Guidelines for Surgical Treatment of Pediatric Gastroesophageal Reflux Disease

Introduction

Gastroesophageal reflux (GERD) is a common problem in infants and children. During the first 6 to 12 months of life, vomiting is believed to be the result of an incompetent lower esophageal sphincter mechanism(1). Pathological GERD can present with a wide spectrum of clinical symptoms. Signs and symptoms of GERD vary with age. Infants typically present with regurgitation and emesis. Children present with abdominal pain, thoracic pain and dysphagia more commonly than vomiting(2). Neurologically impaired children have a higher rate of GERD than neurologically normal children and may require treatment for GERD at the time of placement of feeding tubes(1,3).

Surgical treatment for GERD is recommended in certain situations and has benefit over continued medical therapy(1,2,5-7). Gastrostomy placement can worsen symptomatic reflux and increase the need for fundoplication in neurologically impaired children(1-7).
Definition

GERD in children is defined as the failure of the antireflux barrier, which includes the angle of His, and lower esophageal sphincter mechanism. This failure must be greater than that present in the normal infant and child. This can be differentiated on the basis of appropriate weight gain in infants(1). GERD in infants and children can produce a variety of respiratory symptoms including reactive airway disease, bronchitis and pneumonia. The exact cause of GERD is not known but the lower esophageal sphincter pressure, presence of adequate lengths of intraabdominal esophagus and pinch-cock action of the diaphragm are important components(2,12).

Diagnosis

Clinical symptoms must be evaluated and include vomiting and failure to thrive especially in infants. Respiratory symptoms can include reactive airway disease, recurrent bronchitis, pneumonia, or laryngospasm(1,2,9,10,12,15). GERD has been implicated in some cases of sudden infant death syndrome (SIDS)(1,2,12,15). Older children may complain of heartburn type pain and infants and young children may be irritable secondary to the pain from esophagitis. Infants and young children may also present with failure to thrive(1, 2,7).

Confirmatory testing in a symptomatic patient should be performed and relies on the demonstration of one or more of the following tests being abnormal:
  1. Upper gastrointestinal imaging (to exclude other causes of emesis, may also demonstrate reflux)
  2. 24 hour pH probe testing
  3. Gastric emptying scan (radio nuclide-labeled 99mTc sulfur colloid liquid or semisolid food can assess gastric emptying, also sensitive for GERD)
  4. Esophagoscopy with biopsy demonstrating esophageal mucosal injury
  5. Bronchoscopy with aspiration for lipid laden macrophages
Various congenital anomalies lead to increased incidence of gastroesophageal reflux disease by changing esophageal length, diaphragmatic action or intra-abdominal pressure. These anomalies include esophageal atresia, congenital diaphragmatic hernia and abdominal wall defects.
Management

Nonoperative therapy is the first line of management for GERD and is age dependent. Most neurologically intact children will respond to medical therapy. Symptoms may recur in a percentage of children. Positioning and thickened formula are used in infants as first line of therapy. This therapy is effective in 80-90% of infants under 14 months of age(2). Prokinetic medications and H2-antagonists or proton pump inhibitors are also used. Most patients will resolve their symptoms with these therapies. Chronic medical therapy may not be appropriate for all individuals with chronic GERD especially with the development of strictures, persistence of chronic pulmonary disease or worsening of reactive airway disease(2,9).

Operative Treatment Of Gerd
Preoperative Work-Up
Before operative intervention, patients should be evaluated with a thorough history and physical examination. Results of treatment with nonoperative therapy should be noted.
It is advisable to undertake a confirmatory test prior to the performance of the fundoplication and this may include:
1. 24-hr intraesophageal pH monitoring(1,2,9,10,12,13) or
2. UGI imaging(1, 2,9,10,12,13,19,20) or
3. Gastric emptying scan(2) or
4. Esophagoscopy with biopsy or
5. Bronchoscopy with washings.

In infants it is advisable to perform upper gastrointestinal series prior to performance of fundoplication to rule out other pathology, which may cause emesis, as this is the most common symptom in this age group.

Patients with neurological deficits requiring gastrostomy placement for feedings may also require evaluation with the above tests prior to tube placement.

Operative Indications

Operation should be considered for:

  1. Infants and children who have failed two weeks of medical management.
  2. Atypical symptoms especially respiratory symptoms with confirmation of GERD by any of the previously mentioned tests.
  3. Patients with complications of GERD such as aspiration, stricture or Barrett’s esophagitis.
  4. In the case of near SIDS and other clinical symptoms of GERD, risk of death may be decreased by operative therapy(15).
  5. Patients with neurologic impairment requiring feeding gastrostomy who are tested to have pathologic reflux are candidates for antireflux procedures
  6. Patients post repair of esophageal atresia with reflux and recurrence of anastomotic stricture(18).
Surgical Techniques

The goal of surgery for GERD is to re-establish the antireflux barrier without creating obstruction to the food bolus. In general, the Nissen fundoplication, which is a complete 360° wrap, best controls the symptoms of GERD but may lead to more episodes of dysphagia and gas bloat than a partial wrap. Toupet (partial 270° posterior esophageal wrap) and Thal (partial anterior 180° wrap) reportedly produce fewer complications.

Selection of appropriate wrap is based on the patient’s symptoms and surgeon’s preference. Closure of the hiatus should be considered. Underlying associated conditions are considered when determining the type of wrap to perform. Partial wraps have fewer reported episodes of dysphagia in the short term. Recent studies suggest that Nissen fundoplication after the first 3 months has equal rate of dysphagia to the partial wrap. There is controversy in the literature regarding recurrence rates with some articles suggesting that recurrence is decreased with 360° wrap and other studies showing no difference in recurrence with partial wraps.
Laparoscopic Treatment of GERD

Laparoscopic treatment of GERD in children relies on videoscopic technology and advances. It has become feasible with the development of instruments specifically designed for infants and children. Benefits may include decreased stress of surgery and shorter recovery times. Shorter recovery times for children lead to decreased absence from work for parents and caregivers. Laparoscopic procedures in children require the dedication of anesthetic staff and more attention to detail than required in adults undergoing the same procedures(4).

The indications for laparoscopic fundoplication are the same as the indications for conventional open procedures. Safe and effective laparoscopic procedures for GERD in children and infants require advanced laparoscopic skills. Surgeons performing laparoscopic fundoplications should be skilled in surgery on children and have added skills in laparoscopy, which includes the ability to suture and knot tie. These laparoscopic skills may be obtained through residency training, fellowship training or courses in which the specific laparoscopic skills are taught. The courses should provide documentation of the procedures taught and practiced during the course. Initial cases should be preceptored by an experienced surgeon. The laparoscopic fundoplication should be performed in such a way that it duplicates the open operation.

Summary
Gastroesophageal reflux is common in infants and children. Gastroesophageal reflux disease (GERD) is the pathologic occurrence of reflux and frequently requires surgery in infants and children. Severe consequences such as SIDS may be a result of GERD. Laparoscopic operations are feasible in children with appropriate indication for surgery. 
References
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  2. O’Neill JA, Rowe MI et al. Gastroesophageal Reflux. Pediatric Surgery Fifth Edition, 1998: 1007-1028.
  3. Humphrey GME and Najmaldin AS. Laparoscopic Nissen Fundoplication in Disabled Infants and Children. J Ped Surg 1996:31(4): 596-599.
  4. Rowney DA, Aldridge LM, et al. Laparoscopic Fundoplication: Anesthesia, Analgesia, and Physiologic Aspects. Ped Endosurgery & Innovative Tech 2000: 4(1): 25-29.
  5. Rothenburg, SS. Experience with 220 Consecutive Laparoscopic Nissen Fundoplications in Infants and Children. J Ped Surg. 1998: 33(2): 274-278.
  6. Collins III JB, Georgeson KE, et al. Comparison of Open and Laparoscopic Gastrostomy and Fundoplication in 120 Patients. J Ped Surg 1995: 30(7): 1065-1071.
  7. Rice H, Seashore JH, Touloukian RJ. Evaluation of Nissen Fundoplication in Neurologically Impaired Children. J Ped Surg 1991: 26(6): 697-701.
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  10. Bliss D, Hirschl R, et al. Efficacy of Anterior Gastric Fundoplication in the Treatment of Gastroesophageal Reflux in Infants and Children. J Ped Surg 1994: 29(8): 1071-1075.
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  13. Evans DF, Robertson CS, et al. Esophageal pH Monitoring for Gastroesophageal Reflux: A United Kingdom Study. J Ped Surg 1991: 26(6): 682-685.
  14. Halpern LM, Jolley SG, et al. Gastroesophageal Reflux: A Significant Association With Central Nervous System Disease in Children. J Ped Surg 1991: 26(2): 171-173.
  15. Jolley SG, Halpern LM, et al. The Risk of Sudden Infant Death From Gastroesophageal Reflux. J Ped Surg 1991: 26(6): 691-696.
  16. Tovar JA, Angulo JA, et al. Surgery for Gastroesophageal Reflux in Children With Normal pH Studies. J Ped Surg 1991: 26(5): 541-545.
  17. Szold A, Udassin R, et al. Laparoscopic-Modified Nissen Fundoplication in Children With Familial Dysautonomia. J Ped Surg 1996: 31(11): 1560-1562.
  18. Bergmeijer JHLJ, Tibboel D, Hazebroek FWJ. Nissen Fundoplication in the Management of Gastroesophageal Reflux Occurring After Repair of Esophageal Atresia. J Ped Surg 2000: 35(4): 573-576.
  19. Hirsch W, Kedar R, Preiss U. Color Doppler in the Diagnosis of the Gastroesophageal Reflux in Children: Comparison with pH Measurements and B-mode Ultrasound. Pediatr Radiol 1996: 26(3): 232-5.
  20. Riccabona M, Maurer U, et al. The Role of Sonography in the Evaluation of Gastroesophageal Reflux—Correlation to pH-metry. Eur J Pediatr 1992: 151(9): 655-7.

This Guideline was prepared by the IPEG Guidelines Committee and was reviewed and approved by the Executive Committee of the International Pediatric Endosurgery Group (IPEG) November, 2002.


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