoms. None of the 131 children with reflux-unrelated respiratory symptoms had a prolonged ZMD (> 3.8 minutes). In comparison, 119 of the 128 children (93%) with reflux-related respiratory symptoms had a prolonged ZMD ( P < .001). The nine children who had a normal ZMD and improvement in their respiratory symptoms with the successful control of GER had advanced esophagitis (n = 4), central apnea (n = 3), or associated disorders in which respiratory symptoms improved with the avoidance of oral feedings (n = 2). In conclusion, the ZMD was confirmed to correlate directly with both the presence and absence of respiratory symptoms caused by GER in children.

The failed antireflux procedure: Analysis of risk factors and morbidity

Between 1976 and 1988 an antireflux procedure (ARP) was performed in 364 infants and children (Nissen, 358; Thal, 6). Recurrent gastroesophageal reflux (GER) necessitating reoperation occurred in 21 patients, a failure rate of 6%. Recurrent GER developed within 28 months of primary ARP in 18 (86%) children. The symptoms of GER became apparent following an episode of forceful emesis in 29% of patients, half of whom had a malpositioned gastrostomy tube. Recurrent GER developed in 28% of children with corrected esophageal atresia. A definitive etiology of ARP failure was identified in 18 (86%) cases: “slipped” fundoplication (15), no fundoplication visualized (2), and paraesophageal hernia (1). Perioperative morbidity, intraoperative blood loss, and length of surgery were significantly increased for secondary ARP. Mortality following reoperation was zero, but three late deaths occurred. Long-term control of GER has been achieved in 78% of children following the second operation.

Intermittent tube feedings and gastroesophageal reflux control in head-injured patients

Intermittent tube feedings and gastroesophageal reflux control in head-injured patients