Surgical management of GER in children

1. Gastro Esophageal Reflux in Children
SANJAY KHOPE, MS, M Ch, FACS
CONSULTANT PEDIATRIC
SURGEON

2. Pathophysiology
Secretion of saliva
Esophageal peristalsis
Esophageal clearance
Lower esophageal sphincter
Intra-abdominal esophagus
Angle of His
Pinchcock action
Gastric volume and emptying

3. Pathophysiology
GER causing GER
Respiratory factors
Medications and Hormones
Underlying Gastric acid
Pepsin, Trypsin and Bile salts
Intra-abdominal pressure
GER congenital problems

4. Diagnosis
◦ History and physical examination
◦ Upper gastrointestinal contrast studies
◦ Esophageal pH monitoring
◦ Endoscopy
◦ Nuclear scintigraphy
◦ Esophageal manometry
SPK 4

5. SPK 5

6. Esophageal pH monitoring
SPK 6

7. Nuclear Scintigraphy
SPK 7

8. Esophageal Manometry
SPK 8

9. Evaluation of children with
GER
Recurrent Vomiting
Heartburn or chest pain
Esophagitis
Dysphagia or odynophagia
Asthma
Recurrent pneumonia
SPK 9

10. Management Protocols
Conservative Therapy
Medical Therapy
Histamine H2 Receptor Antagonists
Proton Pump Inhibitors
Antacids and Surface agents
Prokinetic Agents
Erythromycin
Endoscopy
SPK 10

11. Indication for surgical treatment
Failure of medical Therapy
◦ Persistent pulmonary symptoms
◦ Life-threatening events
◦ Vomiting with failure to thrive
◦ Unremitting heartburn
◦ Inability to wean from medical therapy
Presence of an associated anatomic defect
Esophageal stricture
Post-EA repair stricture
Neurologically impaired children with GER
SPK 11

12. Operative techniques
NISSEN Fundoplication
THAL-ASHCRAFT Fundoplication
TOUPET Fundoplication
Boix-Ochoa Technique
Laparoscopic Fundoplication

13. Associated Procedures & Complications
Pyloroplasty or Antroplasty
Gastrostomy
Complications
Bleeding from short gastric, spleen, aberrant left gastric
Lap: Perforation of esophagus, stomach 1% of cases
Pneumothorax
Conversion to open surgery
Dysphagia/also due to dysmotility
RECURRENT REFLUX-postoperative retching and gagging
Gas bloat and inability to vomit
Dumping Syndrome