Gastroesophageal Reflux With Relevance To Pediatric Surgery Presentation Transcript

1. GE Reflux with relevance to Pediatric SurgeryDr PoonamGuhaMCh Student

PGIMER Chandigarh25/01/10
2. Gastroesophageal reflux (GER) - retrograde flow of gastric contents into the
oesophagus50% of infants less than 2 months of age have vomiting and
regurgitationrising to 70% by 4 months of ageDeclines after 6 months of age1
5% of infants over 12 months displaying them
3. Gastroesophageal reflux disease (GERD) spectrum of reflux exceeds the
physiological norm, resulting in symptoms and complicationsSymptoms:pain,
heartburn, failure to thrive, or chronic cough,Complications:Esophageal mucosal
changes such as inflammation, bleeding, stricture, ulceration, and metaplasia.
5. GERD in TEF
6. GERD in TEFIncidence:Stephen G 1980 65%Ottolenghi 2004 43%Banjar
and Al Nassar 2005 95%; 59% required fundoplicationTrompelt J 2004
52.5%Grosfeld 30-70%
7. GER is also seen in isolated TEF without OA (cause not known)In cases of
isolated esophageal atresia, the incidence of GER after primary repair is 100%.
8. PathophysiologyGERDIncrease in all the complications of GERD
9. GERD in TEFexacerbates anastomotic stricturingdilatation of strictures less
likely to be successfulexacerbates the effects of coexisting
tracheomalaciaPredisposes to metaplasia, Barretts and malignancy
10. Role of anastomotic tension Stephen G jolly 1980 excessive tension at the
esophageal anastomosis was associated with a higher incidence of significant
GER and slow gastric emptying.Weihongguo 1997 (animal experiment)
esophageal anastomosis with mild tension causes severe GER Morabito et al 2006
use of inverted upper pouch flap reduced anastomotic tension and hence
incidence of GER (13%)
11. Anastomotic tension:Shortening of intraabdominal lengthFlattenning of GE
Junct.Elevation of gastric cardia through diaphragmBergmeijer et al 42%
patients had anastomosis under tension; 53% didnt have anastomotic tension
12. Role of gastrostomyGastrostomyalters the anatomy of the stomach, changing
the acuity of the angle of His by stretching the anterior wall of the stomach.
reduce LES pressureKielyand Spitz - prospective, randomized study - higher
incidence of GER in patients with EA who were treated with gasrostomytubes
compared with those with transanastomotic tubes.3050% of children with no
significant reflux prior to gastrostomy will have symptomatic reflux and vomit
feeds postgastrostomyContinuous lower volume feeds can be helpful
13. Abnormal gastric motilityCan be caused secondarily by several months tube
feeding, a gastropexy or mobilization of the lower esophageal pouchVagal
injuryIntraoperativePost op inflammatory damage due to leak/ sticture
14. Abnormal gastric motilityTugay et al. found a disturbance in the contractions
of the musculature of the gastric fundus which resulted in delayed gastric
emptying in patients of TEFAntralhypomotility is present in 45% of adults, and
gastric emptying, as assessed by gastric scintigraphy, is delayed in
36%.Accentuates GERD

15. Investigation protocolMost widely followed:Investigations based on clinical

suspicion:Contrast/ pH monitoring/ endoscopy with biopsyIf symptoms dictate,
vigorous and multiple attempts to demonstrate GER should be made.
16. Delay in diagnosis may occur if anastomotic stricture prevents the passage of
enough barium for demonstration of GER. Barium study of the
esophagogastricjunction should be repeated following dilatation. Distal esophagus
should be visualized whenever possible (i.e., at the time of operative esophageal
dilatation) because esophagitis may be a valuable clue to GER.
17. Lack of correlation between symptomatology and histologic changesFew
authors recommend routine endoscopy in ALL patientsEndoscopic f/u in children
with completely normal biopsies discontinued at age of 3yrsMild esophagitis f/u
extended to at least 6 yrs
18. TreatmentTreatment of GERD aims to relieve symptoms, heal mucosal
damage, and prevent and manage complications of GERD.
19. Treatment protocolWidely followed:Clinical suspicionConfirmation of
DiagnosisNonpharmacologic and pharmacologic measuresFailureARSAt
PGIRoutine prophylactic use of positional therapy and pharmacologic
measuresInvestigations in the face of persistent symptoms
20. Controversies in Medical managementPositioning of the infant Positional
therapy is accomplished by placing the child in an infant seatpropped up to an
inclination of 45 or more, 24 hr a day. Immediate response should be apparent
and in 1-12 wk the reflux will likely stopKeith W. Ashcraft. Early Recognition
and Aggressive Treatment of GastroesophagealReflux Following Repair of
Esophageal A tresia. Journal of Pediatric Surgery, 1977
21. Positioning of the infant sitting position at 60 increases reflux, probably
because of increased intragastric pressure in this position, the prone position with
30 head up decreases reflux. left lateral position has been shown to reduce reflux
in preterm and term neonatesOrenstein, S.R., Effects on behavior state of prone
versus seated positioning for infants with gastroesophageal reflux. Pediatrics,
1990
22. Bermeijer et al - Drug therapy had no positive effect on higher grade reflux. ~
50% children receiving medication as their primary treatment developed an
esophageal stenosisConsider possible alkaline reflux if chronic cough persists
despite antacid therapy
23. SURGERYIndication for surgical correction is failure of medical management
as evidenced by the effect of persistent reflux, reflux esophagitisor Barrett
esophagus, failure to thrive,development of a distal esophageal strictureRefractory
anastomotic stricture, aspiration proven to be secondary to gastroesophageal
reflux50% of patients of EA with GER require operative correction
24. SURGERYNF has typically been considered the best option.Complications:
debilitating dysphagia(50% in one series) wrap disruption, (1/3rd of patients)
recurrent GERDModified NF very short floppy wrap (1-1.5 cm over a large
dilator6% - 47% failure rate noted in the literature
25. In children whose manometry shows esophageal dysmotility, preoperative
consideration may be given to a loose partial wrap12-15%failure rateFailure of
either is more in children <2yrsRoutine concomitant pyloroplasty is not

recommended; may be considered if preoperative evaluation reveals delayed

gastric emptying.
26. Post op strictures and GERDCrucial to determine whether the esophageal
stricture is associated with GER Strictures do not respond to dilatation attempts if
severe GER continues to bathe the stricture with acidInfants with an anastomotic
narrowing should be started on proton pump inhibitors, and the stricture dilated
27. Response to dilatation and medical control of GER is excellentIntralesional
injection of triamcinolone in refractory strictures Recurrent stenosis should be
managed by laparoscopic fundoplication
28. Esophageal ReplacemmentGastric tubes:Reflux is almost always
presentAggravated by the proximity of gastric mucosa to the esophagus. Peptic
ulceration in the remnant distal esophagus and proximal esophageal
stumpChanges of gastric metaplasia have been recorded with anecdotal reports of
malignancies in the Japanese literature
29. Gastric tubes are rendered vagotomised during mobilization and depend on
gravity for drainage. Some advocates of the procedure perform a pyloromyoromy
or pyloroplasty routinely though this is controversial.
30. Colonic interpositionGastric reflux results in peptic ulceration ; may progress
to hemorrhage, perforation resultant empyema; occasionally thoracic aorta may be
involved in fistulisation resulting in life threatening hematemesis. reports of
malignancy arising in colonic interposition
31. Follow upIt is important to demonstrate that reflux has been adequately
controlled before follow-up is discontinued.
32. Divergent viewsReflux reduces with ageincidence of GER increases up to
50% during 5 years of follow-up, and patients with an existing sGER show
worsening of the esophageal histologyHeartburn is still present occasionally in
46% of adults, and is frequent in 11%Endoscopic and pH-metric follow-up of all
patients up to 5 years of age seems justifiable. The follow-up of patients with
symptomatic GER should continue longer.
33. Factors contributing to esophageal malignancy after repair of esophageal
atresia.Combination of gastroesophageal reflux and esophageal dysmotility (poor
esophageal clearance of reflux acid) leading to Barretts epitheliumRetained
esophageal segment after oesophageal replacementSquamouscell carcinoma in
skin tube conduitsAt least three case reports in the literature of adenocarcinomaof
the esophagus in young adults with previous TEF/EA repair
34. GERD in CDH
35. GERD may occur in 80% of the patientsIncidence reduces after 1st yr of
lifePrevalence of 60% at 30yrs has been reported by Vanamo et alSurgical antireflux procedures are needed in 635% of the long-term survivors
36. Pathophysiologyesophageal dysmotility from prenatal obstruction in the
herniathe maldevelopment, malposition, or even absence of the crura as a
consequence of the diaphragmatic defect or as a result of the surgical repair itselfa
shortened esophagus and a loss of the angle of His from an intrathoracic
stomachincreased intraabdominal pressure because of the return of herniated
viscera into the abdomenan increased siphon effect from prolonged ventilatory
support and frequent tracheobronchial suctioning

37. Predictor of post repair GER:size of the diaphragmatic defectrequirement of

patch closure for the repairNeed for advanced respiratory supportSide of the
hernia and the position of the stomach, may not pose as high a riskPreventive
measures:Meticulous attention to the diaphragmatic crura during the repair. A
thorough Ladd procedure
38. Antireflux measures to start prophylactically or at clinical suspicionContrast
radiographs should be performed to eliminate distal obstructionNuclear medicine
studies to assess gastric emptyingARS on failure on medical therapyLow
recurrence rates
39. Jaillard et al proposedprimary ARS at the time of large diaphragmatic defect
repairYigit S. Guner et al proposed use of partial anterior wrap (boixochoa) in
selected patients with an obtuse angle of His and a small, and/or a vertically
oriented stomach during the primary surgery
40. Late complications of CDH-related GER may include Esophagitis
54%Barrett's esophagus 12%adenocarcinoma
41. GERD In Congenital Abdominal Wall Defects
42. Incidence - 50% - 70%Etiology increased intraabdominal pressure after the
closure of the abdominal defectmotility disturbance of the upper gastrointestinal
tractAssociated anomaliesesophageal atresiaduodenal atresiaDiaphramatic hernia
mental retardation or neurological impairment
43. Gastroschisis 16 50%when normal bowel motility was restored after the
initial postoperative period of gut dysfunction, the incidence of GER did not
exceed that of healthy children.Omphalocele 40 50%frequency of GER
considerably exceeds that of normal childrenbenign course with a tendency to
spontaneous improvement.
44. Routine workup for ALL patients of omphalocele in 1st yr; treatment
accordinglyWork up in Gastroschisis and older patients of Omphalocele only
when symptoms arise Severe GERD in neonates with large omphaloceles
requiring staged closuresBeaudoinS. et al recommended surgical antireflux
procedure for these babies in whom moreover the anatomic approach is favorable
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