Anti-reﬂ ux Surgery - Pediatric Practice Gastroenterology

Fundoplication prevents GER by increasing the LES baseline pressure, decreasing the number of TLESRs and the nadir pressure during swallow-induced relaxation, increasing the length of the esophagus that is intra-abdominal, accentuating the angle of His, and reducing a hiatal hernia if present.²⁹⁰ Fundoplication usually eliminates GER, including physiological reﬂ ux.²⁹¹ However, surgery does not correct poor esophageal clearance or improve gastric emptying.^17,292,293

Most of the literature on surgical therapy in children with GERD consists of retrospective case series in which documentation of the diagnosis of GERD and details of previous medical therapy are defi cient, mak- ing it diffi cult to assess the indications for and responses to surgery.^294–296 Children with underlying conditions predisposing to the most severe GERD comprise a large percentage of most surgical series, further confounding efforts to determine the benefi ts versus risks of surgical anti-refl ux procedures in specifi c patient populations.

The absence of systematic postoperative evaluation, including objective testing with pH or impedance studies and endoscopy, further complicates the assessment of surgical outcomes in most series.290,293,297

In general, outcomes of anti-reﬂ ux surgery have been more carefully evaluated in adults than in children.

In one study, at a mean of 20 months after surgery, 61%

of adults were satisfi ed with their outcome; 32% were taking medications for heartburn, 11% required esophageal dilatation, and 7% had repeat surgery.^298,299 This study found that a substantial number of patients underwent fundoplication for questionable reasons. In another study of patients relieved of typical refl ux symptoms postoperatively, up to two-thirds developed new symptoms postoperatively, including excessive gas, abdominal bloating, increased fl atus, dysphagia, diffi - culty with eructation, and vomiting.^299,300 In a large multicenter controlled study, 62% of adults were taking PPIs for refl ux symptoms 7 years after anti-refl ux surgery.³⁰⁰ In another study, 37% of adults were taking anti-refl ux medications at a mean of 5.9 years following anti-refl ux surgery.³⁰¹ Another study showed a similarly high surgical failure rate.

symptoms requiring a repeat procedure 2–24 months postoperatively. Three years after surgery, nine patients (56%) were taking no anti-reﬂ ux medication. Longer term studies in adults have shown little or no difference in procedure time or failure rate between endoluminal and surgical anti-reﬂ ux procedures.^324,325 In some studies, sham-operated patients have done as well as operated patients.^326,327 Other endoscopic GERD treatments have not been studied in children.²⁹⁰

The annual number of anti-reﬂ ux operations has been on the increase in the United States, especially in children under 2 years of age.³¹⁸ In contrast, in adults, rates of fundoplication are declining in the United States and have dropped 30% from their peak in 1999.²⁹⁷ The greatest decline is in teaching hospitals and in young adult patients.

Anti-refl ux surgery may be of benefi t in children with confi rmed GERD who have failed optimal medical therapy, are dependent on medical therapy over a long period of time, are signifi cantly non-adherent with medical therapy, or have life-threatening complications of GERD. Children with respiratory complications including asthma and recurrent aspiration related to GERD are generally considered most likely to benefi t from anti-refl ux surgery when medical therapy fails, but further study is required to confi rm this. Children with underlying disorders predisposing to the most severe GERD are at the highest risk for operative morbidity and operative failure. Prior to surgery, it is essential to rule out non-GERD causes of symptoms, and ensure that the diagnosis of chronic, relapsing GERD is fi rmly established. It is important to provide families with appropriate education and a realistic understanding of the potential complications of surgery, including symptom recurrence.

When pharmacotherapy is required, H₂RAs may be effective for mild GERD in children. However, tac- hyphylaxis develops quickly with symptom recurrence within days to a few weeks of treatment. Therefore, PPIs are becoming the preferred treatment for GERD in infants and children. PPIs have been shown in pediatric studies to be safe and effective. Omeprazole at doses ranging from 0.5 to 4 mg/kg has been shown to decrease GERD symptoms in children after only 14 days.¹⁵⁷ Lansoprazole given at doses of 15 or 30 mg once or twice daily, based on weight, resulted in reso- lution of erosive esophagitis after 3 months of treatment in one study.²⁴⁸ Recently, esomeprazole has been shown to improve GERD-related symptoms and resolve extraesophageal manifestations after 8–12 weeks of therapy in children 12–17 years of age.⁸⁹ In general, studies have suggested beginning PPI treatment with a dose of 1 mg/kg/day divided in one or two doses. Prokinetics such as metoclopramide are effective in approximately 50% of children with GERD; however, gastric compliance and sensory responses that may per-

sist from months to years. Symptoms include gas bloat syndrome, early satiety, dumping syndrome, and postoperative retching and gagging. In a postoperative study of otherwise healthy children, that is, with no underlying disorders, 36% had mild-moderate gas bloat symptoms, 32% were “very slow” to fi nish most meals, 28% were unable to burp or vomit, and 25% choked on some solids. Early and late operative failure may result from disruption of the wrap or slippage of the wrap into the chest.306–308,315 In otherwise healthy children evaluated at a mean of 10 months (1–35 months) following anti-refl ux surgery, 67% had “no complaints” but one- third had objective evidence of operative failure.³¹⁶ Operative complications include splenic or esophageal laceration, each of which occurs in about 0.2% of pediatric cases.³¹⁷ In children, those with underlying disorders, such as NI, are at a substantially greater risk for surgical mortality as are those in early infancy.^304,318 Mortality due to surgery in children without NI is diffi cult to assess because of the heterogeneous population in most surgical studies.

Laparoscopic Nissen fundoplication (LNF) has largely replaced open Nissen fundoplication (ONF) as the preferred anti-reﬂ ux surgery for adults and children, due to its decreased morbidity, shorter hospital stays, and fewer perioperative problems.296,297,312,315,319,320

However, LNF is attended by as high a failure rate as open surgery in adults.^297,315 In a randomized study of ONF versus LNF in adults, LNF patients had a higher incidence of disabling dysphagia.³²¹ In a series of 456 children undergoing surgery 5 years of age, Diaz et al.³¹² reported that those with LNF had a higher re- operation rate than those with ONF. Average time to re-operation with LNF was 11 months versus 17 months for ONF. In children with one to three co-morbidities, the probability of re-operation was 18–24% after LNF, compared with 6–16% for ONF.³¹²

Total esophagogastric dissociation is an operative procedure that is useful in selected children with NI or other conditions causing life-threatening aspiration during oral feedings. The operation has been used either after failed fundoplication or as a primary procedure.^322,323 The esophagogastric disconnection eliminates all GER while allowing tube feedings oral supple- mentation up to the patient’s tolerance. This is a technically demanding operation, and because of the fragile nature of the children involved—most of whom have histories of aspiration and pulmonary compro- mise—it carries signiﬁ cant morbidity.^322,323

Endoluminal endoscopic gastroplication has been described in children as an alternative to surgical fundoplication. When a group of 16 children with GERD refractory to or dependent on medical therapy was evaluated after endoluminal gastroplication, 4 had recurrent

CONCLUSIONS

GERD:

■ Is less easily diagnosed under 1 year of age wherein GER may occur instead.

■ Can resolve in many children, particularly those 1 year of age, but tends to persist in older patients.

■ Is diagnosed based on clinical suspicion (thorough history and physical examination) followed by a they can be associated with neurologic side effects.

Thus, usage should be limited to children with regur- gitation-predominant symptoms. Finally, anti-reﬂ ux surgery should be considered in children with complications of GERD such as aspiration (with or without oral–pharyngeal function), Barrett esophagus, and esophageal strictures. Predictors of fundoplication success are response to medical therapy and surgeon experience (Table 12–4).⁷⁸

Drugs Demonstrated to be Effective in Gastroesophageal Reﬂ ux Disease*

Type of Medicine Recommended Oral Dosage Adverse Effects/Precautions Histamine-2 receptor antagonists

Cimetidine (Tagamet) Safety and effectiveness have not been established in children 16 years (adult dose: 800 mg BID or 400 mg QID)

Breast development in men, headache, diarrhea, dizziness; less commonly, agitation, anxiety, confusion, depression, disorientation, and hallucinations

Famotidine (Pepcid) 3 months: 0.5 mg/kg/dose QD Headache, dizziness, constipation, diarrhea, agitation (1 year)

3 months to 1 year: 0.5 mg/kg/dose BID 1–16 years: 1.0 mg/kg/day BID up to 40

mg BID (adult dose: 20 or 40 mg, BID) Nizatidine (Axid) 12 years:150 mg BID (adult dose:

150 mg BID)

Pyrexia (i.e., fevers), nasopharyngitis, diarrhea, vomiting, irritability, nasal congestion, cough Ranitidine (Zantac) 1 month to 16 years: 5–10 mg/kg/day,

divided BID (adult dose: 150 mg, BID or QID)

Headache, irregular heartbeats, dizziness, liver problems, rash, changes in the counts of blood cells in your blood, constipation, nausea, vomiting, possible allergic reaction including anaphylaxis

Proton pump inhibitors

Esomeprazole (Nexium) 1–11 years: 10 or 20 mg, QD Headache, diarrhea, abdominal pain, nausea, somnolence

12–17 years: 20 or 40 mg, QD (adult dose 20 or 40 mg, QD)

Lansoprazole (Prevacid) 1–11 years: 30 kg 15 mg QD Diarrhea, abdominal pain, nausea, constipation 30 kg 30 mg QD (adult dose: 15

or 30 mg, QD)

Omeprazole (Prilosec) 1–16 years: 5 to 10 kg 5 mg QD Respiratory system events, fever, headache, abdominal pain, nausea, diarrhea, vomiting, ﬂ atulence

10 to 20 kg 10 mg QD 20 kg 20 mg QD (adult dose

20 mg QD)

Pantoprazole (Protonix) No pediatric dose available (adult dose: 40 mg QD)

Headache, abdominal pain, liver function tests abnormal, nausea, vomiting Rabeprazole (Aciphex) 12 years 20 mg QD (adult dose:

20 mg QD)

Pain, pharyngitis, ﬂ atulence, infection, constipation

Sources:

1. Drugs@FDA. Food and Drug Administration. Available at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.SearchResults_

Browse&DrugInitial Z.

2. PDRhealth Prescription Drugs. Available at http://www.pdrhealth.com/drugs/drugs-index.as.

*Drug information updated October 2009.

Table 12–4.

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14. Jadcherla SR, Duong HQ, Hoffmann RG, Shaker R.

Esophageal body and upper esophageal sphincter motor responses to esophageal provocation during maturation in preterm newborns. J Pediatr. 2003;143:31–38.

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18. Omari TI, Rommel N, Staunton E, et al. Paradoxical impact of body positioning on gastroesophageal reﬂ ux and gastric emptying in the premature neonate. J Pedi- atr. 2004;145:194–200.

19. Waring JP, Feiler MJ, Hunter JG, Smith CD, Gold BD.

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course of empiric therapy, which often resolves symptoms. Diagnostic testing such as a GI series to rule out anatomic abnormalities or endoscopy for GI bleeding and refractory symptoms should be utilized as needed to rule out alternative diagnoses, complications, and predisposing conditions.

■ Is often treatable conservatively when mild. Suspected milk protein intolerance, which can masquerade as GERD in infancy, necessitates a trial of protein hydro- lysate formula.

■ PPIs are superior for symptomatic relief and mucosal healing, and are safe for long-term use, with an adverse event proﬁ le similar to adults.

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