SAGES Guidelines for Surgical Treatment of GERD

In 2021, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) published the following guidelines regarding the management of gastroesophageal reflux (GER) disease (GERD) in pediatric patients^[69]:

No recommendation can be made with regard to surgical management versus medical management of chronic or refractory GERD in pediatric patients
Children with GER who are candidates for surgery may be treated with either robotic or laparoscopic fundoplication, depending on feasibility and shared decision-making by surgeon and patient
Pediatric patients without large hiatal hernias may be treated with either partial or complete fundoplication, as guided by shared surgeon-patient decision-making
For pediatric GERD patients without large hiatal hernias who are undergoing fundoplication, minimal rather than maximal dissection during fundoplication is suggested

NASPGHAN/ESPGHAN Guidelines for Treatment of Pediatric GERD

In 2018, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) issued updated clinical guidelines for the management of GERD in infants and children.^[68]

Guidelines for nonpharmacologic treatment of GERD include the following:

It is suggested to use thickened feedings for visible regurgitation or vomiting in infants
It is suggested to modify feeding volume and frequency by age and weight to avoid overfeeding in infants
It is suggested to make a 2- to 4-week trial of extensively hydrolyzed protein (or amino)-based formula in infants with suspected GERD after failed optimal nonpharmacologic treatment
It is recommended not to use positional therapy to treat GERD symptoms in sleeping infants
It is suggested to consider head elevation or left lateral positioning to treat GERD symptoms in children
It is suggested not to use massage therapy for treatment in infants
It is suggested not to use current lifestyle interventions or complementary modalities for treatment
It is suggested to inform caregivers and children regarding the association between excessive body weight and increased prevalence of GERD
It is recommended to provide education to patients and parents as part of treatment

Guidelines for pharmacologic treatment of GERD include the following:

It is suggested not to use antacids or alginates for long-term treatment
It is recommended to use proton pump inhibitors (PPIs) as first-line treatment of reflux-related erosive esophagitis
It is suggested to use histamine-2 receptor antagonists (H2RAs) to treat reflux-associated erosive esophagitits if PPIs are unavailable or contraindicated
It is recommended not to use H2RAs or PPIs to treat crying or distress in otherwise healthy infants
It is recommended not to use H2RAs or PPIs to treat visible regurgitation in otherwise healthy infants
It is recommended to institute a 4- to 8-week course of H2RAs or PPIs to treat typical GERD symptoms
It is suggested not to use H2RAs or PPIs to treat extraesophageal symptoms unless typical GERD symptoms are present or diagnostic testing suggests GERD
It is recommended to evaluate treatment efficacy and exclude alternative causes of symptoms if patients do not respond to 4-8 weeks of optimal medical therapy
It is recommended to carry out regular assessment of the ongoing requirement for long-term acid-suppressing therapy
It is suggested to consider baclofen before surgery for children in whom other pharmacologic therapy has failed
It is suggested not to use domperidone to treat GERD
It is suggested not to use metoclopramide to treat GERD
It is suggested not to use any other prokinetics (eg, erythromycin or bethanechol) as first-line treatment

Guidelines for surgical treatment of and newer treatment options for GERD include the following:

It is suggested to consider antireflux surgery in pediatric GERD patients who have (a) life-threatening complications after failed optimal medical therapy, (b) symptoms refractory to optimal therapy after evaluation to exclude other underlying diseases, (c) chronic conditions with a significant risk of GERD-related complications, or (d) a need for long-term pharmacotherapy to control signs or symptoms
It is recommended not to use total esophagogastric disconnection as first-line surgical treatment in infants
It is suggested to consider total esophagogastric disconnection as as a rescue measure for neurologically impaired children after failure of fundoplication
It is suggested to consider transpyloric/jejunal feeding as an alternative to fundoplication in the treatment of GERD that is refractory to optimal treatment
It is recommended not to use radiofrequency ablation (RFA) in the treatment of GERD that is refractory to optimal treatment
It is suggested not to use endoscopic full-thickness plication in the treatment of children with GERD that is refractory to optimal treatment

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Media Gallery

Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
Arterial blood supply and lymphatic drainage of the esophagus.
Nissen fundoplication.
Toupet partial fundoplication.

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Author

Tom Jaksic, MD, PhD Professor, Department of Surgery, Harvard University Medical School; Surgical Director, Center for Advanced Intestinal Rehabilitation, Senior Associate in Surgery, Vice-Chairman of Pediatric Surgery, Children's Hospital Boston

Tom Jaksic, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, College of Physicians and Surgeons of Ontario, Royal College of Physicians and Surgeons of Canada, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth Azarow, MD Program Director, Pediatric Surgery, Children's Hospital and University of Nebraska Medical Center; Professor, Department of Surgery, Uniformed Services University of the Health Sciences

Kenneth Azarow, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael G Caty, MD Professor of Surgery and Pediatrics, State University of New York at Buffalo; Consulting Staff, Department of Pediatric Surgery, Children's Hospital of Buffalo

Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Association for Surgical Education

Disclosure: Nothing to disclose.

Chief Editor

Robert K Minkes, MD, PhD, MS Professor of Anatomy and Surgery, Founding Faculty, Orlando College of Osteopathic Medicine

Robert K Minkes, MD, PhD, MS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

YiMing Avery Ching, MD Research Fellow, Department of Pediatric Surgery, Children’s Hospital of Boston