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Gastroesophageal Reflux With Relevance To Pediatric Surgery
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Gastroesophageal Reflux With Relevance To Pediatric Surgery

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Relavant perspectives of GERD in relation to Pediatric Surgery

Relavant perspectives of GERD in relation to Pediatric Surgery

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Gastroesophageal Reflux With Relevance To Pediatric Surgery Gastroesophageal Reflux With Relevance To Pediatric Surgery Presentation Transcript

  • 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
  • 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 in CDH
  • 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
  • GERD In Congenital Abdominal Wall Defects
  • 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
  • THANK YOU