Anti-Reflux Surgery

The information provided on Crying Over Spilt Milk is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician.

– Introduction

Reproduced with the permission of P.A.G.E.R. – Pediatric Adolescent Gastroesophageal Reflux Association Inc. PO Box 486, Buckeystown, MD 21717, USA. Website:
Membership dues are $25.00 US dollars per year + an additional $15.00 for personal cheques (bank cheques avoid this additional charge). Membership includes subscription to the Reflux Digest.

Welcome to the first in a series of conundrum issues. The dictionary defines a conundrum as a question that has as its answer another question. A pretty appropriate word for a medical condition in which there are no cures, only a number of imperfect treatments and few occasions where the choice is obvious. As we said in the last newsletter, GER is a mystery disease in the what-do-we-do-about-it sense. A conundrum condition.
As we prepared to do this issue, the stack of articles on surgery that Joel gathered was impressive. No doubt, somewhere within it there are some good answers. But the more we examined our original plan to bring you a fabulous, up-to-the-minute description of all the anti-reflux surgeries, the more we realized what an impossible task this was. Our understanding of GER has changed dramatically in the past four years and the pace seems to be picking up. A thorough update on surgery would be outdated before you received it. (Not that we have the staff to write one – this took 2 1/2 months!) This issue of the Reflux Digest does give you some basic information on anti-reflux surgery but we have tried to concentrate more on how a parent makes a decision about surgery. A tough assignment but Caroline did a great job!

When Beth first asked me to write for the surgery issue, my initial response was very positive. I welcomed the chance to inform you, our members, about the very viable option of fundoplication; the life-saving potential, as well as the important negative complications that can occur post-operatively. As I read through the journal articles and drew on my family’s two experiences with fundoplication, my response changed somewhat. I faced the great challenge to educate and inform you about the surgery, yet not alarm or persuade you one way or another regarding fundoplication. You, your family, and team of physicians need to make the choice that is right for your child. One must remember that there is no perfect surgery for reflux just as there is no perfect medication, and while it may be the only choice many of us have, we need to understand that this is not a cure.
“One must appreciate the scope and magnitude of this condition. ” What a great sentence about such a complicated and frustrating disorder/disease. One I hope every family and physician remembers!

Fundoplication is the most common type of anti-reflux surgery and appears to be the only one currently done on children. The goal of anti-reflux surgery is to keeping food and acid from backwashing by using the muscles of the upper portion of the stomach (fundus) to help the sphincter between the stomach and esophagus (lower esophageal sphincter or LES) work better. The fundus is wrapped around the bottom few centimeters of the esophagus so that the contraction of the stomach muscles squeezes the LES just enough to keep it closed most of the time but still allow swallowing and belching.
The most important thing to remember is that surgery is a mechanical way to suppress symptoms of a disorder that is seldom mechanical in nature. Pharmacotherapy is also primarily an attempt to suppress symptoms. Neither is a “cure.” Both have side effects / complications but so does uncontrolled reflux.


The Nissen version of the fundoplication (shown above) has been performed since the 1960’s and more is known about its effectiveness than about newer techniques. The Nissen wrap involves bringing the fundus full circle around the esophagus (360 ) from the back (posterior) and stitching in the front. Other techniques are variations involving: wrapping less than 360 ; how much the stomach is pulled up and how much of the esophagus it covers; whether the stomach is fully or partially loosened from surrounding tissue (mobilized); precisely how damage to nerves is prevented; whether a tube is inserted into the esophagus to prevent over tightening of the wrap; whether the surgeon proceeds clockwise or counter clockwise; ad nauseam.
“Laparoscopic fundoplication” does not refer to the type of fundoplication but the type of incision made to access the stomach. In this technique a number of very small incisions are made in the abdomen and a fiber optic camera is used along with other special instruments. The smaller incisions drastically decrease hospitalization time because the incisions heal quicker. The actual surgery takes longer and is obviously a bit trickier to learn but many surgeons and patients prefer it. It is not clear whether total recovery time is shorter.

Anti-reflux surgery is the third most common surgical procedure performed on kids. Inguinal hernia repair, and central venous catheter placement are more common. GER, however, not the only reason a fundoplication is performed. It is done in conjunction with repairs of birth defects of the esophagus, after placement of a g-tube and it is more common in patients who also have other serious medical problems.

Improvements in any treatment can lead to a pendulum swing in favor of that treatment just as studies highlighting problems can provoke a swing away from a given treatment. Recent studies about the efficacy of medications may be provoking a trend toward surgery. A few surgeons are also questioning whether the results of surgery would be better if the patients choosing surgery were not already in such bad shape – certain technical variations can’t be performed if the damage is too great. A valid question.
There are other anti-reflux procedures that are not often performed on kids. The Angelchik prosthesis is a silicone collar that is placed around the LES. Problems with them migrating and puncturing organs seems to be overshadowing any positive traits.

The decision to consider surgery is usually made if one or more of the following conditions is present:
Esophagitis – mild to severe damage to esophagus.
Apnea / Apparent-Life-Threatening-Event – cessation of breathing, possibly as a reaction to refluxate threatening the airway. An overly aggressive protection instinct can result in a spasm of the airway (laryngospasm / obstructive apnea).
Failure to thrive – failure to gain or maintain weight can eventually lead to developmental problems or compromise overall health.
Pneumonia / Asthma – aspiration of acid or acid vapors. May be a crisis situation if medication is not quickly effective.
Airway Damage – from acid exposure. Lung problems are not always audible with a stethoscope. Nasal polyps and vocal cord nodules are not always recognized as possible symptoms of GER.
Strictures – scaring of the esophagus. Often narrows the opening and interferes with swallowing. Often recurs even when GER is controlled by meds or surgery.
Barrett’s Esophagus – precancerous changes in the esophageal tissue. May not be as rare in children as previously assumed. It is not clear whether a fundoplication will reverse or stop the changes.
Quality of Life Issues – pain that interferes with daily activities.
G-tube – surgically placed port for introducing food through the abdominal wall. Children who have one often develop reflux. This may be because the stomach is unable to move. New tube styles may help.

The criteria for determining whether a child is a candidate for surgery are not set in stone. There are a number of questions that parents should discuss with their primary care doctor and all specialists.
? Is the GER causing damage that may not be reversible?
? Is the GER causing life threatening symptoms?
? Is this a crisis or is there time to explore options?
? Are symptoms not adequately controlled by medications?
? Do symptoms recur when medication is withdrawn?
? Have all medications and combinations been thoroughly explored?
? What is known at the present time about the long-term affects of medications?
? How does this compare with current concerns about uncontrolled, chronic reflux?
? Does full compliance with positioning and feeding techniques make a difference?
? Have helpful techniques been applied consistently?
? Is the child young enough that the GER can still be expected to resolve?
? In the parents’ opinion, is the pain experienced by the child impacting on his quality of life?
? Is tube feeding a medical option and practical option?
? Has testing shown GER or the symptoms of GER?
? Have there been contradictory tests?
? Have any tests been suggestive of another medical problem?
? Have other conditions that cause GER symptoms been fully ruled out? (We will be addressing this in a later issue of Reflux Digest.)

Children with other serious medical disorders often have GER. Unfortunately, they are less likely to respond to medications and experience a much higher rate of serious complications with medicines, anesthesia, and surgery. Many of these kids are hospitalized on multiple occasions and compromised nutrition can be a complicating factor.
Children with digestive system abnormalities, cystic fibrosis, pulmonary disease, genetic disorders, neurologic disorders, seizures, muscular disorders, cyclic vomiting, allergies, conditions requiring supine or head down positioning, and kids with unusual posture (scoliosis, body casts etc) are all at risk for reflux and often difficult to treat.
? If the child has other medical issues, have you fully investigated the impact on all of the available options?

Children with delayed emptying or motility disorders are not good candidates for fundoplications. Fundoplication alone is not done on children with swallowing disorders because the food will not move into the stomach.

Sometimes several tests are needed to make this critical decision.
Barium swallow or upper g.i. – contrast x-ray done to rule out anatomical problems like large scars or a rotated stomach. If done on videotape with an experienced radiologist or speech therapist, it can diagnose ineffective swallowing which is a contraindication for anti-reflux surgery. A longer duration test can show delayed emptying.
Endoscopy / Esophagoscopy / with biopsy – fiber optic camera allows visualization of the esophagus. Some damage is visible with an endoscope but biopsies (tissue samples) can reveal microscopic damage. Incapacitating pain without severe damage may still warrant surgery.
pH monitoring – esophageal acid measurement continues to be the “gold standard” for diagnosing reflux. The major drawback is that a “positive” test reflects the number of events but even an isolated reflux event can cause life-threatening problems. Events immediately after meals or acid mixed with bile (alkaline) does not register but can cause significant damage. Conversely, high acid levels don’t always cause damage. Portable machines are preferable because no hospitalization is required and they show more about reflux in real life conditions.
Scintigraphy / Milk Scan / Gastric Emptying study – uses a radio isotope to track how long food remains in the stomach and whether it enters the airway. Suspected or confirmed motility disorders are reasons to decide against surgery. A very traumatic test. Diagnosis of delayed emptying means other options or simultaneous stretching of the pylorus at the bottom of the stomach (pyloroplasty) need to be discussed.
Manometry – measures the pressure of the sphincter areas and the effectiveness and coordination of peristaltic action that moves food the correct direction. Still mostly a research tool.
Allergy testing – neither traditional or nor non-traditional testing are recommended very often by the experts but it is strongly suggested by many of our parents. [See the letter by Cathy Evans below.]

This is a difficult question for anybody to answer. It is measured differently by different researchers. Whether or not refluxing is totally stopped can’t be known for sure because only those patients with significant symptoms after surgery are retested. Many patients do not answer follow-up questionnaires. Whether or not the original symptoms subside seems to depend somewhat on how severe they were, which symptoms they were, and whether there were coexisting medical problems. Many studies compare the outcomes of specific surgical techniques but this also influenced by the surgeon’s skill and experience with the particular technique. An individual surgeon’s success rate also depends on the ratio of low risk and high risk patients he or she takes.
The percentages vary drastically depending upon the specific studies you read and how healthy the group was:
A ” successful result ” or complete cessation of symptoms gets percentages from the mid 50’s to upper 80’s with most studies reporting numbers in the higher part of this range.
A” good result ” or a substantial improvement in symptoms is reported at about 10-20% of the time.
A ” poor result” is variously defined as “minimal or no improvement in symptoms,” “worsening of symptoms,” “occurrence of new symptoms,” or “disruption of the wrap.” This gets from 0-15% overall but special populations have high much rates of poor results.
The re-do rate is 0-15% for disruption of the wrap.
Keep in mind that a child with multiple illnesses that contracts pneumonia twice in the follow period may negatively affect the statistics yet that child may have had more cases of pneumonia or died without surgery.
None of these address parents’ most burning questions because very few studies compare surgery to medical management. The effectiveness of medications is not as good as we would wish, and some new studies of long-term results are depressing. The likelihood of a good outcome for your child is something to discuss with your child’s doctors.

Every case varies, but aside from the usual surgical risks of anesthesia, infection and accidental damage to the tissues, some complications may include:
Small bowel obstruction – scar tissue adhesions form in the abdominal cavity as a result of many surgeries. For some reason adhesions are more common after any anti-reflux procedure and if they block the passage of food through the intestines it can require emergency surgery. The “typical” symptom of an obstruction, vomiting, may not happen after a fundoplication so patients and families need to know what else to watch for. Any signs of an obstruction need to be investigated immediately. Adhesions glue parts of the body together that are supposed to be separated and can be responsible for pain that is perceived in the left shoulder and other odd sensations.
Disruption of fundoplication – the stitches come undone and the stomach returns to previous position. Most reports in the literature involve falls and other accidents. Some parents report that a good case of the stomach flu or food poisoning will cause retching violent enough to pop the wrap.
Hiatus Hernia – the junction of the esophagus and stomach slides through the diaphragm into the chest cavity. Lately, more care is being taken to anchor everything securely and minimize the size of the opening in the diaphragm separating the abdominal cavity from the chest.
Stricture – scarring and narrowing of esophagus. Most often this is a recurrence of a scar present before surgery. Even stopping acid exposure totally doesn’t always prevent a recurrence.
Obstruction at fundoplication – esophageal motility is present but the food can’t pass into the stomach
Delayed gastric emptying – the stomach may be slower than before at sending food to the intestines or a delay that was not a big issue before can be come a real problem. Pyloroplasty promotes faster emptying.
Dumping syndrome – rapid emptying of the stomach causes symptoms including severe nausea, abdominal cramping, retching, pale skin, and sweating. Diet changes may help. Routine pyloroplasty is not favored because dumping may occur.
Failure to eat solid meals – liquids and foods are introduced slowly after the surgery. Certain foods may not be tolerated. A naso-gastric tube may be placed to enable a slow drip of formula into the stomach or IV nutrition may be used. Both fear of choking and current pain may be problems .
Gas bloat – inability to belch means gas must travel the length of the intestines.
Retching – “dry heaves.” One parent described as “watching an invisible bully punch your kid in the stomach – repeatedly.”
Dysphagia – esophageal motility is diminished and swallowing is affected. Great care is taken when working near the nerves that control swallowing. Low motility and a new wrap means food gets stuck in the esophagus. This had been more commonly reported with laparoscopic procedures and techniques are being modified accordingly.
Tube feeding dependence – if children are fed by tube after surgery, it can be difficult to convince them to resume eating. (See letter from Mary Gillman below.)

Understanding GER and all of the medical options and home care techniques is critically important to deciding whether to do surgery. We strongly encourage parents to read articles about GER but articles on surgery may not be appropriate. Most articles about surgery are comparisons of techniques but the parents are not the ones to chose the technique.
One article from a surgery journal is fairly easy to read and puts surgery in the broader context of all treatments. Unlike some articles in surgery journals it is not pro-surgery but neither is it anti-surgery. Charles Bagwell, “Gastroesophageal Reflux in Children,” Surgery Annual, vol 27, 1995, pp 133-163.
If you have a really strong stomach, you can get all the gory details ( right down to which hand the surgeon should use to perform each step of a fundoplication) in “Laparoscopic Anti-Reflux Surgery,” by McKernan and Champion in The American Surgeon, vol 61, pp 530-36, 1995.

Written in 1999.

Page may be printed or reproduced for personal use of families, as long as PAGER membership information contained at the top of this page and Crying Over Spilt Milk’s URL are included. It may not be copied to other websites or publications without the permission of PAGER.

Click on this to view the page – Ask the Doctors

  • We hit 3000 Facebook Page likes yesterday, but I'm not sure if Susannah Taylor or Kelly Dunlea was the 3000th like. We would like to send you both a little something when our supplies arrive in a couple of weeks. Kellly, I already have your address. Susannah, can you please message me yours? If someone knows Susannah can you please let her know? Wahoo, what a milestone!

  • There is also some recent medical research out along the same lines. I'll post the review article in the comments. Skip to the last page and the take home messages to decide if you want to read it. <a href="; rel="nofollow"></a&gt;

    Bath time is a lovely, splashy affair for little ones and a comforting signal to parents that bedtime is not too far away, and now research shows just how

  • And another one from Postnatal Depression Awareness Week. Sorry, that I'm a few weeks behind on my emails, but at least the information is still relevant: <a href="; rel="nofollow"></a&gt;">

  • <a href="; rel="nofollow"></a&gt;. - htm - sorry, I think I may have missed the week.

    The most risky time to become mentally unwell is after having a baby. Thirteen per cent of women in New Zealand suffer from Postnatal Depression with 20% suffering from anxiety during and after pregnancy*. Postnatal Depression Awareness Week is ...

  • Sorry for the long post but in desperate need of advice from people with experience. My baby girl is 10wks old today and from 1.5weeks old been medicated for reflux, first just Gaviscon, then added Rhanitadine. Doc upped the dose until we were on the max dose and it still didnt make a difference so doc switched to Omeprazole liquid, upping the dose every couple of weeks and still doing Gaviscon. Baby is still super uncomfortable, spilling (more like vomiting out of nose and mouth and it keeps going like she is vomiting not a 'normal' spill, freaks her out big time) after almost every feed (before we started meds it was after every feed, so have seen some improvement) and i can smell the acidity. She has diarrhea quite often and have had blood in her stools 3-4 times. Doc said today that shes out of ideas :-( She did prescribed us Pepti Junior to try and dropped Omeprazole to once a day. My baby is so tired, she wants to sleep but keeps wriggling and grizzling, just cant get comfortable so would really appreciate advice. We do all the usual stuff like having her elevated etc. *Reposting as had to delete other post to edit :-)

  • Gastric Reflux Support Network NZ shared Motivational and Inspirational Quotes's photo.

  • Gastric Reflux Support Network NZ shared Inspiring and Positive Quotes's photo.

    Thank you to all those strong parents out there who help out in this page!

    Inspiring and Positive Quotes <3

  • My baby is 7 weeks . she has low weight gain and doesn't feed well and has &quot;silent&quot; reflux. She is very gassy as She is currently on karicare gold + and lady from peads has suggested I try normal karicare infant and see how she goes till she sees us. But I've done some research and reviews are saying aptamil gold HA . any advice suggestions? I'm going to use gaviscon in the mean time .

  • can i post a question, why does nobody seem to answer reflux questions. Why can't the doctors help the mothers? my baby is 5 months old, we have run every possible test, gone through a lot. He does not sleep at night, wakes up 5 times. on the best most expensive milk. He is eating. Still wakes up. I don't understand, i cant go on like this, i look like a Zombie. make mistakes because i am so tired. gone to a Chiro, tested kidneys, the list is just never ending, seen several Peads. no luck. Surely in this day and age somebody out there knows what to do with reflux babies, seems every second mom i meet, has a reflux baby with no answers. And dont tell me it will get better, when, i need sleep.

  • Hey ladies. How do i know if my baby has reflux??? What are the signs?? My little girl (4weeks) spills quite often but not too often..? She just doesn't sleep in the day? Literally all day... Unless being held and up right.. Doesn't sleep well at night either unless up right on my chest? Hellllp. Shes breastfed.

  • For anyone who was confused by the information given on the news last night, this came through in my emails today: <a href="; rel="nofollow"></a&gt; so direct from the Ministry of Health rather than the media's interpretation.

  • There is a new question about sleep by Stephanie to the page. Does anyone want to share their experiences and help her out? Have a look at her question.

  • Hi :) can anyone please tell me their experiences with sleep training a reflux baby/teaching bub to self soothe?

  • The Gastric Reflux Support Network NZ's newsletter was out yesterday. There is some information in it about the BreastFedNZ app and also about how to join your Support Networks. If you are not a member and would like to receive the newsletter or have access to a Local Support Network or a Network for support on Feeding issues, Laryngomalacia or EGID / EoE, please complete a membership form: <a href="; rel="nofollow"></a&gt;

    Gastric Reflux Support Network NZ for Parents of Infants & Children Charitable Trust Membership & Confidentiality Agreement Form First Name: Last Name: Email Address: Street Address: City/Town: Area: Auckland Canterbury Gisborne Hawkes Bay Marlborough Nelson Northland Otago Southland Taranaki...

  • Gastric Reflux Support Network NZ shared Judy Arnold - Infant and child Consultant's photo.

    Judy is having a question and answer session today?? Head over to her page.

    It must be time for another question and answer time. Tomorrow afternoon 1 pm-2.30 pm. This is your opportunity to ask me questions. Spread the word,,,

  • Vikky Wintersgill-Taylor I used this page hundreds of times for help ya might get some tips x

  • Questions, questions...more people have posted questions on our page. Help me out and share your experiences. :-)

  • Does anyone with a baby with silent reflux use infacol as well as rhuger? I used rhuger for my first child but doesn't seem to be helping as much woth number 2 I just like that was its natural, rhuger has helped a bit but he's spilling up more now for some reason (10weeks old) advise appreciated ☺

  • Hi guys how do you feed your reflux babies? Do you find it best to let the baby drink the milk in 2-3 goes or do you find it best to have larger 20 minutes breaks?

  • Gastric Reflux Support Network NZ looking for answers.

    Hi everyone - there are more questions to the page that you might be able to share your experience around.

  • Hi. Have a question for any parents who have used zantac to control silent reflux. Baby is responding really well to it but almost 3 weeks in it seems to be causing a bit if constipation. Have just started using coloxyl drops for that but I suspect it is making the reflux worse , has anyone noticed this with these two medications ? And are there any alternatives that you have found work well for constipation ? Baby is 8 weeks old . Thanks in advance 😊

  • Hi all. My lil(literally) 9 weeks old bubba born 2.1kgs at 37 weeks *iugr baby* has been diagnosed with GORD and has cyanotic/apnea episodes from it. He is on omeprazole, gaviscon and pepti junior but all these doesnt seem to help much and he still has these cyanotic episodes randomly (awake or asleep). He was admitted to the kids ward at waitakere hospital when he was 2 weeks old. Hubs and i resorted in taking turns in staying up taking care of him at night as he needs constant supervision. These episodes happen very silently and randomly so we dont know when it will happen or when it happens.. We also have 2 older toddlers.. anyway anyone else went through/going through the same thing? Should we bring bubs back to his gp? how do you get seen by a specialist?

  • ... And more posts to the page. :-)

  • Hi there, does anyone have experience/success with getting their baby allergy tested? I went to a herbalist on recommendation of a friend. He tested me for intolerances and as a result I am now on a strict dairy/gluten/yeast/egg/soy and corn free diet ($430 poorer and starving...the herbs have done nothing). I've been dairy and gluten free since miss 3 months was diagnosed with GERD at 3 weeks but I'm sure there is more to it as her poos are full of mucous and she is still in pain dispite being medicated. Any suggestions? :)

  • What is someone called who specialises in GERD? What kind of specialist are they? I think it's time for us to delve further into this issue that my 3.5 year old is dealing with. Recommendations appreciated. We are CHCH based. :) Will obviously go through my GP but nice to know if there is anyone in particular who is great? Thanks in advance!