Ask the Doctors

Reproduced with the permission of P.A.G.E.R. – Pediatric Adolescent Gastroesophageal Reflux Association Inc. PO Box 486, Buckeystown, MD 21717, USA. Website: http://www.reflux.org/
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.

Kathryn Anderson M.D., Chief of Pediatric Surgery, Children’s Hospital Los Angeles, CA (CHLA)

Q – As a pediatric surgeon, what indications or criteria must a child meet before discussing a fundoplication surgery for GERD?
Before considering gastric fundoplication, a child must have clinical evidence of GER which may include one or more of the following: vomiting, malnutrition, failure to thrive, developmental delay, esophagitis, esophageal stricture, pulmonary complications such as aspiration pneumonia, asthma, restrictive airway disease, chronic cough and apnea.
Reflux is associated with a variety of neurological diseases. Children who have cerebral palsy, Downs syndrome/chromosomal anomalies, hydrocephalus or severe head injury should be suspect for GER although they may not exhibit the common clinical signs or symptoms. These children may ruminate or have a history of vomiting with bizarre neck and torso spasm referred to as Sandifer’s syndrome.
When GER is suspect, one or more of the following studies may be ordered to confirm diagnosis: Esophagram with gastrointestinal follow-through (“Upper-GI”). This is most common of radiologic studies to evaluate for reflux. It will also identify other anatomic problems which may cause vomiting. The study has its limitations as it only identifies GER occurring at the time of the study.
Gastroesophageal scintiscan. This is a highly sensitive radiologic study which will identify GER as well as measure gastric emptying time.
24-Hour pH monitoring. This study may be ordered in difficult diagnostic situations. A pH probe is placed in the distal esophagus via the nose where it remains for 24 hours measuring the number and severity of acid/alkali reflux.
Esophagoscopy. If a child is still suspect for GER despite negative results, an esophagoscopy with biopsy can identify the presence of esophagitis secondary to reflux as well as complications such as esophageal stricture.
It is important that the above tests be done by a qualified individual with pediatric experience for accurate evaluation.
Treatment is dependent on the age of the child and the severity of symptoms. Infants often have reflux which resolves by 6-8 months of age. Unless GER is severe, medical therapy should be attempted prior to surgical corrections. This may include smaller feeds given more frequently, thickened feeds and keeping infants in a prone upright position to minimize reflux and promote gastric emptying. Infants and children may be started on medications which increase the pressure of the distal esophageal sphincter and promote emptying of the stomach if dietary measures fail.
If, despite medical management, the child still has evidence of reflux, then surgical correction of the problem is appropriate.
Q – Could you briefly describe what fundoplication surgery is, the average hospital stay, and the average recovery time?
Fundoplication, simply described, is a surgery which mobilizes the gastroesophageal junction below the diaphragm to increase the length of the intra-abdominal esophagus. The upper portion of the stomach (fundus) is wrapped around the esophagus to create a valve-like mechanism which prevents the reflux of stomach contents back into the esophagus. The stomach may be wrapped completely or partially around the esophagus in varying degrees. The different degrees and orientation of the wraps are referred to by separate names.
The average hospital stay following a fundoplication is 4-5 days, and is dependent on the child’s ability to return to full feeds either by mouth or gastronomy tube if one has been placed. The child should be essentially recovered in approximately 2 weeks.
Q – What are the most common complications post-operatively?
Complications which may occur vary in severity. They may include:
– Inability to begin or advance feeds orally or by gastronomy tube due to a delay in intestinal function following surgery. This may present as abdominal distension.
– Inability to begin oral feeds due to post- operative swelling at the surgical site. Food will pool in the esophagus and not pass into the stomach causing the child to gag and vomit. This situation usually resolves within a few weeks.
– Inability to tolerate full feeds as the gastric capacity is temporarily reduced after surgery.
– Retching.
– Slip of the wrap above the diaphragm.
– Disruption of the wrap.
Q – What are the names of the various types of fundoplications you and your surgical staff perform at CHLA?
Nissen and Toupet fundoplication.
Q -Do you prefer of perform a specific type of fundoplication? Why?
The gold standard for any type of fundoplication is the Nissen wrap. This is because there has been the greatest experience in this procedure. It is a relatively simple procedure, its complications are known, and there has been a long medical follow up. Any other type of procedure must be measured against the Nissen wrap. I perform a modification of the Nissen called Toupet fundoplication when I can but I do not have a long term experience with this and again, the gold standard is Nissen.
Q – Who should decide which type of fundoplication if performed?
The surgeon is the one to decide which type of fundoplication is performed which is based on his/her expertise, experience and preference.
Q – Many parents ask, “Will this be the only surgery my child will need, and will the problem be fixed after surgery?” Could you please comment on this?
As with all surgical procedures, there are no guarantees of outcome. The child may be completely relieved of signs and symptoms, which is our goal, or have any of the complications listed above at any given time. The children may do very well for an extended period of time and then present with a “slip” or disruption of the wrap. The potential complications of surgery must be weighed against complications which will occur if a fundoplication is not done.
Q – Laparoscopic Fundoplications seem to be a hot topic, what are your comments?
Laparoscopic fundoplication is increasingly being performed in both children and adults. Again it is a new procedure and the long term results are completely unknown. It must be measured against the known standard of the open Nissen fundoplication.
Q – In your opinion, what should a parent/family look for or require of their pediatric surgeon?
Pediatric surgeons should be experienced in surgery for the gastroesophageal reflux and should have an interest in this condition. Since this is such a common operation, most periodic surgeons have considerable experience with it during their training and beyond. Pediatric Surgery is a defined specialty which requires two years of training beyond completed training in general surgery. There is a certificate of special competence in Pediatric Surgery which is an examination by the American Board of Surgery and eligibility for this follows completion of the American Board of Surgery Certificate in General Surgery. These are the formal requirements for a pediatric surgeon and you should make sure that you surgeon has these qualifications.
Q – Do you feel it is important for the parents to ask their surgeon for his/her success and failure percentages in whatever type of fundoplication surgery they consistently perform?
This is a difficult question to answer because there are a lot of rare procedures in Pediatric Surgery (GER surgery is not one of them). In these cases the training and the qualification to take care of children and the technical ability of the surgeon is far more important than the actual number of a particular type of procedure that has been performed. You can only measure success and failure percentages when the surgeon has done hundreds and hundreds of these cases. Most good surgeons have essentially the same success and failure rate so an individual question about surgeons success and failure rate is not really very relevant.
Q – How do parents go about getting an reliable referral for a pediatric surgeon?
Pediatricians usually know who the good pediatric surgeons are and in general , you should follow the advice of you pediatrician. However you need a certain comfort level with the person who is going to operate on your child and for any reason at all you are not comfortable with that individual, then you should seek another consultation. You are required to put a great deal of trust into someone who is operating on you child and it is difficult to do so if you do not trust them instinctively, if you don’t like them, or if they do not spend the time explaining the procedure to you in language which you understand or if they do not answer you questions. This is over and above the answer to the qualifications above.

Dr. Benny Kerzner, Chief of Gastroenterology and Nutrition, Children’s Hospital National Medical Center, Washington, DC (CHNMC)

Q – As a pediatric gastroenterologist, what indications or criteria must a child meet before you would suggest a fundoplication for a child with GERD?
The indication for surgical management of gastroesophageal reflux disease (GERD) is a failure of medical treatment. The treatment failure might be obvious but frequently it is a judgement call. One balances many factors:
– the likelihood of spontaneous resolution of the symptoms (as occurs in children under two);
– the potential for long term surgical failure (as is more common in neurologically damaged children);
– the extent to which reflux is compromising health (protection of lungs is a paramount consideration); and
– to what extent lifestyle will be disturbed by needing to avoid surgery (e.g. the need for continuous formula feeding).
Q – What can parents do to assure that surgery is appropriate?
The parents’ role in this decision is critical – not only in assuring that the child receives all of his or her medical therapy but also in helping the medical team gain the true perspective of the gravity of their child’s symptoms.
Q – In your opinion, are there any tests or procedures that should be required before proceeding with a fundoplication surgery?
Before a fundoplication, a barium contrast study to evaluate anatomy is needed. Additional tests ordered depend on the circumstances of the patient and are not mandatory. To appraise the anatomy and pathological changes in the esophagus, the best test is an endoscopic examination. To evaluate gastric emptying, a scintiscan (milk scan) is done. When reflux is not the obvious explanation for symptoms or we wish to evaluate the success of medical treatment, pH metering of the esophagus is used. In principle, however, we aim to do the least amount possible to confidently arrive at a conclusion regarding the need for the anti-reflux procedure. This may be a Nissen fundoplication with or without further surgery to drain the stomach or place a gastrostomy tube.
Q – Do you feel that it would be valuable for the family to get a second GI or Surgical opinion before proceeding with the fundoplication surgery?
Electing to do surgery is always a challenging decision, but the need for a second opinion is by no means universal. I suggest a second opinion when the choices are difficult and when the parents and/or doctors are not confident in the decision reached. On many occasions, failed medical treatment is obvious to all and a second opinion does not seem necessary.
Q – Could you suggest a few basic questions that would be important for parents to ask their gastroenterologist regarding fundoplication surgery?
Parents must ask questions which help them clearly understand that medical options are exhausted. For example, has the optimum dose of the medications been used? Are there alternatives? They should know the success and complication rate of the surgery. They should not only inquire about the depth of experience of the surgical team, including the anesthesiologist, but also about the nursing support available for device (tube) management when applicable.
Q – Laparoscopic fundoplication seems to be a hot topic. What are your comments?
I favor laparoscopic fundoplication, and I believe it is here to stay because the short term post-operative course is so markedly improved. However, laparoscopic techniques differ and portions of the traditional Nissen fundoplication may or may not be done, i.e. mobilizing the stomach and fixing the diaphragm. Patients need to understand these differences and discuss them with their surgeons.
Q – How do parents go about getting a reliable referral to a pediatric gastroenterologist?
The management of GER is fundamental to pediatric GI, and all board certified pediatric GI doctors will have received extensive training in this area. Parents should work with a pediatric GI specialist who relates well to their primary care physician and with whom they can have a frank, two-way conversation. I believe parents should primarily be guided by their primary medical doctors.
Q – What post-operative complications from a fundoplication do you see most commonly in your practice?
The most common post-op complication is gagging, but food rejection and swallowing difficulties are also seen. If these symptoms persist or if they begin weeks or months after surgery, particularly if accompanied by vomiting, disruption of the surgery has probably taken place. Occasionally, diarrhea due to very rapid emptying of the stomach, known as “dumping syndrome,” is seen.

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