Results of the operative treatment of gastroesophageal reflux in childhood with particular focus on patients with esophageal atresia

Abstract

Aim: Although the literature on fundoplications in childhood is relatively extensive, only few reports exist which correlate the rate of complications with the primary disease. Other important questions such as the incidence of postoperative dumping syndrome or Barrett's esophagus in childhood are barely treated. Nor have operative techniques such as single or double-row cuff sutures or the benefit of performing pylorotomy or pyloroplasty in addition to fundoplication been investigated with respect to their recurrence rates. In particular studies on laparoscopic fundoplications tend to be generally confined to a discussion of the feasibility of the endoscopic procedure, the duration of the intervention, the length of the hospital stay and the costs. The study presented here aims to analyze such still unanswered questions listed above for open fundoplication procedures, including an analysis of the authors' own patient population, and to discuss the questions together with the most important reports in the literature. The aim is to create a basis for later studies which will compare conventional and laparoscopic fundoplications.

Methods: In the period between 1993 and 2005, 160 children underwent a fundoplication procedure. From 2003 onwards, fundoplications were carried out laparoscopically. The data of 148 patients were analyzed, some of them on the basis of clinical follow-up and some on the basis of an extensive questionnaire and among others with the help of the parents' support group KEKS.

Results: The underlying disease in 87 patients was reflux disease stemming from esophageal atresia, previous diaphragmatic operation in 8 children and mental retardation with swallowing difficulties in 30 patients. Only 23 patients suffered from isolated gastroesophageal reflux disease without an underlying primary disease. Intraoperative complications occurred in 4.6 % of patients with esophageal atresia (EA), while the rate for the remaining collective of patients was 1.6 %. Postoperative complications were observed in 10.3 % of the children with esophageal atresia and in 8.2 % of the other cases. The recurrence rate was 16.1 % in the children with EA and 6.5 % in the other cases. Dysphagia and/or stenosis occurred in 17.2 % and 6.5 % of children, respectively, and dumping syndrome was observed in 18.3 % of the EA group and only in 1.6 % of the comparison group. An evaluation of 79 esophageal biopsies showed no difference between patients with EA and the comparison group concerning the degree of histological changes. When evaluating the suturing technique, it was found that a double-row fundus suture was more effective in preventing reflux recurrence than a single-row suture but also resulted in an increased rate of dysphagia. When considering the not infrequent occurrence of dumping syndrome, it was found that drainage operations such as pyloroplasty or pyloromyotomy are only indicated for reduced gastric motility. The data of the children without EA, who initially served as a comparison group, was analyzed further. Four summaries of the current literature in table form complete this discussion.

Conclusion: Particularly in children with EA, Nissen fundoplication cannot be considered a procedure with few complications. The problems resulting from disturbed gastric and esophageal motility should not be underestimated nor should the postoperative occurrence of dumping syndrome. Postoperative long-term follow-up until the patients reach adulthood is absolutely necessary to ensure that development of a Barrett's esophagus is not overlooked.