GE Reflux with relevance to Pediatric Surgery Dr PoonamGuhaMCh Student PGIMER Chandigarh 25/01/10
Gastroesophageal reflux (GER) - retrograde flow of gastric contents into the oesophagus 50% of infants less than 2 months of age have vomiting and regurgitation rising to 70% by 4 months of age Declines after 6 months of age 1–5% of infants over 12 months displaying them
Gastroesophageal reflux disease (GERD) – spectrum of reflux exceeds the physiological norm, resulting in symptoms and complications Symptoms: pain, heartburn, failure to thrive, or chronic cough, Complications: Esophageal mucosal changes such as inflammation, bleeding, stricture, ulceration, and metaplasia.
GERD in TEF Incidence: Stephen G 1980 – 65% Ottolenghi 2004– 43% Banjar and Al Nassar 2005– 95%; 59% required fundoplication Trompelt J 2004 – 52.5% Grosfeld – 30-70%
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%.
Pathophysiology GERD Increase in all the complications of GERD
GERD in TEF exacerbates anastomotic stricturing dilatation of strictures less likely to be successful exacerbates the effects of coexisting tracheomalacia Predisposes to metaplasia, Barrett’s and malignancy
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%)
Anastomotic tension: Shortening of intraabdominal length Flattenning of GE Junct. Elevation of gastric cardia through diaphragm Bergmeijer et al – 42% patients had anastomosis under tension; 53% didn’t have anastomotic tension
Role of gastrostomy Gastrostomyalters the anatomy of the stomach, changing the acuity of the angle of His by stretching the anterior wall of the stomach. reduce LES pressure Kielyand Spitz - prospective, randomized study - higher incidence of GER in patients with EA who were treated with gasrostomytubes compared with those with transanastomotic tubes. 30–50% of children with no significant reflux prior to gastrostomy will have symptomatic reflux and vomit feeds postgastrostomy Continuous lower volume feeds can be helpful
Abnormal gastric motility Can be caused secondarily by several months’ tube feeding, a gastropexy or mobilization of the lower esophageal pouch Vagal injury Intraoperative Post op inflammatory damage due to leak/ sticture
Abnormal gastric motility Tugay et al. found a disturbance in the contractions of the musculature of the gastric fundus which resulted in delayed gastric emptying in patients of TEF Antralhypomotility is present in 45% of adults, and gastric emptying, as assessed by gastric scintigraphy, is delayed in 36%. Accentuates GERD
Investigation protocol Most widely followed: Investigations based on clinical suspicion: Contrast/ pH monitoring/ endoscopy with biopsy If symptoms dictate, vigorous and multiple attempts to demonstrate GER should be made.
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.
Lack of correlation between symptomatology and histologic changes Few authors recommend routine endoscopy in ALL patients Endoscopic f/u in children with completely normal biopsies discontinued at age of 3yrs Mild esophagitis – f/u extended to at least 6 yrs
Treatment Treatment of GERD aims to relieve symptoms, heal mucosal damage, and prevent and manage complications of GERD.
Treatment protocol Widely followed: Clinical suspicion Confirmation of Diagnosis Nonpharmacologic and pharmacologic measures Failure ARS At PGI Routine prophylactic use of positional therapy and pharmacologic measures Investigations in the face of persistent symptoms
Controversies in Medical management Positioning of the infant – Positional therapy is accomplished by placing the child in an “infant seat” propped 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 stop Keith W. Ashcraft. Early Recognition and Aggressive Treatment of GastroesophagealReflux Following Repair of Esophageal A tresia. Journal of Pediatric Surgery, 1977
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 neonates Orenstein, S.R., Effects on behavior state of prone versus seated positioning for infants with gastroesophageal reflux. Pediatrics, 1990
Bermeijer et al - Drug therapy had no positive effect on higher grade reflux. ~ 50% children receiving medication as their primary treatment developed an esophageal stenosis Consider possible alkaline reflux if chronic cough persists despite antacid therapy
SURGERY Indication 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 stricture Refractory anastomotic stricture, aspiration proven to be secondary to gastroesophageal reflux 50% of patients of EA with GER require operative correction
SURGERY NF has typically been considered the best option. Complications: debilitating dysphagia(50% in one series) wrap disruption, (1/3rd of patients) recurrent GERD Modified NF – very short floppy wrap (1-1.5 cm over a large dilator 6% - 47% failure rate noted in the literature
In children whose manometry shows esophageal dysmotility, preoperative consideration may be given to a loose partial wrap 12-15%failure rate Failure of either is more in children <2yrs Routine concomitant pyloroplasty is not recommended; may be considered if preoperative evaluation reveals delayed gastric emptying.
Post op strictures and GERD Crucial 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 acid Infants with an anastomotic narrowing should be started on proton pump inhibitors, and the stricture dilated
Response to dilatation and medical control of GER is excellent Intralesional injection of triamcinolone in refractory strictures Recurrent stenosis should be managed by laparoscopic fundoplication
Esophageal Replacemment Gastric tubes: Reflux is almost always present Aggravated by the proximity of gastric mucosa to the esophagus. Peptic ulceration in the remnant distal esophagus and proximal esophageal stump Changes of gastric metaplasia have been recorded with anecdotal reports of malignancies in the Japanese literature
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.
Colonic interposition Gastric 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
Follow up It is important to demonstrate that reflux has been adequately controlled before follow-up is discontinued.
Divergent views Reflux reduces with age incidence of GER increases up to 50% during 5 years of follow-up, and patients with an existing sGER show worsening of the esophageal histology Heartburn 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.
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 Barrett’s epithelium Retained esophageal segment after oesophageal replacement Squamouscell carcinoma in skin tube conduits At least three case reports in the literature of adenocarcinomaof the esophagus in young adults with previous TEF/EA repair
GERD may occur in 80% of the patients Incidence reduces after 1st yr of life Prevalence of 60% at 30yrs has been reported by Vanamo et al Surgical anti-reflux procedures are needed in 6–35% of the long-term survivors
Pathophysiology esophageal dysmotility from prenatal obstruction in the hernia the maldevelopment, malposition, or even absence of the crura as a consequence of the diaphragmatic defect or as a result of the surgical repair itself a shortened esophagus and a loss of the angle of His from an intrathoracic stomach increased intraabdominal pressure because of the return of herniated viscera into the abdomen an increased “siphon” effect from prolonged ventilatory support and frequent tracheobronchial suctioning
Predictor of post repair GER: size of the diaphragmatic defect requirement of patch closure for the repair Need for advanced respiratory support Side of the hernia and the position of the stomach, may not pose as high a risk Preventive measures: Meticulous attention to the diaphragmatic crura during the repair. A thorough Ladd procedure
Antireflux measures to start prophylactically or at clinical suspicion Contrast radiographs should be performed to eliminate distal obstruction Nuclear medicine studies to assess gastric emptying ARS on failure on medical therapy Low recurrence rates
Jaillard et al proposedprimary ARS at the time of large diaphragmatic defect repair Yigit 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
Late complications of CDH-related GER may include Esophagitis 54% Barrett's esophagus 12% adenocarcinoma
Incidence - 50% - 70% Etiology – increased intraabdominal pressure after the closure of the abdominal defect motility disturbance of the upper gastrointestinal tract Associated anomalies esophageal atresia duodenal atresia Diaphramatic hernia mental retardation or neurological impairment
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 children benign course with a tendency to spontaneous improvement.
Routine workup for ALL patients of omphalocele in 1st yr; treatment accordingly Work up in Gastroschisis and older patients of Omphalocele only when symptoms arise Severe GERD in neonates with large omphaloceles requiring staged closures BeaudoinS. et al recommended surgical antireflux procedure for these babies in whom moreover the anatomic approach is favorable