• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer

SAGES

Reimagining surgical care for a healthier world

  • Home
    • COVID-19 Annoucements
    • Search
    • SAGES Home
    • SAGES Foundation Home
  • About
    • Who is SAGES?
    • SAGES Mission Statement
    • Strategic Plan, 2020-2023
    • Committees
      • Request to Join a SAGES Committee
      • SAGES Board of Governors
      • Officers and Representatives of the Society
      • Committee Chairs and Co-Chairs
      • Full Committee Rosters
      • SAGES Past Presidents
    • Donate to the SAGES Foundation
    • Awards
      • George Berci Award
      • Pioneer in Surgical Endoscopy
      • Excellence In Clinical Care
      • International Ambassador
      • IRCAD Visiting Fellowship
      • Social Justice and Health Equity
      • Excellence in Community Surgery
      • Distinguished Service
      • Early Career Researcher
      • Researcher in Training
      • Jeff Ponsky Master Educator
      • Excellence in Medical Leadership
      • Barbara Berci Memorial Award
      • Brandeis Scholarship
      • Advocacy Summit
      • RAFT Annual Meeting Abstract Contest and Awards
  • Meetings
    • 2022 NBT Innovation Weekend
    • SAGES Annual Meeting
      • 2023 Scientific Session Call For Abstracts
      • 2023 Emerging Technology Call For Abstracts
    • SAGES 2021 Annual Meeting
    • CME Claim Form
    • Industry
      • Advertising Opportunities
      • Exhibit Opportunities
      • Sponsorship Opportunities
    • Future Meetings
    • Past Meetings
      • SAGES 2021
      • SAGES 2020
      • SAGES 2019
      • SAGES 2018
    • Related Meetings Calendar
  • Join SAGES!
    • Membership Benefits
    • Membership Applications
      • Active Membership
      • Affiliate Membership
      • Associate Active Membership
      • Candidate Membership
      • International Membership
      • Medical Student Membership
    • Member News
      • Member Spotlight
      • Give the Gift of SAGES Membership
  • Patients
    • Healthy Sooner – Patient Information for Minimally Invasive Surgery
    • Patient Information Brochures
    • Choosing Wisely – An Initiative of the ABIM Foundation
    • All in the Recovery: Colorectal Cancer Alliance
    • Find a SAGES Member
  • Publications
    • SAGES Stories Podcast
    • SAGES Clinical / Practice / Training Guidelines, Statements, and Standards of Practice
    • Patient Information Brochures
    • TAVAC – Technology and Value Assessments
    • Surgical Endoscopy and Other Journal Information
    • SAGES Manuals
    • SCOPE – The SAGES Newsletter
    • COVID-19 Annoucements
    • Troubleshooting Guides
  • Education
    • OpiVoid.org
    • SAGES.TV Video Library
    • Safe Cholecystectomy Program
      • Safe Cholecystectomy Didactic Modules
    • Masters Program
      • SAGES Facebook Program Collaboratives
      • Acute Care Surgery
      • Bariatric
      • Biliary
      • Colorectal
      • Flexible Endoscopy (upper or lower)
      • Foregut
      • Hernia
      • Robotics
    • Educational Opportunities
    • HPB/Solid Organ Program
    • Courses for Residents
      • Advanced Courses
      • Basic Courses
    • Video Based Assessments (VBA)
    • Robotics Fellows Course
    • MIS Fellows Course
    • Facebook Livestreams
    • Free Webinars For Residents
    • SMART Enhanced Recovery Program
    • SAGES OR SAFETY Video
    • SAGES at Cine-Med
      • SAGES Top 21 MIS Procedures
      • SAGES Pearls
      • SAGES Flexible Endoscopy 101
      • SAGES Tips & Tricks of the Top 21
  • Opportunities
    • SAGES Fellowship Certification for Advanced GI MIS and Comprehensive Flexible Endoscopy
    • Foregut Fellowship Certification
    • SAGES Research Opportunities
    • Fundamentals of Laparoscopic Surgery
    • Fundamentals of Endoscopic Surgery
    • Fundamental Use of Surgical Energy
    • Job Board
    • SAGES Go Global: Global Affairs and Humanitarian Efforts
  • Search
    • Search All SAGES Content
    • Search SAGES Guidelines
    • Search the Video Library
    • Search the Image Library
    • Search the Abstracts Archive
  • Blog
    • COVID-19
    • Notes from the Battlefield
    • A (Positive) Way Forward
    • President Posts
    • All Blog Posts
  • Log In

Pediatric Gastroesophageal Reflux Disease

First submitted by:
Bethany Jane Slater
Category
Esophagus, Pediatric Surgery, Stomach and Foregut
Print Friendly, PDF & Email

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.

 

References

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.

3. Rothenberg SS. The first decade’s experience with laparoscopic Nissen fundoplication in infants and children. Journal of pediatric surgery 2005;40:142-6; discussion 7.

4. Rothenberg SS. Experience with 220 consecutive laparoscopic Nissen fundoplications in infants and children. Journal of pediatric surgery 1998;33:274-8.

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.

 

3,146

Share this:

  • Twitter
  • Facebook
  • LinkedIn
  • Pinterest
  • WhatsApp
  • Reddit

Related

Category: Esophagus, Pediatric Surgery, Stomach and Foregut
  • Main Page
  • Help
  • Create a New Wiki

Our Mission

Innovate, educate and collaborate to improve patient care.

Recently, on SAGES…

Surgery is Safer with Vaccination 1

Addressing Religious Concerns About COVID-19 Vaccine

This may be a difficult subject matter for you and your patient to talk about.  Be assured, all major organized religious groups encourage and recommend the COVID-19 vaccine. Listed below are references and websites you can direct your patient towards to help them make an informed decision with regards to their religious concerns against the […]

SAGES Statement on AAPI Violence

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) stands in solidarity with the Asian American and Pacific Islander (AAPI) community. In the summer of 2020, SAGES released a statement condemning the violence, racism, and hatred toward the Black community in the wake of George Floyd and Breonna Taylor’s murders. It is with great sorrow […]

Free SAGES Webinar: Lessons from COVID on Living and Thriving as Surgeons

SAGES recognizes that the COVID-19 pandemic has had a big impact on surgical practice and in surgeon wellness. SAGES’ Reimagining the Practice of Surgery Taskforce will present “Finding the Opportunities: Lessons from COVID and How We Live and Thrive as Surgeons”  to look at ways in which innovative leadership at various levels may help transform […]

Contact SAGES

Society of American Gastrointestinal and Endoscopic Surgeons
11300 W. Olympic Blvd Suite 600
Los Angeles, CA 90064 USA
[email protected]
Tel: (310) 437-0544

Find Us Around the Web!

  • Facebook
  • Twitter
  • YouTube

Important Links

SAGES 2022 Meeting Information

Healthy Sooner: Patient Information

SAGES Guidelines, Statements, & Standards of Practice

SAGES Manuals

 

  • taTME Study Info
  • Foundation
  • SAGES.TV
  • MyCME
  • Educational Activities

Copyright © 2022 Society of American Gastrointestinal and Endoscopic Surgeons