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Seminars in Pediatric Surgery 26 (2017) 56–60

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Gastroesophageal reﬂux Bethany J. Slatern, Steven S. Rothenberg Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado

a r t i c l e in f o

abstract

Keywords: Children Fundoplication Gastroesophageal reﬂux GERD Minimally invasive Nissen Pediatrics Reﬂux Wrap

Gastroesophageal reflux disease (GERD) is a very common condition and affects approximately 7–20% of the pediatric population. Symptoms from pathological GERD include regurgitation, irritability when feeding, respiratory problems, and substernal pain. Treatment typically starts with dietary modifications and postural changes. Antireflux medications may then be added. Indications for operative management in the pediatric population include failure of medical therapy with poor weight gain or failure to thrive, continued respiratory symptoms, and complications such as esophagitis. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. The key technical aspects of laparoscopic Nissen fundoplication include creation of an adequate intra-abdominal esophagus, minimal dissection of the hiatus with exposure of the right crus to identify the gastroesophageal junction, crural repair, and creation of floppy, 3601 wrap that is oriented at the 11 o'clock position. & 2017 Elsevier Inc. All rights reserved.

Introduction 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. GERD is a very common condition and affects approximately 7–20% of the pediatric population.1 A number of physiologic barriers exist to prevent reflux from the stomach into 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, such as esophageal peristalsis, and to limit esophageal injury, such as saliva and other enzymes.2 The adverse effects of GERD occur from the failure of one or more of these factors. Transient lower esophageal sphincter relaxation is the most important pathophysiologic mechanism leading to GERD.3 A number of congenital anomalies also increase the risk of GERD, including esophageal atresia and congenital diaphragmatic hernia.

Clinical presentation The symptoms of GERD are variable and depend on the age and medical condition of the child. Regurgitation is a common n Correspondence to: Bethany Slater, Rocky Mountain Hospital for Children, 2055 High St, Suite 370, Denver, Colorado 80205. E-mail address: Bjslater1@gmail.com (B.J. Slater).

presentation for infants and children with GERD. Pulmonary symptoms such as coughing, wheezing, choking, apnea, and apparent life-threatening events (ALTE) can also be the presenting symptoms of GERD. Older children may complain of more typical heartburn symptoms including retrosternal and epigastric pain. Finally, complications of reﬂux such as esophagitis, stricture formation, and ulcers can lead to pain, dysphagia, and hemorrhage.

Diagnosis Several diagnostic tests may be used both to detect the presence or absence of reflux and to rule out other pathologies. Upper gastrointestinal radiography (UGI) can identify reflux in approximately half of the patients and delineates the anatomy of esophagus and upper GI tract. The level of reflux, presence of a hiatal hernia, and esophageal peristalsis can all be evaluated on a UGI. However, the most useful aspect of this test is to rule out other anatomic abnormalities of the upper gastrointestinal tract, such as malrotation. A 24-h PH probe testing has been considered the gold standard for diagnosing GERD. A score is calculated from the time the pH is less than 4, total number of reflux episodes, number of episodes greater than 5 min, and the longest reflux episode. However, impedance studies, in which multichannel electrode pairs are placed in the esophagus and stomach, are being used more frequently since they measure nonacidic reflux and can be performed while children are on antireflux medications.4 Other diagnostic evaluations such as upper endoscopy with

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squamous epithelium is replaced by columnar epithelium, or other GERD-related complications. Several different surgical procedures have been described for the treatment of GERD. However, the most commonly performed operation is the Nissen fundoplication in which the fundus is posteriorly wrapped 3601 around the lower esophagus. There has not been any literature demonstrating signiﬁcant beneﬁts of one procedure.6

Technique

Fig. 1. Schematic of patient positioning.

biopsies, bronchoscopy with bronchial washings, and gastric emptying studies may also be used to add further conﬁrmatory information or when the diagnosis is unclear. Additionally, some of these studies may be helpful to evaluate for complications of GERD and in patients who have already undergone antireﬂux surgery.

Treatment The treatment of pathological GERD typically starts with dietary modifications and postural changes. For infants, elevation of the head of the bed and frequent small volume meals with thickened formulas or agents are generally recommended. Next, pharmacologic agents may be added consisting of antireflux medication and prokinetic agents. The main acid suppressant agents used for GERD are H2-receptor antagonists and proton pump inhibitors. Motility medications such as metoclopramide have been widely used although studies demonstrating their efficacy have been limited.5 Indications for operative management in the pediatric population include failure of medical therapy with poor weight gain or failure to thrive, continued respiratory symptoms, and complications attributable to GERD. Situations in which a trial of medical treatment may not be necessary include infants who present with ALTEs and no other identifiable etiology. In addition, neurologically impaired infants who require a gastrostomy for feeding and concerns for aspiration may also benefit from a fundoplication at the same time. Finally, initial operative intervention may be indicated for patients found to have Barrett esophagitis, in which

For the laparoscopic Nissen fundoplication, the patient is placed at the end of the table with the surgeon at the foot of the table (Figure 1). For infants, the legs are placed in a frog-leg position and for older children, stirrups with appropriate padding are used to place them in lithotomy position. A monitor is placed over the patient's head. 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 mid clavicular line to the patient's right of the falciform, and a stomach retractor 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 the insufﬂation to assure that the button is far enough from the costal margin (Figure 2). Otherwise, the port should be placed at the costal margin in the mid clavicular line. It should be noted that some authors have tried to limit the number of ports, or even perform the operation using a single-site technique. However, because the geometry and formation of the fundoplication is so important to the success of the operation as well as the risk of recurrence, we choose to continue to use ﬁve ports to insure adequate exposure and proper formation of the wrap. We have moved to minilaparoscopy (3 mm incisions) in larger patients to limit incision sites. This technique has been developed over the past 2 decades with minor revisions to improve outcome.7–9 The left lobe of the liver is retracted superiorly to expose the gastroesophageal junction through the right upper quadrant port. Although a selfretaining 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 toward the left by an assistant through the left upper quadrant port, 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 (Figure 3). 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 (Figure 4). The right crus should be dissected so that the gastroesophageal junction can be clearly

B X

3mm 3mm

3mm (G tube site/ retractor)

(liver retractor)

(Left hand instrument)

5mm

(Right hand instrument)

4mm

(camera)

Fig. 2. (A) Schematic of trocar placement and (B) picture of trocar placement.

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Fig. 5. The fundoplication is created with three 2–0 ethibond sutures. The wrap should be approximately 2–3 cm, ﬂoppy, and oriented at 11 o'clock. Fig. 3. The stomach is being retracted to the right, and the short gastric vessels are being divided with electrocautery.

identified, and an adequate length of intra-abdominal esophagus is confirmed. A posterior crural repair is then performed in all cases to decrease the risk of hiatal hernia formation postoperatively. 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 three sutures (Figure 5). 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. An orogastric tube is usually sufficient to complete the wrap particularly in smaller infants. However, a bougie may be placed before the fundoplication wrap is performed to avoid creating too tight a wrap around the distal esophagus. Ostlie et al.10 has published a table of appropriate bougie sizes for infants weighing less than 15 kg. Complications 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.11 Postoperative dysphagia may initially be due to swelling of the wrap and subside after the edema has resolved. However, occasionally esophageal dilations are required to widen the distal esophagus.

Outcomes Antireflux operations are among the most common procedures performed by pediatric surgeons in the United States. A systematic review of the literature from 1995 to 2010 with 1280 children demonstrated a success rate, as defined as complete relief of reflux symptoms, of 86% in the short term and 72% in the long term.1 Rothenberg9 reported his experience with 2000 Nissen fundoplications over 2 decades and found a wrap failure rate of 4.6%. Children with respiratory symptoms, particularly steroiddependent asthma, have been found to have the greatest benefit from antireflux surgery.12,13 A recent prospective, multicenter study also showed significant reduction of reflux symptoms, total acid exposure time, and acidic reflux episodes in patients after laparoscopic fundoplication.14 A number of technical aspects during fundoplication have been implicated in increased rates of recurrent GERD and reoperation. Minimal dissection of the esophagus leaving the phrenoesophageal membrane intact has been shown to decrease the incidence of postoperative wrap herniation and the need for re-operation.15 In addition, crural repair helps to minimize hiatal hernia formation, and adequate esophageal length is necessary to minimize slippage of the wrap above the hiatus.16 The North American and European Societies for Pediatric Gastroenterology, Hepatology, and Nutrition updated a previous consensus regarding GER and GERD in 2007.12 This document provides evidence-based guidelines for the diagnosis and management of GERD in the pediatric population. Future studies are necessary to fully evaluate the mechanisms of wrap failure and reasons for recurrence to minimize the relapse of symptoms, complications, and need for re-operation. In addition, optimal preoperative evaluation will allow for better selection of patients and maximization of antireflux surgery. Alternative options for the treatment of GERD, such as placement of gastrojejunostomy alone, have been proposed but none have good evidence to support their use.17 In addition, endoscopic procedures have been developed, but they also have not shown comparable outcomes or long-term results.

Alternative methods

Fig. 4. A retroesophageal window is bluntly being created from the right side. Arrow indicates the posterior vagus nerve.

There are a number of other novel techniques to treat GERD, some using an endoscopic or intraluminal approach. The idea being that these are even less invasive than a laparoscopic approach, and therefore may be more acceptable to the patient and referring physician. The experience with these is somewhat

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Fig. 7. A schematic drawing of the LINX system around the lower esophagus. Fig 6. A schematic drawing of the Esophyx device in the stomach.

limited in children, primarily because of the size of the instrumentation and endoscopes used. Also, there is little long-term data, and the majority of these are off-label for pediatric use. They will be mentioned brieﬂy here for completeness.

Stretta The Stretta procedure is an endoluminal antireﬂux procedure using radiofrequency (RF) energy application to the lower esophageal sphincter (LES). The Stretta catheter (Mederi Therapeutics, Norwalk, CT) is placed at the level of the LES (0.5 cm above the Z line), and the “needles” are advanced into the intramuscular layer and the RF energy applied. The catheter is then retracted approximatey 3 cm, rotated 451, and the burn is reapplied. Multiple treatments may be necessary to achieve the desired results. Although the exact mechanism for the technique has not been determined, two models predominate. The thermal injury model postulates that the RF treatment of the LES induces collagen tissue contraction, progressive intramuscular scar buildup, and remodeling and modulation of LES pressure to bolster esophageal sphincter function. The neurogenic model suggests that RF ablates the vagal afferent nerves involved in modulating transient LES relaxations, resulting in fewer transient LES relaxations and thereby decreasing acid exposure of the distal esophagus. There have only been two small series reported in the pediatric patients, and both had a relatively high recurrence or failure rate. 18–19 While this technique might be of some value in certain cases, the long-term consequences of an intramural “burn at the LES” in a pediatric patient are unknown. Further study is necessary before this technique can be recommended for pediatric patients.

TIF The TIF, or transluminal incisionless fundoplication, is also a relatively new technique that is performed endoscopically and has seen limited use in children. A device called the Esophyx (Endogastric Soultions, Redmond, WA) is placed as an over tube on the endoscope. It is advanced into the stomach and then through a vise-like device to inkwell the esophagus into the stomach, creating a nipple valve effect (Figure 6). The “fundoplication” ideally ends up about a 240–2701 wrap. The main limitation of this device is that a patient must be at least 25– 30 kgs for the device to ﬁt in the stomach. There have only been a few reports of the use of this device in children.19–20 Chen et al. used the device in primarily neurologically impaired patients. There was a 30% dysphagia rate and 10% recurrence rate with relatively short-term follow-up (less than 1 year). We have performed the procedure in 20 patients with a 10%

recurrence rate within 2 years.21 Again, the long-term outcome of these patients will require further study. LINX The LINX (Torax Medical, Shoreview, MN) procedure is the newest of the less invasive approaches. This procedure is performed laparoscopically rather than endoluminally, and a magnetic sphincter augmentation device is placed around the esophagus, just above the GE junction. This is basically a series of magnets that are strung together around the esophagus (Figure 7). The ring expands as food boluses pass through but closes down after to prevent reflux. The advantage of this device over a laparoscopic fundoplication is that there is minimal dissection and mobilization of the stomach or esophagus, limiting the risk of hiatal hernia or slipped fundoplication postoperatively. There are no pediatric reports yet with this device, but adult series suggest a 75–80% symptomatic improvement with limited complications. There are a few reports of device migration into the esophagus, and this might be the greatest concern if it was placed in a growing child. This device also has not been given pediatric labeling by the FDA. Again, long-term follow-up and specific pediatric studies will be necessary to analyze the benefit of this technology in children.

Conclusion GERD is frequently encountered in the pediatric population. Most infants and children will have resolution of symptoms over time or with nonoperative methods such as medications. However, a percentage of patients will require surgical treatment due to the persistence of symptoms or from complications of GERD. There are a number of tests available for the diagnosis of GERD and for evaluation of the anatomy of the upper gastrointestinal tract. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. It has a low morbidity rate and a range of recurrence rates. The key technical points of the operation 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, 3601 wrap that is oriented at the 11 o'clock position. Newer techniques and approaches may one day supplant the laparoscopic fundoplication, but currently none of those procedures have enough documented cases or long-term follow-up to make that claim. References 1. Mauritz FA, van Herwaarden-Lindeboom MY, Stomp W, Zwaveling S, Fischer K, Houwen RH, et al. The effects and efficacy of antireflux surgery in children with

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