Approach Considerations
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.
Medical Therapy
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]
Surgical Therapy
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] :
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Lengthening of the intra-abdominal esophagus
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Accentuation of the angle of His
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Increasing the pressure barrier at the esophagogastric junction (EGJ)
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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.
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]
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]
Endoscopic Therapy
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]
Postoperative Care
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).
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:
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Retching
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Gas bloat (patients with this complication are often unable to vomit)
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Dysphagia
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Atelectasis
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Pneumonia
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Wound infection or dehiscence
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Small-bowel obstruction due to adhesions
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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:
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Bowel obstruction
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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]
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Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
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Arterial blood supply and lymphatic drainage of the esophagus.
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Nissen fundoplication.
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Toupet partial fundoplication.
