Surgical Treatment Of Gastroesophageal Reflux Research Articles

Surgical treatment of gastroesophageal reflux in children: L. Leape, M. L. Ramenofsky. Am J Dis Child 134:935–938, (October), 1980

Surgical treatment of gastroesophageal reflux in children: L. Leape, M. L. Ramenofsky. Am J Dis Child 134:935–938, (October), 1980

Surgical Treatment of Gastroesophageal Reflux in Children

Sir. —The article by Leape and Ramenofsky (Journal1980;134:935-938) relating their experience with the surgical management of gastroesophageal reflux (GER) was most interesting. Several points demand further clarification and comment. In the section entitled Selection for Operation, a regimen for medical management is outlined that is patterned after the work of Carre. 1 Much additional information has come to light concerning the physiology of GER, especially in the areas of lower esophageal sphincter function and gastric emptying, since Carre's article appeared. Since delayed gastric emptying may be part of the pathophysiologic process involved in infantile GER, it is probably unwise to thicken feedings (which delays gastric emptying) in infants younger than 4 months. 2 In the same section, no mention is made as to duration of medical management or as to percentage of compliance by the care-givers. Our experience with esophageal manometrics has been different from the authors. Since deglutition

Surgical Treatment of Gastroesophageal Reflux in Children-Reply

In Reply. —Dr Newman raises some important questions regarding the diagnosis and treatment of GER. It is of interest that thickened feedings delay gastric emptying in infants, which in theory may increase reflux. However, the fact is that thickened feedings decrease reflux. This has been noted empirically for 20 years, but also can be measured. In a recent study of 34 infants with GER who underwent a 24-hour pH probe monitoring, 1 we showed that two thirds of these patients had significantly fewer episodes of reflux when feedings were thickened than when they were not. When nonthickened feedings were given to these same patients, episodes of reflux were 50% more frequent than when feedings were thickened. The same study also showed that the prone position was better than the use of the upright position in many patients. However, for most patients, positioning in the chair adequately controls reflux and is

Surgical Treatment of Gastroesophageal Reflux in Children

One hundred children underwent Nissen's fundoplication for complications of gastroesophageal reflux. Indications for fundoplication included refractory pneumonia, apneic spells, intractable vomiting, failure to thrive, esophagitis, esophageal stricture, and Sandifer's syndrome. Except for those with life-threatening complications, fundoplication was performed only in those who had failure with a strict medical antireflux regimen. Four patients were not helped by operation or had a recurrence of symptoms. Of these, three with refractory pneumonia were judged to be failures of selection since reflux was absent postoperatively. The fourth had massive reflux and recurrent vomiting. Eight other patients had radiologic evidence of reflux postoperatively. Six of these were asymptomatic and two had minor symptoms. There was one death and 11 postoperative complications.

Surgical Treatment of Gastroesophageal Reflux

Most investigators agree that the most important goal in correcting gastroesophageal reflux is restoring or developing a competent lower esophageal sphincter. Although the sphincter can be incompetent in its normal intra-abdominal position and rarely a patient may have a competent sphincter in the thorax, generally the sphincter is much more effective in the positive pressure abdominal position. The choice of operative technique will depend upon the abnormal conditions present and the general condition of the patient. The thoracic approach is elected if there is associated intrathoracic disease warranting surgical correction, such as diffuse spasm of the esophagus, achalasia, epiphrenic diverticulum, or a pulmonary lesion requiring biopsy and possible resection. Very obese patients, patients with recurrent hernias, and patients with shortened esophagus are better managed by the thoracic approach. Patients with an essentially normal esophagus are treated with a Mark IV Belsey procedure. If shortening of the esophagus is present, a combination Collis-Nissen technique with fixation below the diaphragm is preferable. The abdominal approach is indicated when there is another intraabdominal disease known or suspected warranting surgical correction. This approach is also useful for the thin or poor risk patient. Usually, through an abdominal incision, we elect to use a modified Nissen fundoplication, with fixation of the fundoplication to the median arcuate ligament or the right crus of the diaphragm. The crural sling is returned to normal dimensions with interrupted sutures. Reflux in the absence of an hiatal hernia initially is treated medically. If symptoms are significant and intractable, a competent lower esophageal sphincter is restored, or developed by the modified Nissen procedure just described. Most reflux strictures at the esophagogastric junction are reversible by dilatation and restoration of a competent sphincter. Firm, fixed, fibrous strictures occasionally cannot be safely dilated. These may be managed by a Thal procedure to correct the stricture and a Nissen fundoplication to prevent recurrent reflux.

Clinical and in vitro analysis of determinants of gastroesophageal competence: A study of the principles of antireflux surgery

The analysis of esophageal manometry and 24 hour esophageal pH monitoring in 266 consecutive patients indicates that the competency of the cardia depends upon the amplitude of the distal esophageal high pressure zone and the length of the abdominal esophagus. These two determinants of competency were examined using human esophagi in a unique in vitro model which allowed control of these parameters, as well as intraabdominal, intragastric, and intrathoracic pressures. The following principles of the function of the abdominal esophagus were graphically illustrated: 1. (1) Competency of a segment of intraabdominal esophagus without intrinsic tone occurs only when intraabdominal pressure is equal to or greater than intragastric pressure. 2. (2) Competency of a segment of intraabdominal esophagus without intrinsic tone is directly related to its length. 3. (3) The length of intraabdominal esophagus necessary to maintain competency is indirectly related to variations in intraabdominal pressure. 4. (4) Competency of a segment of intraabdominal esophagus is augmented by the presence of intrinsic tone, and the shorter the length, the greater the intrinsic tone needed. 5. (5) Competency of a segment of intraabdominal esophagus is augmented by negative intrathoracic pressure. These findings beautifully illustrate the mechanical valvelike function of the abdominal esophagus and the objectives to be accomplished in the surgical treatment of gastroesophageal reflux.

Use of intraoperative esophageal manometrics in surgical treatment of gastroesophageal reflux in pediatric patients

Intraoperative lower esophageal sphincter (LES) pressures and lenghts were measured in 10 pediatric patients requiring surgery for compications of gastroesophageal reflux. LES pressure changed significantly pre- and post-Nissen fundoplication (9.8 +/- 1.51 mm Hg vs. 32.8 +/- 2.68 mm Hg, p less than 0.001). LES length also showed a significant change (1.3 +/- 0.13 cm vs. 2.8 +/- 0.26 cm, p less than 0.001). One week postoperatively LES pressures were significantly greater than preoperative values (26.4 +/- 1.74 mm Hg vs. 15.6 +/- 2.64 mm Hg, p less than 0.01). Eight of 10 patients have been evaluated 6 mo post fundoplication. None has gastroesophageal reflux by acid reflux testing or water siphon barium esophagram. None of the 10 patients has had gas bloat syndrome during the follow-up period.

An Experimental Study of the Effectiveness of Various Antireflux Operations

After a hypotensive lower esophageal sphincter was created in cats by circular myectomy of the distal esophagus, a comparative study was performed of the sphincter-enhancing operations currently in use: the Nissen fundoplication, the Belsey Mark IV, and the Hill posterior gastropexy. Subdiaphragmatic transposition of the myectomized segment was included to assess the effectiveness of intraabdominal positioning on lower esophageal sphincter competence. The mean lower esophageal sphincter pressure after Nissen fundoplication (21.7 ± 1.5 cm H 2O) did not differ significantly from control values (24.3 $pL 1.8 cm H 2O), whereas significantly lower pressures were recorded after the Belsey Mark IV (11.7 ± 1.5 cm H 2O), Hill posterior gastropexy (9.0 ± 1.5 cm H 2O), and subdiaphragmatic transposition (4.0 ± 1.5 cm H 2O) procedures. The adaptive response of the lower esophageal sphincter to increased intragastric pressure was restored to near normal levels by both the Nissen and Belsey procedures, whereas the Hill posterior gastropexy and subdiaphragmatic transposition were less effective. In addition, pH reflux testing clearly indicated that the Nissen fundoplication afforded maximum protection against acid reflux. The experimental evidence suggests that optimum results in the surgical treatment of gastroesophageal reflux are achieved when the resting lower esophageal sphincter pressure and the adaptive response are restored to normal levels. The Nissen fundoplication accomplishes these objectives more effectively than the alternative antireflux procedures.

Surgical treatment of gastroesophageal reflux and its complications.

AbstractAlthough most patients with reflux peptic esophagitis have the sliding type of hiatal hernia, correction of the hernia is incidental and the objective of the surgeon is to reestablish continence of the lower esophageal sphincter (LES). The presence of this crucial closure mechanism between the stomach and esophagus was demonstrated just over 2 decades ago by manometric and cineradiographic studies of the esophagogastric junction. Although the abdominal location of the LES exerts a favorable influence, it is possible to have normal LES function in the supradiaphragmatic position, and the relationship between the sliding hiatal hernia and reflux peptic esophagitis remains unclear. Some patients develop esophagitis in the absence of a hernia.Three surgical methods are in common use today for correcting gastroesophageal reflux: the Belsey cardioplasty, the Nissen fundoplication, and the Hill posterior gastropexy. Results have been analyzed on the basis of clinical, anatomic, and physiologic success. The Nissen fundoplication is the most certain to correct reflux and, as an added advantage, can be performed by either the thoracic or abdominal approach. However, it is associated with the highest incidence of chronic side effects, particularly the “postfundoplication” or “gas‐bloat syndrome.” The Hill procedure can be accomplished only through the abdomen and is associated with a somewhat higher incidence of recurrent esophagitis and recurrent hernia. However, side effects are minimal. The Belsey cardioplasty has the advantage of requiring a minimum of available tissue for its successful accomplishment. However, it can be performed with ease only by the thoracic approach and also has a relatively high incidence of recurrent or persistent esophagitis.For these reasons, we prefer the Hill posterior gastropexy in the medically intractable, but otherwise uncomplicated, patient with reflux peptic esophagitis. The Nissen fundoplication is preferred for cases complicated by prior unsuccessful surgery, stenosis with short esophagus, and marked obesity. The Belsey cardioplasty is most useful in patients who have had extensive prior gastric surgery with loss of available tissue for repair. The combined Thal patch‐Nissen fundoplication is considered the primary treatment of choice in patients with transmural strictures of the esophagus, particularly because it is associated with a low morbidity and mortality.

Complications of vagotomy in the treatment of hiatal hernia.

Inclusion of vagotomy and pyloroplasty in the surgical treatment of gastroesophageal reflux associated with hiatal hernia has long been controversial. To evaluate the morbidity of vagotomy in the treatment of reflux esophagitis, a retrospective study of 311 patients treated by the Hill posterior gastropexy technique of hiatal hernia repair was tabulated. Vagotomy with the anti-reflux operation was performed upon 159 patients (51%). Vagotomy was not included for 152 patients (49%). The incidence of postoperative symptoms with or without vagotomy was almost equally divided--41% without vagotomy and 47% with vagotomy. However, the major postoperative symptoms that occurred in both groups were abdominal cramps and bloating which usually disappeared in the early postoperative period and were attributed to the anti-reflux procedure and not to vagotomy. When vagotomy was included with the anti-reflux operation, the incidence and duration of long term, disabling postoperative symptoms were significantly increased. Diarrhea occurred two times more frequently. Nausea and vomiting occurred ten times more frequently and dumping was present only in vagotomized patients. Long term postoperative symptoms, judged on a basis of symptoms lasting longer than three months duration, occurred in 1% of patients without vagotomy and 26% when vagotomy was included. This study revealed that no additional protection against recurrent symptoms of gastroesophageal reflux or radiographic evidence of recurrent hiatal hernia was provided by inclusion of vagotomy. In conclusion, vagotomy is contraindicated in the treatment of gastroesophageal reflux except in the presence of peptic ulcer disease.

Surgical treatment of gastroesophageal reflux in infants and children: Long-term results in 28 cases

Twenty-eight infants and children with esophageal hiatus hernia are described, six of whom had been operated on before the same disorder. In four patients an esophageal stenosis was present. Right-sided subhepatic anterior gastropexy was performed in 27 patients and resection of an esophageal stricture with subsequent esophagogastrostomy in one. There were no operative deaths. One patient developed an esophageal stricture 6 months postoperatively. The remaining 27 patients were seen from 1 to 18 years after the operation; 85 per cent of the patients had a follow-up period of longer than 3 years. At the follow-up examination, 27 of the patients were free of symptoms. In two of these patients recurrent gastroesophageal reflux was noted on cinefluoroscopic examination. Gastropexy is advocated as the treatment of choice in cases of gastroesophageal reflux that do not react to proper conservative measures. In view of the danger of esophageal stenosis, the importance of early operation is stressed.