Gastroesophageal Reflux With Relevance To Pediatric Surgery


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Relavant perspectives of GERD in relation to Pediatric Surgery

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Gastroesophageal Reflux With Relevance To Pediatric Surgery

  1. 1. GE Reflux with relevance to Pediatric Surgery<br />Dr PoonamGuhaMCh Student <br />PGIMER Chandigarh<br />25/01/10<br />
  2. 2. Gastroesophageal reflux (GER) - retrograde flow of gastric contents into the oesophagus<br />50% of infants less than 2 months of age have vomiting and regurgitation<br />rising to 70% by 4 months of age<br />Declines after 6 months of age<br />1–5% of infants over 12 months displaying them<br />
  3. 3. Gastroesophageal reflux disease (GERD) – spectrum of reflux exceeds the physiological norm, resulting in symptoms and complications<br />Symptoms:<br />pain, heartburn, failure to thrive, or chronic cough,<br />Complications:<br />Esophageal mucosal changes such as inflammation, bleeding, stricture, ulceration, and metaplasia.<br />
  4. 4.
  5. 5. GERD in TEF<br />
  6. 6. GERD in TEF<br />Incidence:<br />Stephen G 1980 – 65%<br />Ottolenghi 2004– 43%<br />Banjar and Al Nassar 2005– 95%; 59% required fundoplication<br />Trompelt J 2004 – 52.5%<br />Grosfeld – 30-70%<br />
  7. 7. GER is also seen in isolated TEF without OA (cause not known)<br />In cases of isolated esophageal atresia, the incidence of GER after primary repair is 100%.<br />
  8. 8. Pathophysiology<br />GERD<br />Increase in all the complications of GERD<br />
  9. 9. GERD in TEF<br />exacerbates anastomotic stricturing<br />dilatation of strictures less likely to be successful<br />exacerbates the effects of coexisting tracheomalacia<br />Predisposes to metaplasia, Barrett’s and malignancy<br />
  10. 10. Role of anastomotic tension <br />Stephen G jolly 1980 – excessive tension at the esophageal anastomosis was associated with a higher incidence of significant GER and slow gastric emptying.<br />Weihongguo 1997 – (animal experiment) esophageal anastomosis with mild tension causes severe GER <br />Morabito et al 2006 – use of inverted upper pouch flap reduced anastomotic tension and hence incidence of GER (13%)<br />
  11. 11. Anastomotic tension:<br />Shortening of intraabdominal length<br />Flattenning of GE Junct.<br />Elevation of gastric cardia through diaphragm<br />Bergmeijer et al – 42% patients had anastomosis under tension; 53% didn’t have anastomotic tension<br />
  12. 12. Role of gastrostomy<br />Gastrostomyalters the anatomy of the stomach, <br />changing the acuity of the angle of His by stretching the anterior wall of the stomach. <br />reduce LES pressure<br />Kielyand Spitz - prospective, randomized study - higher incidence of GER in patients with EA who were treated with gasrostomytubes compared with those with transanastomotic tubes.<br />30–50% of children with no significant reflux prior to gastrostomy will have symptomatic reflux and vomit feeds postgastrostomy<br />Continuous lower volume feeds can be helpful<br />
  13. 13. Abnormal gastric motility<br />Can be caused secondarily by <br />several months’ tube feeding, <br />a gastropexy or <br />mobilization of the lower esophageal pouch<br />Vagal injury<br />Intraoperative<br />Post op inflammatory damage due to leak/ sticture<br />
  14. 14. Abnormal gastric motility<br />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<br />Antralhypomotility is present in 45% of adults, and gastric emptying, as assessed by gastric scintigraphy, is delayed in 36%.<br />Accentuates GERD<br />
  15. 15. Investigation protocol<br />Most widely followed:<br />Investigations based on clinical suspicion:<br />Contrast/ pH monitoring/ endoscopy with biopsy<br />If symptoms dictate, vigorous and multiple attempts to demonstrate GER should be made.<br />
  16. 16. Delay in diagnosis may occur if anastomotic stricture prevents the passage of enough barium for demonstration of GER. <br />Barium study of the esophagogastricjunction should be repeated following dilatation. <br />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. <br />
  17. 17. Lack of correlation between symptomatology and histologic changes<br />Few authors recommend routine endoscopy in ALL patients<br />Endoscopic f/u in children with completely normal biopsies discontinued at age of 3yrs<br />Mild esophagitis – f/u extended to at least 6 yrs<br />
  18. 18. Treatment<br />Treatment of GERD aims to relieve symptoms, heal mucosal damage, and prevent and manage complications of GERD.<br />
  19. 19. Treatment protocol<br />Widely followed:<br />Clinical suspicion<br />Confirmation of Diagnosis<br />Nonpharmacologic and pharmacologic measures<br /> Failure<br />ARS<br />At PGI<br />Routine prophylactic use of positional therapy and pharmacologic measures<br />Investigations in the face of persistent symptoms <br />
  20. 20. Controversies in Medical management<br />Positioning of the infant – <br />Positional therapy is accomplished by placing the child in an “infant seat”<br />propped up to an inclination of 45” or more, 24 hr a day. <br />Immediate response should be apparent and in 1-12 wk the reflux will likely stop<br />Keith W. Ashcraft. Early Recognition and Aggressive Treatment of GastroesophagealReflux Following Repair of Esophageal A tresia. Journal of Pediatric Surgery, 1977<br />
  21. 21. Positioning of the infant – <br />sitting position at 60° increases reflux, probably because of increased intragastric pressure in this position, <br />the prone position with 30° head up decreases reflux. <br />left lateral position has been shown to reduce reflux in preterm and term neonates<br />Orenstein, S.R., Effects on behavior state of prone versus seated positioning for infants with gastroesophageal reflux. Pediatrics, 1990<br />
  22. 22. Bermeijer et al - Drug therapy had no positive effect on higher grade reflux. <br />~ 50% children receiving medication as their primary treatment developed an esophageal stenosis<br />Consider possible alkaline reflux if chronic cough persists despite antacid therapy<br />
  23. 23. SURGERY<br />Indication for surgical correction is failure of medical management as evidenced by the effect of persistent reflux, <br />reflux esophagitisor Barrett esophagus, <br />failure to thrive,<br />development of a distal esophageal stricture<br />Refractory anastomotic stricture, <br />aspiration proven to be secondary to gastroesophageal reflux<br />50% of patients of EA with GER require operative correction<br />
  24. 24. SURGERY<br />NF has typically been considered the best option.<br />Complications: <br />debilitating dysphagia(50% in one series) <br />wrap disruption, (1/3rd of patients) <br />recurrent GERD<br />Modified NF – very short floppy wrap (1-1.5 cm over a large dilator<br />6% - 47% failure rate noted in the literature<br />
  25. 25. In children whose manometry shows esophageal dysmotility, preoperative consideration may be given to a loose partial wrap<br />12-15%failure rate<br />Failure of either is more in children &lt;2yrs<br />Routine concomitant pyloroplasty is not recommended; may be considered if preoperative evaluation reveals delayed gastric emptying.<br />
  26. 26. Post op strictures and GERD<br />Crucial to determine whether the esophageal stricture is associated with GER <br />Strictures do not respond to dilatation attempts if severe GER continues to bathe the stricture with acid<br />Infants with an anastomotic narrowing should be started on proton pump inhibitors, and the stricture dilated<br />
  27. 27. Response to dilatation and medical control of GER is excellent<br />Intralesional injection of triamcinolone in refractory strictures <br />Recurrent stenosis should be managed by laparoscopic fundoplication<br />
  28. 28. Esophageal Replacemment<br />Gastric tubes:<br />Reflux is almost always present<br />Aggravated by the proximity of gastric mucosa to the esophagus. <br />Peptic ulceration in the remnant distal esophagus and proximal esophageal stump<br />Changes of gastric metaplasia have been recorded with anecdotal reports of malignancies in the Japanese literature<br />
  29. 29. Gastric tubes are rendered vagotomised during mobilization and depend on gravity for drainage. <br />Some advocates of the procedure perform a pyloromyoromy or pyloroplasty routinely though this is controversial.<br />
  30. 30. Colonic interposition<br />Gastric reflux results in peptic ulceration ; <br />may progress to hemorrhage, perforation resultant empyema; <br />occasionally thoracic aorta may be involved in fistulisation resulting in life threatening hematemesis. <br />reports of malignancy arising in colonic interposition<br />
  31. 31. Follow up<br />It is important to demonstrate that reflux has been adequately controlled before follow-up is discontinued.<br />
  32. 32. Divergent views<br />Reflux reduces with age<br />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<br />Heartburn is still present occasionally in 46% of adults, and is frequent in 11%<br /> 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.<br />
  33. 33. Factors contributing to esophageal malignancy after repair of esophageal atresia.<br />Combination of gastroesophageal reflux and esophageal dysmotility (poor esophageal clearance of reflux acid) leading to Barrett’s epithelium<br />Retained esophageal segment after oesophageal replacement<br />Squamouscell carcinoma in skin tube conduits<br />At least three case reports in the literature of adenocarcinomaof the esophagus in young adults with previous TEF/EA repair<br />
  34. 34. GERD in CDH<br />
  35. 35. GERD may occur in 80% of the patients<br />Incidence reduces after 1st yr of life<br />Prevalence of 60% at 30yrs has been reported by Vanamo et al<br />Surgical anti-reflux procedures are needed in 6–35% of the long-term survivors<br />
  36. 36. Pathophysiology<br />esophageal dysmotility from prenatal obstruction in the hernia<br />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<br />a shortened esophagus and a loss of the angle of His from an intrathoracic stomach<br />increased intraabdominal pressure because of the return of herniated viscera into the abdomen<br />an increased “siphon” effect from prolonged ventilatory support and frequent tracheobronchial suctioning <br />
  37. 37. Predictor of post repair GER:<br />size of the diaphragmatic defect<br />requirement of patch closure for the repair<br />Need for advanced respiratory support<br />Side of the hernia and the position of the stomach, may not pose as high a risk<br />Preventive measures:<br />Meticulous attention to the diaphragmatic crura during the repair. <br />A thorough Ladd procedure<br />
  38. 38. Antireflux measures to start prophylactically or at clinical suspicion<br />Contrast radiographs should be performed to eliminate distal obstruction<br />Nuclear medicine studies to assess gastric emptying<br />ARS on failure on medical therapy<br />Low recurrence rates<br />
  39. 39. Jaillard et al proposedprimary ARS at the time of large diaphragmatic defect repair<br />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<br />
  40. 40. Late complications of CDH-related GER may include <br />Esophagitis 54%<br />Barrett&apos;s esophagus 12%<br />adenocarcinoma<br />
  41. 41. GERD In Congenital Abdominal Wall Defects<br />
  42. 42. Incidence - 50% - 70%<br />Etiology – <br />increased intraabdominal pressure after the closure of the abdominal defect<br />motility disturbance of the upper gastrointestinal tract<br />Associated anomalies<br />esophageal atresia<br />duodenal atresia<br />Diaphramatic hernia <br />mental retardation or neurological impairment<br />
  43. 43. Gastroschisis – 16 – 50%<br />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.<br />Omphalocele – 40 – 50%<br />frequency of GER considerably exceeds that of normal children<br />benign course with a tendency to spontaneous improvement.<br />
  44. 44. Routine workup for ALL patients of omphalocele in 1st yr; treatment accordingly<br />Work up in Gastroschisis and older patients of Omphalocele only when symptoms arise <br />Severe GERD in neonates with large omphaloceles requiring staged closures<br />BeaudoinS. et al recommended surgical antireflux procedure for these babies in whom moreover the anatomic approach is favorable<br />
  45. 45. THANK YOU<br />