© Borgis - New Medicine 1/2001, s. 39-41
Zofia Dudkiewicz, Eryk Dluski, Barbara Ploska-Urbanek
Gastroesophageal reflux (GER) - surgical management and clinical assessment
Institute for Mother and Child, Warsaw, Poland, Department of Paediatric and Adolescent Surgery
Head: Associate Professor Z. Dudkiewicz, MD, Ph.D.
Summary
On the basis of results achieved in 56 children with gatroesophageal reflux (GER), including 30 patients with P. Robin sequence, which is currently recognized through a number of syndromes and conditions, the authors believe that early symptomatic treatment may in many cases prevent the complications of gastroesophageal reflux. In the initial stages of management, the surgeon should be a partner in searching for the causes of GER and in reaching a joint decision on the selection of a mode of treatment.
The introduction of omeprazole, a potent proton pump blocker, for the treatment of gastroesophageal reflux (GER), the growing experience of pediatricians in the diagnostic management and pharmacotherapy of GER (1, 5, 6, 10), and the experience of surgeons acquired while treating recurrent GER or its postoperative complications have results in the authors reviewing their material and revising their views on gastroesophageal reflux. The term „secondary reflux ” is deeply rooted in the surgeon´s mind, denoting the necessity of searching for causes of this severe symptom. Recognizing the cause often allows prescription of the ultimate symptomatic treatment, and for avoiding sometimes long-term, „on and off ” type pharmacotherapy. Generally supporting the views of our colleague-pediatricians, we still believe a surgeon should become a partner in diagnosing the causes of GER in children at a very early stage.
Material and methods
Our material included 56 children, the management of whose cases changed parallel to the development of new medical concepts and our increasing experience. Ten children were treated in the years 1984-91. At that time, their management was strongly affected by their medical history, clinical assessment, X-ray results, failure to improve following dietary or positioning treatment and prokinetic agent administration. Primary reflux or oesophageal hiatus hernia were diagnosed, and the patients were operated on using the Dor-Nissen method (anterior fundoplication and oesophagohiatoplasty) COLOR="#ff0000">.
Forty-six children were managed in the years 1992--99, including 30 patients with Robin sequence and various forms of „neurological mask ”.
Table 1. Children operated on in the Department of Pediatric and Adolescent Surgery, Institute for the Mother and Child, in the years 1992-99.
| Diagnosis | No. of children | Age at surgery |
Symptomatic treatment (anti-reflux surgery)
Neurological diseases, including 2 patients with Sandifer syndrome |
7 |
1-17 years |
| Cleft palate (complete bilateral cleft and Robin sequence) | 2 | 5-11 months |
| Status post-oesophageal atresia | 2 | 2 months - 1.5 years |
| Cystic fibrosis | 3 | 1-5 years |
| Barret oesophagus | 2 | 6 months - 14 years |
Causal treatment
Robin sequence after 1995 (including total cleft, Goldenhars?, Sandifer, Treacher-Collins syndromes and non-specific neurological symptoms) |
30 |
3-5 months |
At that time the diagnostic management was gradually extended to include endoscopic studies with histological assessment, 24-hour pH-metry, scintigraphy, which is of special importance in children with neurological diseases and the so called Barret oesophagus, as well as oesophageal electromanometry.
Of 46 patients operated on between 1992 and 1999, 16 had anti-reflux procedures. In 30 children who were found to have a defect and oesophageal stenosis at the level of the palatopharyngeal ring, comprehensive diagnostic management revealed GER and the patients were treated surgically by excising the defect that triggered gastroesophageal reflux.
In the years 1992-93, the anti-reflux surgery consisted of Nissen fundoplication. Starting in 1993, subtotal Nissen fundoplication was employed. The change in surgical technique was dictated by contacts between the authors and surgeons from foreign centres, combined with reports on complications following the Nissen procedure. Recently, a laparoscopic procedure has become recognized as the method of choice, which combines a subtotal fundoplication with elements of the Thal operation. The surgery also includes pyloric control and a pyloromyotomy, when needed.
Thirty children with Robin sequence were subjected to causal treatment, consisting of a correction of the palatopharyngeal ring defect, by operating on the cleft palate and eradicating factors causing tightness at this level. The genioglossal muscles, which result in retrorotation of the tongue in children with micrognathia and retrognathism, were elongated.
Results
As a consequence of the accepted treatment protocol, the general condition of children promptly improved, since their pain was alleviated and clinical reflux symptoms were resolved. We were only able to perform extended diagnostic studies for GER after surgery, providing parental consent was granted, in isolated cases. Due to an excessively tight anterior fundoplication, no improvement was achieved in a child with cystic fibrosis, only after a release of the anterior esophageal wall was a satisfactory passage of food obtained and reflux symptoms were resolved.
In 30 children with Robin sequence subjected to cleft palate surgery and genioglossal muscle elongation, the clinical symptoms of GER subsided shortly after the procedure. Follow-up 24-hour reflux studies performed 2-3 months postoperatively showed no signs of GER in 20 patients. One child demostrated only a marked reduction in the number of reflux impulses, while clinical symptoms resolved in the remaining children.
Comments
The growing experience of both pediatricians and surgeons in treating gastroesophageal reflux favour reviewing opinions on diagnosing and treating GER. Experienced pediatricians accept the management algorithm proposed by the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN), or present their modifications of the programme (1, 11). The protocol may be briefly characterized as a three-phase procedure, where surgical treatment is initiated after conservative treatment possibilities, often taking many years, have been exhausted. Although in principle we agree with pediatricians, we find strong collaboration with a surgeon in searching for the anatomical causes of gastroesophageal reflux is missing. In many cases, even several months´ delay while waiting for a satisfactory outcome of conservative treatment is not necessary.
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Piśmiennictwo
1. Celinska-Cedro D: Odplyw zoladkowo-przelykowy u dzieci, Medipress Pediatria 1997, 3:2-7. 2. Dudkiewicz Z, Boczar M: Sekwencja Robina, Pediatria Polska 1996, LXXI:811-815. 3. Dudkiewicz Z, Sekula E, Nielepiec-Jalosinska A: Cleft Palate-Craniofacial, January 2000, Vol. 37, No 2:205-208. 4. Fonkalsrud EW, Ament ME: Gastroesophageal reflux in childhood, Curr Probl, 33:1-70. 5. Gunasekaran T, Hassall E: Efficacy and safety of omepazole for severe gastroesophageal reflux in children, J Pediatr 1993, 123:148. 6. Hunt RH, et al.: Optimising acid suppression for treatment of acid-related diseases, Dig Dis Sci 1995, 40 (suppl. 2):245. 7. Scharli AF: To Nissen or Not to Nissen. Progress in Pediatric Surgery, Vol. 18, Ed by P Wurning, Springer-Verlag Berlin, Heidelberg 1985:p.96-100. 8. Stanowski E: Choroba refluksowa przelyku - wskazania i sposoby leczenia chirurgicznego, Videochirurgia 1998, 3, 1:6-11. 9. Takayasu H, Iwanaka T, Matsumoto M, Okada N, Imaizumi S: Delayed Gastric Emptying after Laparoscopic Fundoplication in Neurologically Impaired Children. Pediatric Endosurgery & Innovative Techniques 1999, 3, 1:11-15. 10. Vic P, Tassine E, Turck D, Gottrand F, Launay V, Farriaux JP: Frequency of gastroesophageal reflux in infants and in young children with cystic fibrosis, Arch Pediatr 1995, 2:742-746. 11. Vandenplas Y, et al.: A proposition for the diagnosis and treatment of gastroesophageal reflux disease in children. A report from an ESPGAN working group on gastroesophageal reflux disease, European Journal of Paediatrics 1994, 152:704-711.
