Reflux strictures of the oesophagus in children: personal experience with preoperative dilatation followed by anterior funduplication

Abstract

Introduction: Oesophageal surgery for reflux stricture is as challenging in adults as in the paediatric age group. Several management protocols, both medical and surgical, are currently proposed, such as bougienage, funduplication without dilatation, funduplication with pre- and postoperative dilatation, resection and interposition, and pharmacological therapy. However, reported results are not univocal. The aim of this work is to demonstrate that preoperative treatment with H2-antagonist combined with oesophageal dilatation and followed by anterior funduplication (Boix-Ochoa procedure with elongation of intraabdominal segment of the oesophagus) is a long-term, effective treatment for reflux stricture in children. It provides a tension free repair and an adequate protection to reflux, thus, preventing recurrences.

Materials and methods: In the last five years we observed oesophageal stenosis in 10 out of 49 children, operated for gastroesophageal reflux (mean age 62.9 months, range 12-156 months). All children underwent treatment with H2-antagonist (Ranitidine) and prokinetic agent (Cisapride), followed by oesophageal dilatations (mean 2.8, range 2-4 cycles) with Savary-Gillard dilators. An open anti-reflux procedure was performed (9 Boix-Ochoa and 1 Nissen) on children where a 9 mm endoscope passed easily through the oesophageal lumen. The pre and postoperative evaluation of all patients included symptoms assessment, esophagogram and endoscopy.

Results: Results were satisfactory in 9 patients. Only one patient where a Nissen wrap was performed, incomplete relaxation was documented radiologically. The patient required several dilatations for residual dysphagia before reaching a symptom free status. All other patients had an average follow-up of 38 months (range, 5 months to 5 years) with relief from dysphagia and no recurrence of stricture. Radiological controls showed good oesophageal lumens, with normally positioned neocardias, opening regularly during barium passage with no sign of reflux. Multiple biopsies from endoscopic controls confirmed complete relief from oesophageal stricture but persistence of Barrett's mucosa.

Conclusions: Our treatment of choice for reflux stricture is preoperative pharmacological therapy followed by series of dilatation with Savary-Gillard dilators till oesophagus is adequately dilated. Antireflux surgery is mandatory when a stricture is observed. We prefer a Boix-Ochoa funduplication with extensive transhiatal mobilization of thoracic oesophagus. This results in a "tension free" fundoplication even when brachioesophagus is present. The procedure appears to be physiological for pediatric patients and in our hands was free from recurrences.