Gastroesophageal reflux is defined as the passage of gastric contents into the esophagus. Gastroesophageal reflux disease (GERD) refers to the pathological symptoms and complications that result from reflux. Gastroesophageal reflux disease (GERD) affects many infants and children in the United States. There are a number of physiologic barriers that exist to prevent reflux from the stomach to the lower esophagus, such as the lower esophageal sphincter, the angle of HIS, and the length of the intra-abdominal esophagus. In addition, mechanisms are present to both minimize the amount of reflux in the esophagus and to limit esophageal injury. GERD results from a failure of one or more of these mechanisms. The symptoms of GERD are variable and depend on the age and medical condition of the child. Presentations may include frequent regurgitation, respiratory symptoms such as wheezing, coughing, or apnea, epigastric pain, or dysphagia.
Several diagnostic tests may be used both to detect the presence or absence of reflux as well as to rule out other pathologies. Upper gastrointestinal radiography (UGI) may identify reflux or a hiatal hernia but also can be used to rule out other anatomic abnormalities of the upper gastrointestinal tract such as malrotation. 24 hour PH probe testing has been considered the gold standard for diagnosing GERD since the 19080’s. A score is calculated from the time the pH<4, total number of reflux episodes, number of episodes >5 minutes, and the longest reflux episode. Multichannel impedance studies may also be performed to detect non-acid reflux. Other studies such as upper endoscopy with biopsies, bronchoscopy with bronchial washings, and gastric emptying studies may also be used in certain circumstances.
The treatment of pathological GERD typically starts with dietary modifications, postural changes, and potentially the addition of pharmacologic agents, particularly anti-reflux medications. Indications for operative management in the pediatric population include failure of medical therapy with poor weight gain or failure to thrive, continued respiratory symptoms, esophagitis, and the finding of Barrett esophagitis. The patient is placed at the end of the table with the surgeon at the foot of the table. Infants are placed in a frog-leg position and older children are placed in stirrups with appropriate padding. A monitor is placed over the patient’s head and an orogastric tube is placed by the anesthesiologist. Five trocars are then inserted with the camera port at the umbilicus, working ports in the right and left mid-quadrants, a liver retractor port in the right mid-quadrant in the anterior axillary line, and a stomach retractor port in the left upper quadrant. The left upper quadrant trocar position should be the gastrostomy tube site if one is to be performed and may be marked before insufflation to assure that the button is far enough from the costal margin. Insufflation pressures may be between 12-15 mm Hg depending on the size and medical condition of the patient.
The left lobe of the liver is retracted superiorly to expose the gastroesophageal junction. Although a self-retaining retractor may be used, a babcock retractor with a locking in-line handle can be placed on the diaphragm to expose the hiatus. With the stomach retracted towards the left by an assistant, the gastrohepatic ligament is divided. The stomach is then retracted to the right and the short gastric vessels are divided either with electrocautery or a sealer device in older children. Short gastric mobilization is necessary to achieve a tension-free wrap. A retroesophageal window is then created bluntly from the right side with care not to injure the posterior vagus nerve. The right crus should be dissected so that the gastroesophageal junction can be clearly identified and an adequate length of intra-abdominal esophagus is confirmed. A crural repair is then performed in all cases to decrease the risk of hiatal hernia formation post-operatively. The stomach is brought through the retroesophageal window and a shoeshine maneuver is performed to assure that the stomach is not twisted. The fundoplication wrap is then performed with 3 sutures. The most superior suture incorporates a small piece of anterior esophagus and right crus to help secure the wrap. The two more inferior sutures incorporate just anterior esophagus. The wrap should be about 2-3 cm and be oriented at the 11 o’clock position. In addition, it is important for the wrap to be above the gastroesophageal junction. (See Video)
For patients that had a gastrostomy button placed at the time of fundoplication, feeds can be started either the first post-operative day or that evening and advanced as tolerated. If no gastrostomy was placed, clear liquids may be started 4-6 hours post-operatively. Patients are then kept on a soft diet for approximately 2 weeks to avoid complaints of dysphagia due to post-operative edema around the fundoplication. Complications after laparoscopic nissen fundoplication include hiatal hernia, slipped wrap, recurrent GERD, persistent dysphagia, and gas bloat syndrome. Risk factors for recurrence include younger age, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilation. Anti-reflux operations are among the most common procedures performed by pediatric surgeons in the United States. Most series report high success rates in the short- and long-term. Recurrence rates range from approximately 4-20% in the literature. The key technical points to minimize recurrence include creation of an adequate intraabdominal esophagus, minimal dissection of the hiatus with exposure of the right crus to identify the gastroesophageal junction, crural repair, and creation of floppy, 360 degree wrap that is oriented at the 11 o’clock position.
1. Hollwarth ME. Gastroesophageal Reflux Disease. In: Coran AG, Adzick, N. S., Krummel, T. M., Laberge, J., M., Shamberger, R. C., Caldamone, A. A., ed. Pediatric Surgery. Philadelphia, PA: Elsevier; 2012.
2. Iqbal CW, Holcomb, G. W., 3rd. Gastroesophageal Reflux. In: Holcomb GW, 3rd, Murphy, J. P., Ostlie, D. J., ed. Ashcraft’s Pediatric surgery. London: Elsevier; 2014.
5. Rothenberg SS. Two decades of experience with laparoscopic nissen fundoplication in infants and children: a critical evaluation of indications, technique, and results. Journal of laparoendoscopic & advanced surgical techniques Part A 2013;23:791-4.
6. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of pediatric gastroenterology and nutrition 2009;49:498-547.
7. Mauritz FA, van Herwaarden-Lindeboom MY, Stomp W, et al. The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2011;15:1872-8.
8. Desai AA, Alemayehu H, Holcomb GW, 3rd, St Peter SD. Minimal vs. maximal esophageal dissection and mobilization during laparoscopic fundoplication: Long-term follow-up from a prospective, randomized trial. Journal of pediatric surgery 2015;50:111-4.