Pediatric Gastroesophageal Reflux Surgery

The anatomy of the esophagus, stomach, and EGJ is critical in the understanding of the pathogenesis of reflux.

The proximal esophagus contains the upper esophageal sphincter (UES), which comprises the cricopharyngeus and thyropharyngeus muscles. The body of the esophagus is made up of inner circular and outer longitudinal muscular layers. The proximal third of the esophagus is smooth muscle, which transitions to striated muscle in the distal two thirds. The lower esophageal sphincter (LES) is the distalmost segment of the esophagus (3-5 cm in adults), and its ability to prevent reflux depends on a number of anatomic factors.

As the esophagus passes through the diaphragmatic hiatus, it becomes the abdominal esophagus. The right crus of the diaphragm forms a sling around the esophagus so that the esophagus narrows when the diaphragm contracts.[16, 17, 18] At this level, the phrenoesophageal ligament, which is the reflection of the subdiaphragmatic fascia onto the transversalis fascia of the anterior abdominal wall, also encircles the esophagus (see the image below). The EGJ is in the abdomen and forms the angle of His. The acute angle and the length of abdominal esophagus both contribute to the normal closure of the esophagus when intragastric and intra-abdominal pressures are high.

Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.

The blood supply of the esophagus is segmental (see the image below). The inferior thyroid artery supplies the cervical esophagus. Branches of the bronchial arteries and branches directly off of the aorta supply the proximal and distal thoracic esophagus, respectively. Finally, branches of the left gastric and inferior phrenic artery supply the abdominal esophagus. A relatively constant branch connects the left gastric and inferior phrenic arteries (the Belsey artery).

Arterial blood supply and lymphatic drainage of the esophagus.

The blood supply of the stomach is rich, with overlap among the vessels. The lesser curvature is supplied by the left and right gastric arteries, which are branches of the celiac trunk and the proper hepatic artery, respectively. The greater curvature is supplied by the right gastroepiploic artery arising from the gastroduodenal artery and the left gastroepiploic artery and the short gastric arteries originating from the splenic artery. This excellent collateral blood supply of the stomach allows the surgeon to ligate much of the arterial supply (ie, the short gastric arteries during fundoplication) without risk of ischemia.

Nearly all infants have some degree of GER, but it is usually transient and does not cause any morbidity.[2] However, in some children, the reflux is pathologic and persistent, causing feeding difficulties, failure to thrive, aspiration or respiratory complications, esophagitis, and esophageal stricture. GERD occurs on a continuum that ranges from mild physiologic reflux to a severe debilitating problem.

In healthy term and preterm infants, the mechanism of GER is primarily frequent transient relaxation of the LES and otherwise normal esophageal motor function.[19] Transient LES relaxation occurs normally and is a mechanism to vent air from the distended stomach.[18] However, in some children, LES relaxation is frequent and prolonged, leading to pathologic reflux.

Unlike physiologic LES relaxation, GER is primarily observed during episodes of sphincter relaxation unassociated with swallowing.[20] Some children, such as those with neurologic disorders, may be predisposed to frequent LES relaxation, which leads to irritation of the esophageal mucosa by hydrochloric acid. Esophagitis causes further dysfunction of the LES, creating a cycle of continuing injury.

In addition to LES relaxation, esophageal dysmotility may also play a role in pediatric GER. In a study of 25 pediatric patients with GERD, esophageal manometry and 24-hour pH probes were used to correlate esophageal contractions with acid-reflux episodes[21] ; patients with GERD had significantly fewer and less sustained esophageal contractions than those without reflux. This difference may be important, in that the presence of esophageal dysmotility in a subset of pediatric GERD patients could be a relative contraindication for operative management.

The passage of food from the esophagus to the stomach is facilitated by a transient relaxation of the distal esophagus, which is initiated by swallowing-induced peristaltic waves. The resting tone of the distal esophagus is important in preventing reflux of gastric contents into the thoracic portion of the esophagus. The anatomic area integral to the prevention of reflux is the abdominal esophagus, where the high-pressure zone (HPZ) is located.

The HPZ depends on many factors, including an adequate length of intra-abdominal esophagus, an intact phrenoesophageal ligament, a normal diaphragm, and sufficient gastric emptying. Symptoms of reflux tend to occur when the sphincter pressure is in the range of 0-5 mm Hg.[22] About 81% of patients in whom the intra-abdominal esophagus is 1 cm or shorter have reflux, whereas 38% of those with an intra-abdominal segment longer than 3 cm have reflux.[23]

Neurologically impaired children, including those with mental-motor retardation, seizure disorders, and hydrocephalus, appear to have a higher prevalence of GER after age 1 year than neurologically normal children do. Several reasons are postulated for this phenomenon, including a reduction in LES pressure with elevations in intracranial pressure and abnormal esophageal peristalsis secondary to CNS dysfunction.[24]

Children with a history of esophageal atresia, tracheoesophageal fistula, or both also have a high prevalence of GER, which often lasts into adulthood.[25, 26, 27] This is likely due to a shortened esophagus or superior displacement of the EGJ following surgical repair, abnormal esophageal peristalsis, and delayed gastric emptying (DGE).[28]

Other factors implicated in the genesis of GER include abnormal or altered anatomy, such as hiatal hernia, short esophagus, and gastrostomy. Medications that decrease LES pressure, such as methylxanthines and calcium-channel blockers, may also exacerbate GER.

The prevalence of GER varies by age. In a study of parent reporting and symptom scores, 67% of healthy infants aged 4 months had GER[29] ; the prevalence decreased to 21% by age 7 months. A 1-year follow-up study by the same author demonstrated that vomiting spontaneously resolved in nearly all of these cases.[30] An estimated 85% of premature infants have GER; the vast majority of cases resolve without treatment.[31]

Children with neurologic disorders also have an increased prevalence of GER. In one referral center, the rate of GER was higher in patients older than 1 year with neurologic impairment than in healthy children (69% vs 47%).[24] Another study found that 65% of patients who underwent antireflux surgery were neurologically impaired.[32]

Long-term data in children have been relatively sparse as compared with data in adults; however, the success rate of antireflux surgery is generally thought to be good. A series of more than 1000 laparoscopic Nissen fundoplications over 10 years in infants and children revealed good outcomes, with a 4% wrap-failure rate.[13] A second report of studies of 1280 children concluded that the median success rate was 86%.

A few reports of objective postoperative testing questioned the benefit of surgery.[33] One study found a beneficial effect of surgery on the rate of reflux-related hospitalizations in children aged 1-4 years, but this effect was not noted in older children. In fact, this study demonstrated that older children with developmental delay experienced an increased rate of reflux-related hospitalizations after surgery.[34]

The 24-hour pH study has been used to objectively evaluate outcomes following antireflux surgery. A prospective review of 53 pediatric patients treated with the laparoscopic Thal fundoplication found that 25% had pathologic reflux at follow-up, though 90% of patients reported that they were symptom-free. This underscores the need for additional objective outcome studies.

Both surgical and medical management tend to have a high failure rate in children with neurologic impairment.[24] Many of these children have serious coexisting morbidity and relatively short life expectancy.

A study of 46 infants examined 5 years after Nissen fundoplication found that 24% had died of other medical problems.[35] Of the survivors, 74% had no recurrent symptoms, 12% required repeat operation or fundoplication, and 45% had had at least one postoperative complication. Another report of 109 children who underwent either Nissen or Boix-Ochoa antireflux procedures, with up to 10-year follow-up, found recurrent reflux in 20% of patients (91% of these cases occurred in the Boix-Ochoa group).[36]

In a study of 300 fundoplications (277 primary, 23 redo) in 279 pediatric GERD patients, Koivusalo et al found that primary fundoplication led to control of symptoms in nearly 90% of patients and reduced the rate of esophagitis as well.[37] Primary fundoplication failed in 15% of patients; factors increasing the risk of failure included an underlying disorder, esophageal atresia, and hiatoplasty. Of the 23 redo procedures, 32% failed.

In a study of 820 pediatric patients who underwent Nissen fundoplication, Banerjee et al found that 190 (23%) underwent further procedures for management of GER at a median age of 21 months (range, 6-186), and of these 190, 90 (47%) had gastrojejunal feeding.[38]  Patients who had previous gastrojejunal feeding were more likely to have a failed redo fundoplication than those who did not have gastrojejunal feeding.

Many healthy infants have physiologic reflux. Approximately 40% of healthy infants have at least one episode of emesis a day, with more than 5 mL of nonbilious emesis per episode.[39, 40] These minor reflux episodes (spit-ups) usually resolve by the time the patient reaches the age of 6 months and do not cause any serious sequelae. In some children, gastroesophageal reflux (GER) is pathologic, leading to irritability, apnea, recurrent pneumonia, respiratory dysfunction, esophagitis, or failure to thrive.

Generally, a thorough history and a careful physical examination elicit signs and symptoms of reflux. In addition, an infant or child may have a history of frequent emesis, aspiration events, asthma, or feeding difficulty. A careful assessment of growth parameters and nutritional status is an important component of the physical examination and preoperative evaluation. Because one of the indications for antireflux surgery is failure to thrive, operative candidates may be malnourished.

The presenting symptoms of gastroesophageal reflux disease (GERD) in infants and children differ from those seen in adults and vary with age. Anorexia and feeding difficulty correlate with erosive esophagitis on endoscopy and are common presentations in children aged 1-5 years.[41] Infants may present with frequent regurgitation in addition to feeding difficulties.[42]

Feeding difficulties in infants were evaluated in a study investigating the clinical outcomes of GERD treatment.[43] According to a retrospective review of 28 infants with feeding difficulty prior to GERD treatment, posttreatment evaluation with both endoscopy and videofluoroscopy demonstrated marked functional improvement in infant swallowing.

GERD has been closely linked to respiratory problems due to recurrent aspiration of gastric contents.[44] A Pediatric Health Information System Database analysis of 12,067 patients found that GERD was the most common discharge diagnosis in patients admitted with an apparent life-threatening event.[45] Reflux should also be ruled out in a child with recurrent pneumonia or chronic nocturnal cough. Considerable controversy remains as to whether GERD is causally or temporally associated with sudden infant death syndrome (SIDS).[46, 47]

The relationship of GERD with childhood asthma is more defined, and the prevalence is thought to be 40-60%.[48, 49] In a prospective evaluation of pediatric patients with GER and asthma, investigators demonstrated a significant reduction in the use of bronchodilators and inhaled steroids after treatment for reflux disease. This effect was not seen in control patients with asthma and no diagnosis of GER.[50]

Some authors dispute the association between GER and lung disease.[51] The use of multichannel intraluminal impedance has permitted further investigation into the role of nonacid reflux in the pathogenesis of GER-related respiratory disease. An examination of 28 children with persistent respiratory symptoms despite antacid therapy demonstrated that symptoms were more frequently associated with nonacid reflux.[52]

A follow-up study of 24 children with asthma found a higher correlation between asthma and reflux detected by impedance (which is able to detect both acid and nonacid reflux) in comparison with detection by pH probe alone (acid reflux).[53]

Esophageal mucosal damage from gastric acid exposure is common in patients with GERD and can lead to esophagitis or esophageal stricture. Barrett esophagus, a premalignant process characterized by replacement of the normal squamous cells of the lower esophagus with columnar cells typically found in the stomach, has been linked to chronic reflux in older children. It has been surmised that this metaplasia is due to constant acid exposure during times of healing.[54] Barrett esophagus necessitates serial follow-up with endoscopy and biopsy.

An upper gastrointestinal (GI) barium study, though no longer the diagnostic study of choice, may be useful in the evaluation of gastroesophageal reflux (GER) disease (GERD) when performed by an experienced pediatric radiologist. The sensitivity of this study in diagnosing the occurrence of reflux and the presence of esophagitis is low,[55] but esophageal motility and anatomic abnormalities (eg, hiatal hernia, stricture, malrotation) may be identified.

Gastric-emptying (GE) scintigraphy (milk scan) involves ingestion of a radiolabeled meal (historically, radiolabeled milk), with serial images recorded up to 60 minutes after ingestion. This study may be used to diagnose and quantitate reflux but is primarily used to assess GE and to identify delayed emptying. Late images showing isotope in the lungs indicate pulmonary aspiration.

Both an upper GI barium study and GE scintigraphy may be helpful in the diagnosis of GER, but they are not sensitive. The primary diagnostic tool for GER today is the pH probe study. Impedance/pH monitoring is being investigated as a potentially superior diagnostic modality. Newer technologies that are being studied in pediatric GERD include intraprocedural mucosal impedance technology and the functional luminal imaging probe (FLIP).[3]

Endoscopy is used to visualize and obtain a biopsy sample from the esophageal mucosa and to diagnose esophagitis, stricture, and Barrett esophagus. Although there is no validated grading system for children, erosion or ulceration is indicative of esophagitis. Biopsy should be performed in most cases, even if the mucosa appears relatively normal, because there is a significant tendency for histologic grade to exceed visual endoscopic findings.[56]

Endoscopic ultrasonography (EUS) has been described as an adjunct to endoscopy for evaluating the integrity of Nissen fundoplication in children and adults.[57, 58, 59]

The 24-hour pH probe monitor is the standard diagnostic test for GER. Originally described by Johnson and De Meester in 1974, this test uses a catheter at the lower esophageal sphincter (LES) to measure episodes of reflux over a 24-hour period. An esophageal intraluminal pH of less than 4.0 for at least 15 seconds defines an episode of reflux.

Recorded values include the following:

• Total time with pH below 4.0
• Upright time with pH less than 4.0
• Supine time with pH less than 4.0
• Number of reflux episodes longer than 5 minutes
• Duration of the longest reflux episode

A composite score is calculated on the basis of these results. This test has since been evaluated and validated in children.[60, 61] This test is more sensitive and specific for acid reflux than barium esophagography.[55]

Disadvantages of 24-hour pH probe monitoring include the inability to diagnose nonacid reflux and to distinguish primary and secondary (allergy to milk protein or other food) causes of reflux,[62] the inability to determine the presence or severity of esophagitis, and poor tolerance of the probe in some children.

Esophageal impedance/pH monitoring is a technique that can be used to detect both acid and nonacid reflux. This test uses a probe similar to that used in standard pH monitoring to measure the change in electrical resistance that occurs across its sensors with the passage of intraluminal material.

Advantages of this test include the ability to identify the content, direction, and localization of any reflux.[63] This test may yield better diagnostic sensitivity than the pH probe in patients treated with antacids. Disadvantages include a lack of standardized pediatric normal ranges[64] and increased cost relative to the standard pH probe.[63]

Esophageal manometry is used to assess the contractility of the esophageal body, the upper esophageal sphincter (UES), and the LES. Although not diagnostic for GER, this study may reveal LES hypotension in the setting of reflux or abnormal peristalsis in patients with esophageal dysmotility or severe esophagitis.

Esophageal manometry may also be used to identify children with motility disorders in whom antireflux surgery would be contraindicated. A study by Mattioli et al found no correlation between motility pattern and outcome and did not advocate routine use of this modality.[65]

Endoscopic biopsy may be used to diagnose esophagitis or Barrett esophagus. Infiltration of neutrophils and eosinophils, papillary hyperplasia, and basal-zone thickening are all linked to the diagnosis of GERD.[66] Barrett esophagus is characterized by intestinal metaplasia of the esophageal mucosa; columnar intestinal epithelium and goblet cells replace the normal squamous epithelial lining of the esophagus. In children with chronic aspiration, lipid-laden macrophages may be visible in bronchoalveolar-lavage specimens.

The primary indication for antireflux surgery in children with gastroesophageal reflux (GER) is failed medical therapy. Other indications include a history of recurrent aspiration events with or without pneumonia, reactive airway disease, apnea or near-miss sudden infant death syndrome (SIDS), refractory emesis, failure to thrive, esophagitis, esophageal stricture, Barrett esophagus, and associated anatomic anomalies (eg, a large hiatal hernia).[67]

In some children, reflux is caused by gastric or intestinal motility disorders or by gastric outlet obstruction. Antireflux surgery may be contraindicated in these patients, especially without a gastric emptying procedure. Contrast scintigraphy (milk scan) or upper gastrointestinal (GI) barium study may be used to identify these patients. Antireflux surgery may also be contraindicated in children with esophageal dysmotility disorders. In children with weak or uncoordinated peristalsis of the esophagus, fundoplication may slow passage of food from the esophagus even further.

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 pediatric gastroesophageal reflux disease (GERD).[68]  In 2021, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines for the surgical treatment of GERD in adults and children.[69]  (See Guidelines.) 

For additional information, see Pediatric Esophagitis.

First-line treatment for GER is generally medical, with surgery reserved for complications of GERD or failed medical therapy.

Positioning change is a simple intervention that may help. A study evaluating the effects of infant positioning on combined impedance and pH probe monitoring found that placing the infant in the left-side-down or prone position postprandially decreased esophageal exposure to GER.[70]

Another study evaluating left lateral versus right lateral positioning found that right lateral positioning facilitated gastric emptying but was associated with more GER than the left lateral position.[71] Teaching parents proper positioning, as well as optimal feeding technique with frequent low-volume feedings and thickened food, may improve symptoms.

A study of conservative therapy taught in a primary care setting found a significant improvement in symptoms, with 24% of infants normalizing their Infant Gastroesophageal Reflux Questionnaire-Revised score after 2 weeks.[72]

The use of thickened formula to treat GER has been studied extensively.[73] A meta-analysis of 14 randomized controlled trials found that this measure decreased the percentage of infants with regurgitation, reduced the number of vomiting and regurgitation episodes, shortened the duration of the longest reflux episode, and improved weight gain in comparison with control subjects.[74] However, the number of reflux episodes and the reflux index (percentage of examination time with pH < 4.0) were unaffected by thickened feedings.

In infants with confirmed GERD, management with medications is appropriate. Acid suppressants are useful in treating esophagitis induced by acid reflux and should be used either alone or concomitantly with prokinetic agents.[75]

Histamine-2 receptor antagonists (H2RAs; eg, ranitidine, cimetidine, famotidine, nizatidine) and proton pump inhibitors (PPIs; eg, omeprazole, esomeprazole, lansoprazole) have been shown to be effective in the treatment of GER. Numerous studies demonstrated the effectiveness of H2RAs in adults with reflux, and three randomized controlled trials with children showed H2RAs to be effective in both relieving symptoms and healing esophagitis.[76, 77]

Numerous randomized controlled trials found PPI therapy to be superior to H2RAs in adults with GERD.[78] PPIs are also used to treat GER in children. Although no randomized placebo-controlled studies have been conducted in children, multiple studies have shown that PPIs are generally well tolerated,[79, 80, 81, 82] even in infants and neonates. The improvement in symptoms may be dose-related,[83] with higher doses being associated with a faster response.[84]

However, studies of lansoprazole have also shown that infants younger than 10 weeks have different pharmacokinetics and require a lower dose[85] and that adverse effects may be more common in those younger than 28 days.[86] Several studies report that PPIs are an effective treatment of reflux esophagitis, but none has demonstrated superiority over high-dose H2RAs.[87, 88, 89, 90, 91]

Prokinetic agents improve esophageal peristalsis, increase gastric emptying, and increase lower esophageal sphincter (LES) tone. Cisapride is effective in decreasing reflux; however, it was removed from the market because of its potentially lethal cardiotoxicity and is available only in a limited-use protocol.[92, 93, 94]

Metoclopramide is an antidopaminergic and cholinomimetic drug that has been used in medical management of GERD. In 2009, the US Food and Drug Administration (FDA) issued a black box warning for this drug owing to its association with tardive dyskinesia, an irreversible neurologic effect. Some studies have shown that the adverse effects of metoclopramide are independent of dose and duration of use.[95, 96, 97]

Erythromycin is a macrolide antibiotic that stimulates motility by exerting a direct effect on the motilin receptors of the intestines.[98] A double-blind randomized controlled trial of erythromycin versus placebo evaluated time to attain full enteral feeding in very-low-birth-weight preterm infants with feeding intolerance. Although reflux symptoms improved over time in both groups, there was no statistically significant difference between the groups with regard to either resolution of reflux symptoms or time to reach full enteral nutrition.[99]

Two other drugs that increase peristalsis of the esophagus and stomach are bethanechol and domperidone. Prucalopride shows promise as a potential treatment for pediatric reflux disease.[3]  Intrapyloric injection also appears promising in this setting.

Antireflux surgery should be considered when medical therapy fails (ie, when patients have continued symptoms, refractory esophagitis, or complications of GERD). Children with neurologic impairment are more refractory to medical therapy as compared with otherwise healthy children.[100]

Surgery is usually reserved for patients who experience continued reflux and complications of reflux esophagitis despite medical therapy. In the pediatric population, more than 50% of antireflux operations are performed in children younger than 1 year.[101] Antireflux surgery improves symptoms (esophagitis, pulmonary infections, failure to thrive) in more than 95% of children, with an associated morbidity of less than 7% and a mortality of less than 1%.[102, 14]

The principles of surgical therapy for GERD include the following[103] :

• Lengthening of the intra-abdominal esophagus
• Accentuation of the angle of His
• Increasing the pressure barrier at the esophagogastric junction (EGJ)
• Approximation of the crura

Nissen fundoplication is the operation most commonly performed to treat GERD today (see the image below). It involves wrapping the gastric fundus 360° around the distal esophagus.

Nissen fundoplication.

Alternatives to Nissen fundoplication include the Thal procedure (anterior 180° fundoplication), the Toupet procedure (posterior 270° fundoplication; see the image below), the Boix-Ochoa procedure[104] (restoration of intra-abdominal esophagus and recreation of the angle of His), and Watson fundoplication (anterior 120° fundoplication). Comparisons between these various operations have demonstrated an equivalent rate of complications, revisions, and long-term satisfaction.[105, 106, 59, 107]

Toupet partial fundoplication.

The Nissen procedure and other related procedures may be performed laparoscopically.[108] Laparoscopic fundoplication has been well studied and accepted as equivalent to open procedures in adults.[10, 109, 11] Findings from early follow-up studies suggested that laparoscopic fundoplication in children is also comparable with open surgery and is associated with a shorter hospital stay.[12, 13, 14, 15, 110]

The safety of laparoscopic as compared with open fundoplications has been evaluated in children as young as 1 year.[111] Some have found the reoperation rate to be higher after the laparoscopic procedure.[112] Laparoscopic antireflux operations have also been reported to be safe and effective in children after the repair of esophageal atresia.[113]

Hill et al reported three cases in which the patient's anatomy prevented fundoplication. In these cases, a cardiaplication was successfully performed.[114]

Delayed gastric emptying may occur in patients with symptomatic GERD and appears to be more common in children with neurologic impairment.[115] In addition, delayed gastric emptying prior to surgery is thought to be a risk factor for recurrent reflux.[116] Although a gastric-emptying operation may be performed in conjunction with fundoplication, its routine use is controversial.[117, 118]

One study has shown accelerated gastric emptying in children after laparoscopic Nissen fundoplication, suggesting that procedures to improve gastric emptying, such as pyloroplasty, may not be indicated.[119] Dumping syndrome is a potential complication of all gastric-emptying procedures.

Operative details

Although the Nissen 360º fundoplication is the most commonly performed antireflux procedure, a partial wrap may be preferable in some children with esophageal dysmotility, in that it is less likely to cause esophageal obstruction in the context of abnormal esophageal peristalsis.[120]

Each type of fundoplication may be tailored to the patient and to the surgeon's preference. For example, most surgeons approximate the crura of the diaphragm. Many also divide the short gastric vessels, believing that this allows a looser wrap and leads to less postoperative dysphagia. However, some have suggested that these are unnecessary and time-consuming steps.[121]

Two other procedures that are often performed concomitantly with antireflux surgery in children are a gastric-emptying procedure and placement of a gastrostomy tube (G-tube). Delayed gastric emptying is reported in approximately 50% of children with GER.[122] Some have recommended that all children have contrast scintigraphy preoperatively. Those with slow gastric emptying (ie, >60% of isotope retained in the stomach after 90 min) should be considered for a gastric-emptying procedure, such as antroplasty or pyloroplasty.[116, 115, 123] This recommendation is controversial because other studies have shown that fundoplication alone accelerates gastric emptying.

Finally, some children who have antireflux surgery also benefit from a G-tube. Many surgeons place G-tubes in children with neurologic impairment at the time of fundoplication.[124] In addition, a G-tube may be indicated in children with failure to thrive or malnutrition preoperatively. In addition to enabling postoperative feeding, it allows drainage or venting of the stomach postoperatively, as needed.

Robot-assisted laparoscopic fundoplication

Robot-assisted laparoscopic fundoplication in children has been reported with good results.[125]  Reduced operating time is a purported benefit of the robot-assisted approach; however, a prospective study comparing operating times for robotically assisted Thal fundoplication with those of conventional laparoscopic techniques found that although certain challenging steps of the procedure were more efficient, the lengthy setup required negated any overall benefit.[126]

The ongoing development of GER therapy includes several endoscopic procedures that have gained favor in adult populations and that may replace surgery in some patients. These procedures include radiofrequency (RF) ablation (RFA; also referred to in this setting as the Stretta procedure), the injection of inert substances at the LES, and endoscopic gastroplication.

In the Stretta procedure, a catheter is used to deliver RF energy, creating thermal lesions deep to the mucosa at the EGJ. An open-label trial of 112 adult patients with 12-month follow-up showed an improvement in GERD scores and mental health, as well as a decrease in acid exposure and requirement for PPIs, with no serious complications.[127] Another study compared the Stretta procedure with laparoscopic fundoplication in 140 adults with favorable results.[128] This procedure has also been reported in small numbers of children, with some short-term success.[129]

Other described procedures include endoscopic injection of inert substances into the mucosa or muscle of the EGJ and endoscopic plication, which involves the placement of mucosal or transmural sutures at the LES-EGJ. A report on this gastroplication with an EndoCinch device in 22 adults and 1-year follow-up showed that patients had improved reflux scores and health-related quality of life, as well as decreased acid exposure and PPI requirements.[130] Long-term data on these techniques are lacking, and the safety and efficacy of these techniques in children remain to be defined.[131] However, one report described successful gastroplication in 17 children, with a mean age of 12.4 years.[132]

Some surgeons leave a nasogastric tube in place or leave the G-tube to gravity until return of bowel function. This is not always done, particularly if a laparoscopic approach is employed. The patient should be started on a clear liquid diet initially (either by mouth or feeding tube), then slowly transitioned to formula or soft solids. Although there is scant evidence in children, many surgeons believe that laparoscopic surgery hastens the postoperative return of bowel function and advances the diet more quickly than open surgery.

Fundoplication usually provides immediate symptom relief; however, it can be associated with complications. Problems occur more frequently in children with neurologic impairment than in otherwise healthy children,[32] and vigilance is required (see Complications).

Antireflux surgery itself is associated with complications, including retching, bloating, and unwrapping or slippage of the fundoplication. In addition, antireflux surgery may not eliminate the need for antireflux medications. A retrospective cohort study of 342 children undergoing laparoscopic Nissen fundoplication found that 76% had been restarted on antireflux medications within 1 year of surgery and that the use of antireflux medications postoperatively was unchanged in neurologically impaired patients.[133]

Postoperative complications may occur early or late. Early complications include the following:

• Retching
• Gas bloat (patients with this complication are often unable to vomit)
• Dysphagia
• Atelectasis
• Pneumonia
• Wound infection or dehiscence
• Small-bowel obstruction due to adhesions
• Delayed gastric emptying

Retching most often occurs in children with neurologic impairment and in those who are air swallowers preoperatively.[134] Retching may indicate an underlying gastric dysrhythmia and loss of central inhibition of the gastric emetic reflex that is exacerbated by the operation.[135, 136] It may be managed with prokinetic agents, temporary nasogastric tube placement or G-tube decompression. A gastric-emptying operation may also be required.

Dysphagia may result from postoperative edema and spontaneously resolves.

Early small-bowel obstruction from adhesive disease may be managed with a brief trial of nasogastric tube decompression and watchful waiting, but failure to resolve should prompt surgical exploration.

Late complications include the following:

• Bowel obstruction
• Wrap failure, including wrap disruption, slipped wrap, herniation of the wrap into the chest, or excessively tight wrap

Patients in whom the wrap fails typically present with dysphagia, retching,[134] or recurrent reflux symptoms. In patients with suspected wrap failure, an upper GI barium study may help to evaluate the integrity and anatomy of the repair, and endoscopy may be used to diagnose recurrent or persistent esophagitis. In a retrospective review, 66% of patients undergoing revision fundoplications had a hiatal hernia on upper GI contrast studies.[33] Wrap failure may necessitate a revision fundoplication if recurrent GER cannot be controlled medically.

Neurologic status seems to be a major predictor of surgical success. Findings from one study of 234 children over a 5-year period found a much higher incidence of late postoperative complications in the neurologically impaired group than in neurologically normal control subjects (26% vs 12%).[32]

Esophagogastric disconnection[137] has been suggested for use in select children with severe neurologic impairment.[34]  Although some have advocated this procedure as a primary procedure in children with severe neurologic impairment, most surgeons have considered it a last resort.[35, 36]  

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

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