Trying to decide whether a child should undergo a fundoplication is often quite difficult. The best candidates with gastroesophageal reflux disease (GERD) don’t need surgery because medical treatment is usually effective. Typical patients who fail medical treatments may have numerous comorbidities that could cause a complicated postoperative course or failure of the procedure.
One aspect about the surgery that has been questioned has been whether surgery causes dysmotility of the esophagus. A recent article describes a study, which enrolled only ten children who had surgery; however, these patients underwent extensive preoperative and postoperative evaluations to try to provide more information about the motility effects of fundoplication (J Pediatr 2013; 162: 566-73).
Patients were considered for surgery if they had failed medical therapy. Four of the ten patients were neurologically-impaired. Testing included automated impedance manometry, 24-hour pH-impedance, gastric emptying breath test, and GERD questionnaires (though the authors note that GERD questionnaires are not validated in children aged 1-12 years). Median patient age was 6.4 years, with a range of 1-17 years.
Surgery: laparascopic anterior partial fundoplication
- 4 patients developed postoperative dysphagia, two patients had redo fundoplications (one due to dysphagia and one due to persistent emesis).
- Postsurgery, GER measures were reduced. Total number of acid reflux episodes dropped from an average of 37 to an average of 10. Total GER (acid and nonacid) episodes dropped from an average of 97 to an average of 66. The percentage of time with pH<4 dropped as well from an average of 12.5% to an average of 3.1%.
- Average gastric emptying time was unchanged: 64 minutes pre surgery and 63 minutes post surgery.
- Conventional esophageal motility measures/peristaltic contractions were unaltered. However, patients with postoperative dysphagia had longer gastric emptying times compared with those who did not develop postoperative dysphagia.
Related blog posts:
- -Gastroenterology 2011; 141: 1938 LOTUS study in JAMA summarized. JAMA 2011; 305: 1969. Medical rx outperformed surgery. 92% under control (remission) with long-term medical Rx vs 85% with surgery & fewer side effects of medical Rx.
- -Clin Gastro & Hepatology 2009; 7: 1292, 1264 (editorial). 12 yr outcomes for surgery vs PPI. n=154 omeprazole, n=144 surgery. Similar long-term outcome ~50% with long-term remission.
- -JPGN 2010; 50: 25. Reflux detected by impedance does NOT determine fundoplication outcome. n=34.
- -JPGN 2006; 43: 185. Effect of fundo: no change in gastric motor activity & increased discomfort with distention
- -Pediatrics 2006; 118: 2326. n=1142. Fundoplication decreased hospitalization rates for children <4yrs; in older children with developmental delay, there were increased hospitalization rates after fundoplication. (47% had no hospitalizations prior to fundoplication.)
- -Clin Gastro & Hep 2004; 2: 978-984. Gilger et al. n=198. 63% required p-op medical treatment for recurrent GERD -retrospective review 1996-99.
- -J Pediatrics 2011; 159: 597. Hypoglycemia (likely due to dumping) was common post-op. n=285. 24% of screened children with low glucose (only 1.3%of those without formal screening). 2/3rds with hypoglycemia had preceding hyperglycemia. Only 53% had dumping symptoms. Many in this cohort were NICU pts -~1/3rd of pts had mean age of 3months & another ~1/3rd with mean age of 6months.Rx often was continuous feeds.
- -Pediatrics 2006; 118:1828. 48,665 antireflux surgeries done from 1996-2003 (~7000/yr) in US
- -Clin Gastro & Hep 2006; 4: 299. Frequent complications p-op and frequent need for GERD meds. dysphagia in 19%, dilation in 6%, repeat surgery in 2%, mortality in 0.8% (n=3145). 50% required GERD meds.
- -Gastroenterology 2001; 121: 5-14 & 214. Dysmotility with GER reflects severe disease & is present ~30%. According to this study, dysmotility does not affect postoperative outcome, is not corrected by fundoplication, may occur p-op, and requires no tailoring of surgical mgt.