Neurologically Impaired Children Research Articles

Measurement of body composition by deuterium oxide dilution technique and development of a predictive equation for body fat mass among severe neurologically impaired children.

Neurologically impaired (NI) children are at risk of malnutrition, which consequently impacts their health and quality of life. Accurate nutrition assessment is an important step in guiding appropriate nutrition support. Conventional anthropometric measurements among NI children have some limitations. Determining body composition requires more complex equipment, which is not routinely performed. This study was conducted to evaluate the association between anthropometric parameters and body composition assessed using the deuterium dilution technique (DDT) in NI children. A cross-sectional study enrolled severe NI children aged 1-20 years who received home enteral nutrition for at least 3 months. Weight, length, and 4-site skinfold thickness were measured. Body composition was determined using DDT following the International Atomic Energy Agency (IAEA) protocol. A total of 37 NI children (56.76% male, median age 7.2 years) were enrolled. The prevalence of underweight, stunting, and overweight were 22, 38, and 35%, respectively. Body composition analysis showed the mean (SD) of total body water (TBW) and fat mass (FM) were 10.52 (4.51) kg and 9.51 (6.04) kg, respectively. Multivariate GLM analysis showed that the factors associated with FM were age (β = 0.07 [0.05,0.08]; p < 0.001), body mass index (BMI) (β = 0.82 [0.52, 1.12]; p < 0.001), biceps skinfold thickness (BSF) (β = 0.49 [0.23,0.75]; p = 0.001), and subscapular skinfold thickness (SSF) (β = -0.24 [-0.46,0.03]; p = 0.030). A predictive equation for FM was constructed. A high prevalence of malnutrition was found among severe NI children despite enteral nutrition support. Our findings showed that age, BMI, BSF, and SSF were associated with FM. The predictive equation of FM was proposed and needed to be further validated and applied to clinical practice.

Total esophagogastric dissociation (TEGD) in neurologically impaired children: the floor to parents

Total esophagogastric dissociation (TEGD) was proposed to treat gastroesophageal reflux disease (GERD) both as a rescue in case of fundoplication failure and as first-line surgery in neurologically impaired children (NIC). Aim of the study is to evaluate the impact of TEGD on the quality of life (QoL) of both NIC and their caregivers focusing on the parents’ point of view. A retrospective observational study was conducted on all NIC who underwent TEGD in our center between 2012 and 2022. A questionnaire centered on the parents’ point of view and investigating QoL of NIC and their caregivers was administered to all patients’ parents. Data were compared using Fisher exact test and Mann–Whitney test; a p-value < 0.05 was considered statistically significant. 12 patients were enrolled in the study. Parents reported improvements in weight gain (p = 0.03), sleep disorders, apnea, regurgitation and vomiting (p < 0.01). Caregivers also declared a decrease in number of hospitalizations, particularly related to severe respiratory infections and ab ingestis pneumonia (p = 0.01). We also documented a reduction of caregivers’ worries during food administration (p < 0.01). 50% of parents whose children were subjected to both fundoplication and TEGD would suggest TEGD as first line surgical treatment instead of fundoplication. According to parents’ point of view, TEGD improves significantly NIC QoL and 50% of them would enthusiastically suggest TEGD as first-line surgical approach to GERD in NIC.

Effectiveness of robotic assisted laparoscopic nissen fundoplication in neurologically impaired children with severe gastroesophageal reflux disease

Laparoscopic Nissen Fundoplication is still the most widely used surgical technique in the treatment of gastroesophageal reflux disease (GERD) in children. However, there are some technical and anatomical difficulties in the treatment of reflux in NIC with GERD. All these difficulties lead to the high rate of surgical failure observed in neurological impaired children (NIC). Robotic surgery provides several advantages in overcoming these difficulties. This study is the first study to evaluate the effectiveness of robotic surgery in the treatment of GERD in children with severe or moderate neurological impairments reported in Turkey. This study took place between January 2018 and February 2020. We retrospectively evaluated the records of eleven children with severe or moderate neurological problems who were treated using the robotically assisted laparoscopic Nissen fundoplication (RALNF) technique for demographic data, anesthesia time, pre-console time, console time, and postoperative complications. Nine of the patients (81.8%) had serious and two had moderate neurological problems. All of the patients applied to the emergency department at different times due to recurrent lung infections. While the first RALNF console time was 240 minutes, this study revealed that this time decreased to 45 minutes. None of the patients had complications related to the surgical procedure, but four patients required postoperative intensive care unit up to two months due to several problems related to NIC. RALNF can be safely applied to pediatric patients with GERD with severe and moderate NIC.

The impact of two weeks of traditional therapy supplemented with virtual reality on balance control in neurologically-impaired children and adolescents

BackgroundThe aim of the study was to assess whether two weeks of therapy (traditional and VR) may improve balance in children and adolescents with neurological problems of different origins and whether the deterioration in gait dynamic balance showed by patient's ground reaction forces (GRF) determinates therapy effectiveness. Methods29 participants aged 9–17 attended traditional therapy supplemented by tailor-made games. Therapy comprised exercises improving balance, range of motion, posture control, proprioception, muscle strength. Biodex Balance System was used for main assessment before and after therapy in tests: Postural Stability, modified Clinical Test of Sensory Integration and Balance, and Limits of Stability. Participants underwent gait analysis before the therapy to determine GRF. An increased maximal lateral component or decreased maximal anterior component in the push-off phase taking place in both legs were regarded as deterioration. This enabled the division into two groups with and without such a deterioration. Results were compared between the groups before and within groups before and after therapy. ResultsThe precision of forward-backwards body sway improved most significantly in the group with decreased GRF and reached the level of the second group, who worsened antero-posterior repeatability during stance on an unstable surface with eyes open. ConclusionTwo weeks of combined traditional and VR therapy tailored to patients’ functional weakness positively influenced the balance of neurologically impaired children. The group with decreased gait dynamic balance improved the tasks, which were intensively trained in the games. The second group remained more spontaneous in the trained direction.

Sleep surgery in syndromic and neurologically impaired children.

To examine surgery performed for obstructive sleep apnea (OSA) in children with syndromic or neurologic comorbidities. Medical records of 375 children with OSA were retrospectively reviewed, including 142 patients with trisomy 21, 105 with cerebral palsy, 53 with muscular dystrophy, 32 with spinal muscular atrophy, 18 with mucopolysaccharidoses, 14 with achondroplasia, and 11 with Prader-Willi. Apnea-hypopnea index (AHI), complications, length of postoperative stay, and endoscopic findings. 228 patients received 297 surgical interventions, with the remainder undergoing observation or positive pressure ventilation. Adenoidectomy was the most common procedure performed (92.1% of patients), followed by tonsillectomy (91.6%). Average AHI decreased following tonsillectomy, from 12.4 to 5.7 (p=0.002). The most common DISE finding was the tongue base causing epiglottic retroflexion. Lingual tonsillectomy also resulted in an insignificant decrease in the AHI. Adenotonsillectomy, when there is hypertrophy, remains the mainstay of management of syndromic and neurologically-impaired children with OSA. However, additional interventions are often required, due to incomplete resolution of the OSA. DISE is valuable in identifying remaining sites of obstruction and guiding future management.

Neuro-Enteric Dysfunction in Children with Severe Neurological Impairment

Visceral hyperalgesia, intestinal dysfunction and unexplained irritability in neurological impaired children is a medical enigma for many healthcare professionals. The neuro-medical management can be challenging and difficult, due to poor understanding of the underlying aetiology and pathophysiology of the condition. Neuro-enteric axis has been proposed as emerging physiologic mechanism in the pathogenesis of many gastrointestinal diseases. The bidirectional connection between enteric and central nervous system may represent a direct relationship between neurological system and gut physiology. Insult to the brain indirectly contribute to the ongoing gut and brain axis sequalae. Microbiota has been an important modulator in the brain-gut axis. Irritability episodes in severe neurological impairment children has been commonly associated with pain originated from gastrointestinal pathology. Management of such condition requires a holistic approach to tackle multidimensional factors that has contributed to the ‘totality’ of the symptoms.

The outcomes of fundoplication and gastrostomy in neurologically impaired children in a tertiary care hospital in Saudi Arabia.

Objectives:To evaluate the outcomes of fundoplication and gastrostomy (GT) in neurologically impaired (NI) children.Methods:A retrospective review of medical charts was performed on 178 NI children up to the age of 14 years inclusive, who underwent fundoplication and GT between 1999 and 2014.Results:After fundoplication, the incidence-rate (person-month) of all hospital admissions (0.95 versus 0.13; p<0.001), gastroesophageal reflux (GER) - related admissions (0.67 versus 0.09; p<0.001), and admissions for seizures (0.21 versus 0.01; p<0.001 were significantly decreased. Furthermore, all emergency department visits (0.94 versus 0.23; p<0.001), GER visits (0.61 versus 0.12; p<0.001), seizure visits (0.24 versus 0.01: p<0.001) were significantly reduced. The mortality rate after fundoplication was 35%. The risk factors for predicting mortality were being male (odds ratio: 2.2, p=0.027) and being a do not resuscitate (DNR) child (odds ratio: 5.2, p<0.001). Majority of the children that died within a year after the procedure were DNR.Conclusions:Fundoplication with GT is effective in reducing hospital admissions and emergency department visits from GER and seizures in NI children. Because of high mortality within a year of fundoplication with GT in DNR children, anti-reflux medications with GT might be an alternative.

Body hydration assessment using bioelectrical impedance vector analysis in neurologically impaired children.

Dehydration is common and frequently under-diagnosed in chronic malnourished children, leading to life-threatening conditions. In this pilot study we applied bioimpedance vector analysis (BIVA) to determine hydration status in 52 neurologically impaired (NI) paediatric patients (14.08 ± 5.32). Clinical and biochemical data were used to define malnutrition and dehydration. Body composition analysis and hydration were also assessed by BIVA and we considered 143 normal-weight healthy subjects (15.0 ± 1.7), as controls for hydration status assessment. BIVA revealed a pathological hydration status in NI children, showing higher resistance (p < 0.001) and reactance values (p = 0.001) compared to controls. No differences in reactance and resistance were detected between well-nourished and under-nourished subjects. Four patients out of 52 showed mild signs of dehydration; no severe dehydration was detected. Laboratory data, suggestive for dehydration, were similar in well-nourished and under-nourished NI subjects. In conclusion, in our sample of NI paediatrics, dehydration according to clinical signs and laboratory data was under-diagnosed. BIVA showed specific bioelectrical characteristics that could be compatible with impaired hydration status. Further studies are necessary to confirm that BIVA may an applicable tool for defining dehydration status and guiding rehydration in NI children.

Total Esophagogastric Separation in Neurologically Impaired Children: Outcome and Efficacy

Background: Gastroesophageal reflux disease (GERD) is one of the most clinical disorders affecting the gastrointestinal tract of neurologically impaired children (NIC). The reported incidence of GERD in NIC ranges from 15% to 75%. For a long time Nissen fundoplication became the first choice for management with some complications. For this reason, and as an alternative to repeated fundoplications, total esophagogastric separation (TEGS) became popular in treating these cases. Even some studies consider TEGS as a primary approach for GERD in NIC. Purpose: The aim of the study was to assess the efficacy and outcome of total esophagogastric separation in cases of severe gastroesophageal reflux in neurologically impaired children. Materials and Methods: Medical records of 11 patients who underwent total esophagogastric separation (TEGS) with Roux en Y anastomosis for recurrent GERD in our institute in pediatric surgery unit, Medina children hospital, KSA, were reviewed retrospectively. Selective criteria included all cases of recurrent GERD in NIC after fundoplications. TEGS was not performed in any case as a primary procedure. Results: Our study included eleven cases, seven males and four females. Their ages ranged from 6 to 14 years. All of them were neurologically impaired, with difficulty to take oral feeds and all cases had GERD or its related complications preoperatively. Median operating time was 5 hours ranging from 3.5 to 7 hours with a median blood loss of 200 ml. Hospital stay ranged from 5 to 17 days with a median of 9 days and median ICU stay was 3.5 days. Complications occurred in four cases (36.3%) with no mortality. Three cases needed reoperations (27.2%). Two cases (18.2%) developed hiatus hernia and were operated between 8 and 10 months postoperatively. Two cases (18.2%) develop adhesive intestinal obstruction who underwent conservative management and passed smoothly. Conclusion: TEGS, is considered as a safe, effective and reliable operation for treating cases of recurrent GERD after fundoplications in neurologically impaired children especially those who are dependent on enteral tube feeding.

Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis.

Neurologically impaired children (NIC) suffer severe gastroesophageal reflux (GER) with poor fundoplication outcome. Aims of the study were: (1) to determine the recurrence of GER after fundoplication in NIC; (2) to compare fundoplication versus gastro-jejunal tube feeding insertion (GJ) and fundoplication versus total esophagogastric dissociation (TEGD) in primarily treating GER in NIC. Using defined search strategy, two investigators identified all comparative studies reporting the mentioned procedures to primarily treat GER in NIC. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 3840 titles/abstracts screened, 14 studies on fundoplication (2716 pts.) reported a recurrence/persistence of GER higher in NIC (14.2 ± 8.3%) than in neurologically normal (9.4 ± 5.2%; p = 0.0001), with an increased incidence of re-do fundoplication (12.6 ± 7.0% versus 9.1 ± 4.5%; p < 0.01). Three studies revealed a similar risk of undergoing subsequent fundoplication after GJ (4.9 ± 2.1%) or initial fundoplication (12.0 ± 0.6%; p = ns). Four studies showed a lower recurrence of GER following TEGD (1.4 ± 1.1%) than fundoplication (24.8 ± 1.4%; p = 0.002). NIC are at risk of recurrence/persistence of GER after fundoplication or GJ. TEGD seems more effective to primarily treat GER in NIC. Prospective randomized controlled trials are necessary to establish which is the ideal treatment of GER in NIC.

Analyses of the relationship between a ‘number of reflux episodes’ exceeding 70 and the pH index in neurologically impaired children by evaluating esophageal combined pH-multichannel intraluminal impedance measurements

Background: The present study aimed to evaluate the characteristics associated with a number of reflux episodes (NoRE) of 70 by comparing the clinical and multichannel intraluminal impedance pH measurements (pH/MII) and pH index (pHI) in neurologically impaired (NI) children.Patients and methods: NI children (1–16 years of age) in whom pH/MII had been measured for GERD study were enrolled in this study. All children were divided into NoRE >70 or ≤70 and pHI >4.0 or ≤4.0, >5.0 or ≤5.0 or >7.0 or ≤7.0. In addition, the NI children with pHI >4.0, >5.0 and >7.0 were subdivided into NoRE >70 and ≤70 groups. The clinical and pH/MII measurements were compared between each of the two groups. The cutoff values of pHI and baseline impedance (BI) (Z6) were calculated to discriminate NoRE >70 and ≤70.Results: A total of 61 NI children were enrolled in this study. There was a significant difference in the acid-related parameters, the NoRE (nonacid) and BI between NoRE >70 and ≤70, acid-related parameters and BI between pHI >4.0 and ≤4.0, >5.0 and ≤5.0 and >7.0 and ≤7.0 groups. Furthermore, a significant difference was still observed in the BI between NoRE >70 and ≤70 groups among patients with pHI >4.0, >5.0 or >7.0. The cutoff values of pHI and BI (Z6) for discriminating NoRE >70 and ≤70 were 9.2 and 1049Ω, respectively.Conclusion: The present study indicates that NoRE 70 corresponds to GERD in which patients suffer severe acid exposure with pH of around 9% and esophageal mucosal damage with low BI value in NI children.

Analysis of Growth, Nutritional Status and Hospital Visitation Scores Associated with Reflux After Nissen Fundoplication in Neurologically Impaired Children with Gastroesophageal Reflux.

Neurologically impaired children (NIC) often experience swallowing difficulties and gastroesophageal reflux disease (GERD). Although these conditions could place children in a state of poor nutritional status and prevent them from thriving, there is insufficient research evaluating growth and nutritional status following fundoplication in these patients. This is a retrospective study of patients who were neurologically impaired and underwent Nissen fundoplication between April 2001 and March 2015. Seventy-six patients were enrolled, and the follow-up period was 12months or longer. Growth was measured by the change in body weight and height. Nutritional status was measured by the change in body mass index, serum albumin and protein level. Median age at operation was 1.85years old, and median body weight was 10kg. The respective Zscores for weight and height showed significant improvements after 1year since the operation compared to 1year within the operation (-2.42±2.19 vs. -1.31±1.96, P<0.001) (-1.6±2.16 vs. -1.05±1.69, P=0.002). The respective Zscores for body mass index, albumin and protein also showed improvements after 1year since the operation compared to 1year within the operation (-2.07±2.99 vs. -0.89±2.1, P<0.001) (3.55±0.48 vs. 3.86±0.45, P<0.001) (6.22±0.76 vs. 6.65±0.51, P<0.001). Hospital visitation scores associated with reflux were significantly lower after the operation (4.1±3.43 vs. 1.18±1.67, P<0.001). In summary, after Nissen fundoplication in NIC with GER, growth and nutritional status improved significantly. Also, hospital visitation scores associated with reflux decreased after the operation.

PP‐8 ESOPHAGEAL HIGH RESOLUTION MANOMETRY IN NEUROLOGICALLLY IMPAIRED CHILDREN AND GASTRO‐OESOPHAGEAL REFLUX DISEASE

Objectives:Mechanism underlying the occurrence of Gastroesophageal reflux disease (GERD) in neurologically impaired children (NIC) is poorly understood. We sought to characterize, by Esophageal High Resolution Manometry (EHRM), alterations of esophageal motility associated with GERD in NIC and to compare with a group with a suspicion of GERD and normal psychomotor development (NDP).Methods:EHRM and multichannel intraluminal impedance/pH‐metry (MII/pH) were conducted in 7 NIC and 9 patients with suspicion of GERD and NPD. Esophagogastric junction relaxation (EGJr), the presence/pressure troughs of the oesophageal segments, the distal contractile integral adjusted for esophageal length (DCIa) and the pressurization frontal velocity (PFV) were analyzed by EHRM.Results:Three out of 7 NIC (42.8%) and 4 out of 9 patients with NPD (44.4%) resulted positive to MII/pH (p = 1). No statistical differences were observed for EGJr and PFV between NIC and NPD patients. DCIa was significantly lower in NIC subjects respect to NPD patients (p &lt; 0.01). Comparing NIC with GERD and patients with GERD and NPD we found that third segment was absent in 2/3 (66,6 %) of NIC respect to NPD patients (p &lt; 0.05) and that the third pressure trough was significantly lower in NIC respect to NPD patients (p &lt; 0.05). There were no statistical differences with respect to the first and second pressure trough between NIC and NDP patients.Conclusions:NIC have esophageal motor dysfunction that can be detected by EHRM. Some esophageal manometric alterations could be predictive of GERD in NIC and could explain a different pathogenesis of GERD in NIC and in patients with NPD.

Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children — a single centre experience

Background and aimsGastrooesophageal reflux disease (GERD) is a significant problem in children with neurological impairment (NI) with high failure rates for fundoplication. Fundoplication with vagotomy and pyloroplasty (FVP) can improve the outcome by altering the sensory or motor dysfunction associated with the reflux. We report our comparative outcomes for simple fundoplication (SF) and FVP in NI children. MethodsCase records of all patients having fundoplication under a single consultant at a tertiary UK paediatric surgical centre between January 1997 and December 2012 were retrospectively assessed for recurrent symptoms and redo surgery. The data were collected using a Microsoft Excel database and analysed on Graphpad prism software program. Data are median (range). P value <0.05 was considered significant. ResultsData were available for 244 out of 275 patients who underwent fundoplication during this period (157 SF and 87 FVP). Neurological disease or known syndromes were recorded in 158 patients. Thirty-five children had congenital anatomical abnormalities. Laparoscopic fundoplication was done in 37 cases. Revisional surgery for recurrent symptoms was performed in 22 patients. In the neurologically normal children, all of whom had SF, the revision rate was 6.5%. In the NI children the revision rates were 18.5% for SF and 3.9% for FVP, respectively (Fisher’s exact, P<0.05). The median time to redo surgery was 10 (1–63) months, and the median time to follow up was 19.5 (2–177) months. ConclusionsThere appears to be a significantly lower need for redo surgery following FVP than SF in children with NI.

Esophagogastric dissociation reduces the re-operation rate for persistent gastroesophageal reflux in severely neurologically impaired children.

In this study we want to demonstrate the effectiveness of the esophagogastric dissociation as a first level operation in treatment of the gastroesophageal reflux in severe neurologically impaired children, in term of a reduction of reoperation rate. We divided patients operated from 1998 to 2005 in a group A, composed by children treated with fundoplication, and in a group AR, composed by the patients of group A who had a recurrence of reflux and that was treated with esophagogastric dissociation. Patients operated from 2005 to 2013 were selected on the basis of the severity of the neurological impairment and were divided in a group B, treated with fundoplication, and in a group C of more severe impaired children, treated with esophagogastric dissociation. Data regarding the complications of the A and C groups were analyzed with Fisher's test. We evaluated 63 patients: 34 (54%) in group A, 11 in group AR, 15 (23.6%) in group B, 14 (22.4%) in group C. The Fisher's test showed a non significant difference with a p value of 0.2. Despite of statistic result we believe that TOGD is a useful procedure as the first choice of surgical management in severe neurological impaired children affected by gastroesophageal reflux.

Unilateral versus bilateral wrap crural fixation in laparoscopic Nissen fundoplication for children.

Introduction:Gastroesophageal reflux (GERD) is common in neurologically impaired (NI) children. Fundoplication and gastrostomy have previously been indicated in NI children with GERD who have not responded to medical treatment. The most common reason for fundoplication failure is intrathoracic migration of the wrap.Objective:The aim of the study is to measure the effect of wrap fixation on the final outcome of laparoscopic Nissen fundoplication in NI children.Patients and Methods:A retrospective file review was conducted for all NI children who underwent laparoscopic Nissen fundoplication in 2 tertiary pediatric surgery centers in the United Arab Emirates from February 15, 2006 to February 15, 2013. Redo fundoplication patients were excluded from the study. Patients were divided into 2 groups: group 1 in which the fundoplication wrap was fixed to the right crus only, and group 2 in which the wrap was fixed to the right and left crus simultaneously.Results:The study population included 68 patients; there were 47 male and 21 female children. Mean age at time of surgery was 8.2 years. Recurrent GERD at 1 year postoperatively was 26% versus 7% in group 1 and group 2, respectively, by upper contrast study. Redo surgery was required in 21% versus 3% in group 1 and group 2, respectively.Conclusions:Bilateral fixation of the wrap to diaphragmatic crura significantly reduced recurrent GERD, in laparoscopic Nissen fundoplication for neurologically impaired children, with no increased risk of morbidities. Future prospective studies should be conducted with larger patient populations and longer follow-up periods.

Pre and post-operative evaluation of gastroesophageal reflux and esophageal motility in neurologically impaired children using combined pH–multichannel intraluminal impedance measurements

BackgroundGastroesophageal reflux disease (GERD) in patients with neurological impairment (NI) has not been fully studied before and after fundoplication procedure because their characteristics such as generalized gastrointestinal dysmotility, non-acid reflux, and the proximal reflux due to feeding of enteral nutrition via a nasogastric tube prevent their GERD from being detected by 24 h pH monitoring. The aim of this study was to elucidate whether multichannel impedance–pH measurement (pH/MII) is able to detect the subtypes of GERD and the differences in the reflux episodes of the severity of GERD, the ingestion pathway, and before and after fundoplication. The second aim was to determine whether a trial evaluation of dry swallows was able to be used to assess the esophageal motility of NI patients as an alternative examination.Patients and methodsThe 24 h pH/MII was conducted on 20 NI children [15 were the patients before Nissen’s fundoplication (BN), of whom, six were fed orally (FO) and nine were fed via nasogastric tube (NGT), and five were the patients after Nissen’s fundoplication (AN)]. All reflux episodes were evaluated and compared between patients with pathological GERD (PG) and non-pathological GERD (NG) and between patients who had FO and NGT and patients between BN and AN. Dry swallows were conducted to evaluate the esophageal motility. The average bolus presence time (BPT) and total bolus transit time (TBTT) were compared between the PG and NG, FO and NGT, and the BN and AN subgroups.ResultsA total of 1,064 reflux episodes were detected by pH/MII. Of those, 303 (28.5 %) were non-acid-related and 477 episodes reached the proximal esophagus. Of the 12 patients (57.1 %) showing pathological GERD, two cases (16.7 %) demonstrated predominantly weakly acidic PG. More than half of the reflux episodes of PG patients reached to the proximal esophagus. The numbers of total reflux and proximal reflux episodes in the PG were significantly higher than those in NG patients. The number of proximal reflux episodes in the FO group was significantly higher than that in the NGT groups, whereas NGT patients showed more non-acidic reflux episodes than FO patients. A trial evaluation of dry swallows demonstrated no significant differences in this study.ConclusionThe pH/MII was useful to detect the subtype of GERD in NI patients which could not be detected by 24 h pH monitoring. It can, therefore, be considered to have first priority for testing NI patients who are suspected to be suffering from GERD.

Laparoscopic Proximal Roux-en-Y Gastrojejunal Diversion in Children: Preliminary Experience from a Single Center

Neurologically impaired children (NIC) have a high risk of recurrence of gastroesophageal reflux (GER) following fundoplication. A postpyloric feeding tube may be useful when gastric emptying disorders occur; however, dislocation and difficulty in feeding management often require more aggressive procedures. Total esophagogastric dissociation (Bianchi's TEGD) is an alternative to the classic fundoplication procedure, whereas laparoscopic gastric bypass is a frequently performed procedure in morbid obesity, improving gastric outlet. The aim of this paper is to present a preliminary experience on the laparoscopic Roux-en-Y gastrojejunal bypass, associated with Nissen fundoplication and gastrostomy, to treat and prevent GER in NIC with gastric emptying disorders. Eight neurologically impaired children underwent surgical treatment because of feeding problems and pulmonary complications. The procedure included: 1) hiatoplasty, 2) Nissen fundoplication, 3) 20-cm Roux-en-Y gastrojejunal anastomosis and jejuno-jejunal anastomosis, and 4) gastrostomy. All cases were fed on postoperative day 3 without any intraoperative complications. One case developed an obstruction of the distal anastomosis due to adhesion and needed reoperation. Outcome was clinically evaluated with serial upper gastrointestinal contrast studies and endoscopies. Laparoscopic proximal Roux-en-Y gastrojejunal diversion, without gastric resection, is a safe, feasible procedure that improves gastric emptying and reduces the risk of GER recurrence. Yet, long-term results still have to be evaluated.

Outcomes of tonsillectomy in neurologically impaired children

Children with neurologically impaired (NI) swallow can undergo tonsillectomy safely and effectively. Retrospective review. Forty-five children with documented dysphagia were compared to age- and procedure-matched normal children for operating room and clinical experience. Three further studies were limited to the NI children only: preoperative and postoperative video swallow studies (VSS), and polysomnography (PSG) for sleep-disordered breathing history. Long-term telephone follow-up of clinical outcomes was performed. There were no differences between the two groups measured by tonsil size or intraoperative or late post-tonsillectomy hemorrhage, but lowest measured oxygen levels were statistically different. No intraoperative complications, early post-tonsillectomy hemorrhage, hospital readmission, or mortality occurred in either group. Three NI children each had an episode of aspiration pneumonia (early or late) without sequelae. Of the 32 VSS available for review, postoperative aspiration incidence was significantly improved, but with new-onset aspiration occurring in five children. Of available matched pre- and postoperative PSG, 91% confirmed resolution of identified preoperative obstructive sleep apnea. Long-term telephone follow-up of 20 NI children revealed improved breathing (95%), communication (90%), and feeding efficiency (55%). This study suggests tonsillectomy in NI children can be performed safely with appropriate monitoring and precautions with a 48-hour hospital postoperative stay recommended. Swallowing safety appears to improve both objectively and subjectively in most NI children following tonsillectomy. Both preoperative and postoperative VSS are recommended for any NI child undergoing tonsillectomy. Long-term follow-up identified improved quality of life measures for the majority of the NI children queried.

Erosive Eosinophilic Esophagitis in Rumination Syndrome

Rumination syndrome involves bringing up partially digested food into the pharynx voluntarily, followed by reswallowing or expelling. It was discovered in the 17 century; however, knowledge of the disorder has remained sparse until recently. Indeed, the first case of adult rumination in Japan was reported as recently as 2006. Due to this recent increase in awareness, notions about the disease have remained in a state of constant fluctuation. While first believed to be a disease of neurologically-impaired children between 3 and 8 months of age, it is now widely recognized as occurring in men and women of all ages and cognitive abilities. Originally rumination was labeled benign; however, it is now known to cause such complications as weight loss, malnutrition, dental erosions, halitosis, electrolyte abnormalities, abdominal discomfort, weight loss, choking, aspiration, and pneumonia. Similarly, while the absence of gastroesophageal reflux disease was an original criterion for the syndrome, it has been found that many of these patients have evidence of “pathologic gastroesophageal reflux.” Some suggest that thorough upper gastrointestinal workup, such as upper esophageal barium studies and EGD, not be done on children presenting with rumination, despite the presence of abdominal pain or other accompanying gastrointestinal symptoms. We performed a thorough upper gastrointestinal workup on a patient with concurrent rumination syndrome and heartburn, and were intrigued by the findings.