gastroesophageal%20reflux%20disease%20in%20children
GASTROESOPHAGEAL REFLUX DISEASE IN CHILDREN

Gastroesophageal reflux is categorized as a disease [gastroesophageal reflux disease (GERD)] when reflux is associated with warning signs &/or complications, & requires further evaluation.

It is more common in formula-fed infants than in purely breastfed infants.

There is increased incidence in infants at 4 months of age.

Surgical Intervention

Indications for Antireflux Surgery

  • Failed medical management
  • Noncompliance with therapy, medication side effects, inadequate symptom control, refractory gastroesophageal reflux disease(persistence of gastroesophageal reflux disease symptoms in compliant patients despite standard treatment or twice-daily dosing of proton pump inhibitor for at least 8 weeks)
  •  Severe erosive gastroesophageal reflux disease or severe gastroesophageal reflux disease complications (eg peptic stricture, Barrett’s esophagus)
  • Extraesophageal conditions (eg pulmonary aspiration, asthma, recurrent aspiration related to gastroesophageal reflux disease)
  • Long-term management required
  • Patient/parent/guardian preference
    • Despite success with medications, may opt for surgery due to cost of medications, life-long need to take acid-suppressive agents
    • However, should be advised against surgery if symptoms are well controlled on medical therapy
Antireflux Surgery
  • Has evolved from open type to a laparoscopic procedure & in recent years, to transoral incisionless fundoplication
  • Surgical success is highest in patients presenting with typical gastroesophageal reflux disease symptoms & demonstrating good response to treatment with proton pump inhibitor
    •  In considering antireflux surgery, inform patients regarding the risk of long-term proton pump inhibitor therapy after surgery 
  • Esophageal manometry & ambulatory reflux studies should be done before surgery to rule out other disorders, eg achalasia, non-reflux-induced esophageal spasm, scleroderma
Fundoplication
  • Involves either a partial (Toupet or Thal) or a complete (Nissen/360 degrees) wrap of the lower esophageal sphincter with a section of the stomach, thus, increasing lower esophageal sphincter pressure
    • Nissen fundoplication is more commonly performed in children
    • Partial fundoplication is preferred in patients with more severe disease accompanied by motor abnormalities 
  • No statistically significant difference was observed in normal children when studies compared Nissen, Toupet, & Thal fundoplication; recurrence rate was lower however for children with neurological disorders who underwent Nissen fundoplication
  • Laparoscopic Nissen technique is preferred over open Nissen fundoplication due to lower morbidity rates, shorter hospital stay, & fewer perioperative complications
  • Complications include inability to belch & vomit, persistent dysphagia, postprandial pain, epigastric fullness, bloating, temporary swallowing discomfort, intense flatus
Total Esophagogastric Dissociation (TEGD; Bianchi's procedure)
  • Surgical alternative for patients with failed attempts at fundoplication or those with severe neurologic diseases
  • Completely eliminates risk of gastroesophageal reflux disease recurrence
  • Involves the complete transection of the esophagus from the stomach & creation of esophagojejunal anastomosis
Endoscopic Procedures
  • Further studies are needed to prove the efficacy of endoscopic procedures as an alternative surgical treatment for gastroesophageal reflux disease in children
Endoluminal Endoscopic Gastroplication
  • An endoscopic treatment option for gastroesophageal reflux disease involving the creation of numerous folds or plicae in the gastric mucosa below the lower esophageal sphincter
  • Recent procedures, eg titanium beads implantation & full-thickness plication, intend to reduce acid reflux episodes or transient lower esophageal sphincter relaxations & increase lower esophageal sphincter basal pressure
  • Studies have shown successful outcomes in patients who have been symptom-free at 1 year post-op, & with recurrence rates as low as 25% at 3rd year post-op
Stretta Procedure
  • A procedure involving the application of radiofrequency energy around the gastroesophageal junction, with the goal of reducing reflux by creating scars along the lower esophagus
  • The scarring created serves as high pressure zones & areas where vagal afferent fibers are interrupted
Enteral Tube Feeding
  • Involves placement of a nasojejunal or gastrojejunal tube, allowing bypass of the stomach during feeding
  • Indications include infants, children & young people who will benefit from decreased intragastric feeding causing regurgitation, or reflux-related pulmonary aspiration; infants with poor weight gain & faltering growth associated with gastroesophageal reflux disease; neurologically-impared children at increased risk for complications post-op
  • Clinical decision & planning should include an individualized nutrition plan, strategies to reduce duration of enteral tube placement, & anticipation of removal
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