Last Update: October 16, 1996
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Database: Medline <1991 to October 1996> Title Gastroesophageal reflux in children. Author Bagwell CE Address Division of Pediatric Surgery, Medical College of Virginia, Richmond, USA. Source Surg Annu, 27:1995, 133-63 Abstract Whereas all of these surgical modifications and new approaches are somewhat preliminary and have yet to achieve widespread clinical application, they illustrate an awareness of shortcomings in the present operative management of reflux as well as a gradual disenchantment with complications seen in many children, especially the neurologically impaired. However, the final analysis of surgical treatment for these children should not be viewed in an overly pessimistic light. Strategies for management of gastroesophageal reflux remain multifaceted, and operative intervention has a laudable role in the relief of symptoms for many afflicted children. However, the child's presentation and symptomatology should be predominant in planning therapy, operative or otherwise. It is the goal of this review to point out several points in this respect: 1. The diagnosis of gastroesophageal reflux may be difficult to pinpoint. 2. Multiple tests for reflux may offer conflicting results. 3. Clinical presentations associated with reflux do respond to treatment, which may include operative intervention. 4. The risks of anti-reflux procedures are greater than have been previously recognized, especially in the chronically ill and neurologically impaired child. 5. New approaches offer some promise to lower the risks of complications inherent in operative treatment of pathologic gastroesophageal reflux. 6. The best management plan for surgical treatment of reflux in children is evolving with less of a conviction for "prophylactic" fundoplication procedures, especially in the neurologically impaired child, and there is a recognition that underlying motility disorders may require modification of the operative approach or even the decision to operate. It is only through an awareness of the significant benefits as well as the considerable risks of operative treatment that the contemporary surgeon can best serve the interests of a child with gastroesophageal reflux. It is hoped that these guidelines will be helpful in this regard. Title Care of the infant with gastroesophageal reflux and respiratory disease: after the Nissen fundoplication. Author Parrish RS; Berube MC Source J Pediatr Health Care, 9: 5, 1995 Sep-Oct, 211-7 Abstract In cases of severe gastroesophageal reflux with failed medical management over a period of 3 to 6 months and/or extreme aggravation of respiratory disease, surgical intervention is necessary. The operative choice in infants and the most commonly used and successful surgery for the control of gastroesophageal reflux is the Nissen fundoplication. Care of the infant with a Nissen fundoplication should be focused on meeting the needs of the infant and the family. An understanding of the disease process, effects of fundoplication, and family process are essential for the nurse practitioner in planning care for these infants and their families. Title Gastroesophageal reflux in childhood. Author Fonkalsrud EW; Ament ME Address Pediatric Surgery, UCLA School of Medicine, USA. Source Curr Probl Surg, 33: 1, 1996 Jan, 1-70 Abstract Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time. Title Laparoscopic Thal fundoplication in severely scoliotic children. Author van der Zee DC; Bax NM Address Department of Pediatric Surgery, University Children's Hospital Wilhelmina, Utrecht, The Netherlands. Source Surg Endosc, 9: 11, 1995 Nov, 1197-8 Abstract Surgical treatment of gastroesophageal reflux in severely scoliotic children can be quite bothersome because sometimes the working space between the subcostal margins, iliac crest, and spinal column is very limited; the hiatus lies extremely deep away and is frequently rotated, making exposure more difficult. The laparoscopic approach could lend the necessary extension to the surgeons' hands to reach the deep hiatus. Moreover the entrance of the ports can be adjusted to the special requirements dictated by the scoliosis. Between February and December 1994 laparoscopic Thal fundoplication was performed in five severely scoliotic children; four also had a feeding gastrostomy. There were no intraoperative complications. The laparoscopic approach allowed improved operative visibility. Mean hospital stay was 3 days. The children displayed no symptomatic postoperative gastroesophageal reflux, which was confirmed by 3 months postoperative pH study. The laparoscopic approach of fundoplication allows improved visibility and easier access to the hiatus in severely scoliotic patients in comparison to the open approach. Results so far are good. Title Gastroesophageal reflux. Diagnostic and therapeutic approaches. Author Hillemeier AC Address Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109-0200, USA. Source Pediatr Clin North Am, 43: 1, 1996 Feb, 197-212 Abstract The clinical challenge of determining the medical conditions that are associated with obvious symptoms of gastroesophageal reflux and what diagnostic tests are appropriate to define this relationship is substantial. To determine which infants may be suffering from pathologic conditions associated with subtle signs of gastroesophageal reflux is even more challenging. This determination is essential to avoid subjecting many healthy infants to costly and potentially invasive testing. This article focuses on the physiology, clinical presentations, diagnosis and evaluation, and therapy of gastroesophageal reflux. =============== The following file is the result of a 11/95 search on the MEDLINE database with the key words gastrostomy or fundoplication, limited to pediatric age groups and english language records since 1991. <3> Unique Identifier 95212769 Authors Heine RG. Reddihough DS. Catto-Smith AG. Institution Department of Gastroenterology, Royal Children's Hospital, Parkville, Victoria, Australia. Title Gastro-oesophageal reflux and feeding problems after gastrostomy in children with severe neurological impairment. Source Developmental Medicine & Child Neurology. 37(4):320-9, 1995 Apr. Abstract This study evaluated the effect of percutaneous endoscopic gastrostomy (PEG) on the feeding problems and gastro-oesophageal reflux (GOR) of 30 consecutive children with severe neurological impairment who had PEG between October 1990 and March 1993. Evaluation was by questionnaire, clinical history, examination, 24-hour oesophageal pH monitoring and endoscopy. Gastrostomy placement significantly reduced feeding time, feed-related choking episodes and frequency of chest infections. Family stress was significantly reduced in two-thirds of cases. Significant weight-gain occurred. The clinical severity of GOR was significantly increased in eight patients and fundoplication was required in five. 24-hour oesophageal pH measurements before PEG did not reliably predict subsequently increased GOR. Seven patients died, but their deaths were apparently unrelated to GOR. PEG effectively provides nutrition, improves feed-related stresses, but may exacerbate GOR. <4> Unique Identifier 95314867 Authors Veit F. Schwagten K. Auldist AW. Beasley SW. Institution Department of Surgery, Royal Children's Hospital, Parkville, Victoria, Australia. Title Trends in the use of fundoplication in children with gastro-oesophageal reflux. Source Journal of Paediatrics & Child Health. 31(2):121-6, 1995 Apr. Abstract OBJECTIVE: To document changing trends in the indications for fundoplication in children with gastro-oesophageal reflux and to identify the main shortcomings and complications of the procedure. METHODOLOGY: Retrospective review of 405 consecutive children undergoing fundoplication between 1978 and 1992 inclusive. RESULTS: Trends in the indications for fundoplication related to broadening of its use in those with severe neurological impairment and uncontrolled reflux, and to changes in the management of patients in the neonatal period. Complications included unwrapping with recurrence of reflux, hiatal hernia, adhesive small bowel obstruction, dumping syndrome, post-operative persistence of oesophageal stricture, excessively tight wrap and poor oesophageal clearance (mostly in oesophageal atresia patients). CONCLUSIONS: This study identified those patients most likely to develop complications following fundoplication. This may assist in the pre-operative assessment of the likely benefit of fundoplication in children who often have other complex problems. <5> Unique Identifier 95235856 Authors Fonkalsrud EW. Ellis DG. Shaw A. Mann CM Jr. Black TL. Miller JP. Snyder CL. Institution Department of Surgery, University of California Los Angeles School of Medicine, USA. Title A combined hospital experience with fundoplication and gastric emptying procedure for gastroesophageal reflux in children. Source Journal of the American College of Surgeons. 180(4):449-55, 1995 Apr. Abstract BACKGROUND: Operative treatment of symptomatic gastroesophageal reflux (GER), often together with neurologic feeding disorders, is very common in infancy and childhood. Delayed gastric emptying (DGE) has been observed frequently in association with GER in children. STUDY DESIGN: A retrospective review was performed on 1,200 consecutive patients 18 years of age and younger operated upon for symptomatic GER or neurologic feeding disorders, or both, at two pediatric surgery centers in widely separated geographic areas in the United States of America, to compare the results after fundoplication with or without a gastric emptying procedure (GEP). RESULTS: Operations included gastroesophageal fundoplication (GEF) alone (871 patients), GEF plus GEP (286 patients), reoperative GEF plus GEP (30 patients), and GEP alone (13 patients). Thus, 27 percent of the total and 40 percent of the last 494 children with reflux had a GEP. Delayed gastric emptying with retention of more than 60 percent of an isotope meal appropriate for age at 90 minutes was present in 241 of the 451 children with reflux studied. Major neurologic disorders were present in 219 (25 percent) of 871 children who underwent GEF alone and in 247 (75 percent) of 329 children who had a GEP. All patients operated upon from both hospitals were relieved of recurrent emesis, and those with failure to thrive showed significant weight gain; pulmonary symptoms were relieved in 94 percent. Recurrent GER developed in 47 (5.2 percent) of 901 children who had GEF alone, but in only four (1.2 percent) of 329 patients who had a GEP. CONCLUSIONS: The excellent clinical results with low morbidity in this largest reported clinical experience with GEP in childhood suggest that a GEP should be combined with GEF for symptomatic children who have both GER and DGE. Minimal investigative studies are necessary for most neurologically impaired children who require a feeding gastrostomy. <6> Unique Identifier 95296639 Authors Hallerback B. Glise H. Johansson B. Institution Dept. of Surgery, NAL, Trollhattan, Sweden. Title Laparoscopic Rosetti fundoplication. Source Scandinavian Journal of Gastroenterology - Supplement. 208:58-61, 1995. Abstract BACKGROUND: Early experiences with laparoscopic fundoplication using the Rosetti technique are presented and compared with retrospective results from conventional fundoplication procedures. METHODS AND RESULTS: We have performed 70 consecutive laparoscopic procedures. Conversion to open surgery was done in seven cases because of anatomical reasons and in two because of peroperative progressive subcutaneous emphysema and CO2-retention. The complication rate was low. The range of postoperative hospital stay is 1-4 days for non-converted patients. Symptomatic follow-up has hitherto been performed in 41 patients with a follow-up time of 3-9 months. The follow-up results do not differ from those achieved in patients operated upon with the conventional open Nissen (n = 41) and Rosetti (n = 36) techniques. Pre- and postoperative control of 24 h pH and lower esophageal sphincter pressure (LESP) in 19 laparoscopically treated patients showed normalization of LESP in all cases and postoperative 24 h pH < 4 ranging between 0 and 3%. CONCLUSIONS: Laparoscopic and reflux surgery is effective for the treatment of reflux esophagitis. Follow-up results compare well with open surgery. <7> Unique Identifier 95320707 Authors Bagwell CE. Institution Division of Pediatric Surgery, Medical College of Virginia, Richmond, USA. Title Gastroesophageal reflux in children. [Review] Source Surgery Annual. 27:133-63, 1995. Abstract Whereas all of these surgical modifications and new approaches are somewhat preliminary and have yet to achieve widespread clinical application, they illustrate an awareness of shortcomings in the present operative management of reflux as well as a gradual disenchantment with complications seen in many children, especially the neurologically impaired. However, the final analysis of surgical treatment for these children should not be viewed in an overly pessimistic light. Strategies for management of gastroesophageal reflux remain multifaceted, and operative intervention has a laudable role in the relief of symptoms for many afflicted children. However, the child's presentation and symptomatology should be predominant in planning therapy, operative or otherwise. It is the goal of this review to point out several points in this respect: 1. The diagnosis of gastroesophageal reflux may be difficult to pinpoint. 2. Multiple tests for reflux may offer conflicting results. 3. Clinical presentations associated with reflux do respond to treatment, which may include operative intervention. 4. The risks of anti-reflux procedures are greater than have been previously recognized, especially in the chronically ill and neurologically impaired child. 5. New approaches offer some promise to lower the risks of complications inherent in operative treatment of pathologic gastroesophageal reflux. 6. The best management plan for surgical treatment of reflux in children is evolving with less of a conviction for "prophylactic" fundoplication procedures, especially in the neurologically impaired child, and there is a recognition that underlying motility disorders may require modification of the operative approach or even the decision to operate. It is only through an awareness of the significant benefits as well as the considerable risks of operative treatment that the contemporary surgeon can best serve the interests of a child with gastroesophageal reflux. It is hoped that these guidelines will be helpful in this regard. [References: 92] <8> Unique Identifier 95106084 Authors Bensoussan AL. Yazbeck S. Carceller-Blanchard A. Institution Division of Pediatric General Surgery, Hopital Sainte-Justine, Montreal, Quebec, Canada. Title Results and complications of Toupet partial posterior wrap: 10 years' experience. Source Journal of Pediatric Surgery. 29(9):1215-7, 1994 Sep. Abstract A 270 degrees posterior wrap, described by Toupet, was performed in 112 patients with medically refractory gastroesophageal reflux (GER) over a 10-year period. The mean age was 39 months (range, 2 months to 19 years). Thirty percent of the patients were neurologically impaired (NI). The approximation of the crura, the posterior fixation of the wrap, and the posterior partial fundoplication were performed with nonabsorbable sutures, over a bougie. Thirty percent of the NI and 15% of the neurologically normal (NN) children underwent a gastrostomy. Early postoperative complications were found in 24% of NI and 18% of NN children; these were treated medically, except for two bowel obstructions. Eight patients died for reasons unrelated to surgery, and nine were lost to follow-up. The mean follow-up period for the 95 remaining patients was 3.5 years for NI and 4.9 years for NN children. The evaluation showed that 6 patients had temporary dysphagia and two had food impaction. Nine wrap herniations (10%) were found; three of them without symptoms were noted by routine upper gastrointestinal series and received no treatment. Six wrap herniations with recurrent reflux were reoperated on successfully. With 90% of patients free of symptoms, the results of the Toupet procedure compare favorably with those of the Nissen fundoplication because of the retained ability to belch or vomit. <10> Unique Identifier 95030650 Authors Krishnamoorthy M. Mintz A. Liem T. Applebaum H. Institution Kaiser Permanente Medical Center, Los Angeles, California. Title Diagnosis and treatment of respiratory symptoms of initially unsuspected gastroesophageal reflux in infants. Source American Surgeon. 60(10):783-5, 1994 Oct. Abstract Gastroesophageal reflux (GER) in infants is most commonly thought of as repeated excessive vomiting and failure to thrive, with most infants responding favorably to medical therapy. However, GER may also manifest exclusively with a variety of respiratory symptoms that, if not detected and treated early, may lead to life-threatening complications. During the period of 1987 to 1992, 39 neonates and infants underwent Nissen fundoplication for the treatment of respiratory symptoms attributed to GER. Symptoms included apnea and bradycardia (64%), pneumonia (31%), cyanosis (28%), cough (18%), and stridor (15%). Most patients were ascribed at least one incorrect diagnosis to explain respiratory symptoms. These include apnea of prematurity (38%), bronchopulmonary dysplasia (31%), asthma (8%), and subglottic stenosis (8%). All patients underwent a variety of investigations and medical treatments without noticeable clinical improvement. These included bronchoscopy, esophagoscopy, and polysomnograms. Treatment such as antibiotics, theophylline, bronchodilators, steroids, and oxygen were directed at presumed primary respiratory disease. On the other hand, H2 blockers, metoclopramide, positioning, and thickened feeds were prescribed to treat GER without objective evidence of disease. Ultimately, GER was demonstrated by upper gastrointestinal series in 64%, pH probe in 61%, and both studies in 38%. All patients underwent Nissen fundoplication after failed attempts at medical therapy. A total of 95% of patients had resolution or substantial improvement of respiratory symptoms postoperatively. Preoperative hospitalization averaged 37.0 days, and postoperative stay averaged only 14.2 days. We present a series of patients with GER, all of whom presented with respiratory symptoms.(ABSTRACT TRUNCATED AT 250 WORDS) <11> Unique Identifier 95101825 Authors Lelli JL. Ashcraft KW. Institution Department of Surgery, University of Michigan Medical School, Ann Arbor. Title Gastroesophageal reflux. [Review] Source Seminars in Thoracic & Cardiovascular Surgery. 6(4):240-6, 1994 Oct. Abstract GER is a major pediatric disease. The respiratory, nutritional, and inflammatory complications of this disease process, invisibly hidden in the gastroesophageal junction, have a profound effect on the quality and sometimes the very life of infants and children. The astute pediatrician and surgeon should always keep this disease process in mind when dealing with these problems of children. Having a high suspicion of GER is often necessary to find this hidden enemy. The Nissen fundoplication and the Thal fundoplication are equally successful in the treatment of GER in children. However, the complication rate with the Nissen fundoplication is higher than with the Thal. We feel that the Thal does an outstanding job of treating GER while maintaining normal gastroesophageal function in the developing child, and is therefore our operation of choice for GER. [References: 51] <12> Unique Identifier 95147166 Authors Khoshoo V. Roberts PL. Loe WA. Golladay ES. Pencharz PB. Institution Children's Hospital, New Orleans, LA 70118. Title Nutritional management of dumping syndrome associated with antireflux surgery. Source Journal of Pediatric Surgery. 29(11):1452-4, 1994 Nov. Abstract Eight children were identified as having dumping syndrome by a glucose tolerance test and evidence of rapid gastric emptying. All had undergone a fundoplication with concomitant feeding gastrostomy placement at 18.4 +/- 17.4 months of age (range, 3 to 54 months). Symptoms suggestive of dumping syndrome occurred 1 to 4 months after surgery. There was considerable delay in diagnosis (3 to 8 months). These children were successfully managed with nutritional manipulation alone, using a combination of a complex carbohydrate and a fat emulsion. Complete resolution of symptoms and normoglycemia was achieved in all the children, without any complications. <13> Unique Identifier 94308902 Authors Kazerooni NL. VanCamp J. Hirschl RB. Drongowski RA. Coran AG. Institution Section of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI. Title Fundoplication in 160 children under 2 years of age. Source Journal of Pediatric Surgery. 29(5):677-81, 1994 May. Abstract The natural history of fundoplication in young children with gastroesophageal reflux (GER) had not been analyzed previously. The authors reviewed the charts of 160 children who underwent gastric fundoplication (GF) before the age of 2 years (mean age [+/- SD], 9 +/- 7 months; range, 1 week to 2 years), from 1974 to 1992. Reflux was documented by upper gastrointestinal series in 124 patients, by 24-hour pH probe monitor in 98 patients, and by both in 68 patients. Clinical indications for GF included failure to thrive (FTT) in 68%, emesis (Ems) in 58%, and aspiration pneumonia (Asp) in 53%. Neurological impairment (NI) was present in 47% of all patients, and 13% had esophageal atresia (EA). The type of GF used was a Nissen fundoplication in 79% and an anterior fundoplication (AF) in 21%. Of the 160 patients, 24 (15%) died of unrelated causes. Of the remaining 136, follow-up of at least 2 years was obtained for 96 (mean follow-up period, 5.3 +/- 3.0 years; range, 2 to 15 years). Clinical resolution of symptoms/findings after GF occurred in 87% of children with FTT, 92% with Ems, 70% with Asp, and 71% overall. A second fundoplication was required for 15 children (16%) because of documented recurrent reflux. The type of GF, the age of the patient, and the presence of EA or NI did not significantly affect the success of GF.(ABSTRACT TRUNCATED AT 250 WORDS) <16> Unique Identifier 94358813 Authors Maxson RT. Harp S. Jackson RJ. Smith SD. Wagner CW. Institution Department of Surgery, University of Arkansas for Medical Sciences, Little Rock. Title Delayed gastric emptying in neurologically impaired children with gastroesophageal reflux: the role of pyloroplasty. Source Journal of Pediatric Surgery. 29(6):726-9, 1994 Jun. Abstract The presence of delayed gastric emptying in neurologically impaired children with gastroesophageal reflux has led to controversy regarding appropriate surgical management. The authors reviewed the charts of neurologically impaired children requiring fundoplication to answer two questions: (1) is pyloroplasty needed in addition to fundoplication for delayed gastric emptying? and (2) Does delayed gastric emptying influence the morbidity associated with fundoplication? To answer the first question, 40 neurologically impaired children with delayed gastric emptying undergoing fundoplication were divided into two groups: Nissen and pyloroplasty (n = 21) and Nissen only (n = 19). The Nissen and pyloroplasty group had significantly more postoperative complications (23.8% v 5.0%) and took longer to reach full feeding (14.6 v 3.9) days. There were no differences in the incidence of recurrent symptoms, readmissions, or reoperations. To answer the second question, 58 neurologically impaired children undergoing fundoplication were grouped based on gastric emptying scan results: normal gastric emptying (> 32% in 1 hour) (n = 29) and delayed gastric emptying (n = 29). There were no differences in postoperative feeding tolerance, postoperative complications, recurrent symptoms, readmissions, or reoperations between the two groups. Delayed gastric emptying in neurologically impaired children with gastroesophageal reflux did not increase postoperative morbidity after fundoplication, and the addition of a pyloroplasty to fundoplication provided no additional benefit. The authors conclude that the procedure of choice for neurologically impaired children with gastroesophageal reflux is a fundoplication without pyloroplasty, regardless of the degree of delay in gastric emptying. <17> Unique Identifier 95054830 Authors Watanabe Y. Catto-Smith AG. Institution Department of General Surgery, Royal Children's Hospital, Parkville, Melbourne, Australia. Title The clinical significance of a prolonged stable pH around 4.0 in 24-h pH monitoring. Source Journal of Pediatric Gastroenterology & Nutrition. 19(1):50-7, 1994 Jul. Abstract Esophageal acidity may remain stable for long periods at or near pH 4.0, potentially influencing the estimation of risk of esophagitis in esophageal pH monitoring assessment. Our aim was to determine the frequency and clinical significance of a prolonged stable pH around 4.0 (PSpH4) (pH 3.5-4.5) by retrospective examination of 503 pH records from children and by analysis of clinical information, pH parameters, motility studies, and esophageal biopsies. The frequency, duration, and proportion of total time with PSpH4 were quantified, and the ratio of the time for which the pH was < pH 4.0 during PSpH4 episodes to the total reflux time below pH 4.0 was calculated [stable/reflux (S/R) rate]. One hundred fifty-eight PSpH4 episodes were identified in 80 records. The average duration was 60 min and the S/R rate was 30%. Sixty-one percent of PSpH4 episodes started in the postprandial period (p < 0.05). Proportionally more episodes of PSpH4 occurred with an increased total percentage reflux time (p < 0.01). In recordings with PSpH4, the average number of reflux episodes remained normal, even when the percentage reflux time was > or = 10%. No correlation was shown between PSpH4 and esophageal dysmotility, esophagitis, cardiorespiratory symptoms, or prematurity. PSpH4 did not occur in recordings obtained after fundoplication. We conclude that PSpH4 is common and may result in an overestimation of risk of esophagitis. Qualitative assessment of pH monitoring is necessary along with conventional quantitative measurements. <18> Unique Identifier 94207441 Authors Buchmiller TL. Curr M. Fonkalsrud EW. Institution Division of Pediatric Surgery, University of California Los Angeles School of Medicine. Title Assessment of alkaline reflux in children after Nissen fundoplication and pyloroplasty [published erratum appears in J Am Coll Surg 1994 Apr;178(4):416]. Source Journal of the American College of Surgeons. 178(1):1-5, 1994 Jan. Abstract During an eight month period, 22 children less than 15 years of age (mean age of three years and seven months) who underwent operative treatment of gastroesophageal reflux (GER) were selected for study. All were symptomatic and unresponsive to medical therapy. Preoperative evaluation included esophageal pH probe monitoring in 18 patients, gastric isotope emptying study in 18 patients and contrast studies of the upper part of the gastrointestinal tract in ten patients. Four children with severe neurologic disorders who required placement of a feeding gastrostomy tube underwent fundoplication without preoperative evaluation. All 22 patients had GER and 14 had documented delayed gastric emptying (greater than 60 percent residual at 90 minutes) on radionuclide scan with appropriate meal for age. Each child underwent Nissen fundoplication and tube gastrostomy. Sixteen patients also had a modified pyloroplasty with a 2.5 to 4.0 centimeter vertical seromuscular incision on the antrum. When the patients achieved a full feeding schedule (postoperative day range three to 21 days, mean of 6.2 days), they were put on a fast for six hours and an aspirate was obtained from the gastrostomy tube. Analysis of pH and bile acid content served as indicators of alkaline reflux. The six children without pyloroplasty served as the control group. Intragastric pH ranged from 1.91 to 7.00 (mean of 3.71) and bile acid content ranged from 4 to 150 micrometers per liter (mean of 62 micrometers per liter). No significant differences were seen between patients with fundoplication alone and those with fundoplication and pyloroplasty (p = 0.97 for pH; p = 0.66 for bile acid content). Two patients with pyloroplasty showed slight elevation of intragastric bile acid content at the upper limits of normal. At follow-up evaluation from nine to 23 months (mean of 18 months), all patients were asymptomatic, with only two showing rare gagging. Additionally, nine patients have had complete resolution of their pulmonary symptoms. No patients demonstrated diarrhea, gas bloat or dumping. Nissen fundoplication combined with a modified pyloroplasty or "antroplasty" for delayed gastric emptying provides excellent clinical results with minimal demonstrable bile acid reflux and no change in intragastric pH at the one and one-half year follow-up evaluation. <19> Unique Identifier 94257621 Authors Mira-Navarro J. Bayle-Bastos F. Frieyro-Segui M. Garramone N. Gambarini A. Institution Servicio de Cirugia Infantil, Hospital General de Alicante, Espana. Title Long-term follow-up of Nissen fundoplication. Source European Journal of Pediatric Surgery. 4(1):7-10, 1994 Feb. Abstract A study of 68 children under 7 years of age, who had had an abdominal approach Nissen operation, with a postoperative follow-up of between 4 and 14 years, is presented. The patients were classified into three groups, according to radiological appearance and cuff site. In the first group (40 patients) the cuff was intraabdominal and competent; in the second group (22 patients) the cuff was partially displaced into the thorax and was competent. 92% of the patients of these groups are currently asymptomatic and none required reoperation. In the third group (6 patients), there was disorganization of the cuff, together with its displacement into the chest, recurrence of symptoms and the authors recommended reoperation. Nissen's operation is an effective treatment for gastrooesophageal reflux in children unresponsive to medical treatment. Although displacement occurs frequently, valve competence is unaffected except in those where the cuff has disappeared and there is herniation into the thorax in which case reoperation is necessary. <21> Unique Identifier 94231401 Authors Taylor LA. Weiner T. Lacey SR. Azizkhan RG. Institution Division of Pediatric Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7210. Title Chronic lung disease is the leading risk factor correlating with the failure (wrap disruption) of antireflux procedures in children. Source Journal of Pediatric Surgery. 29(2):161-4; discussion 164-6, 1994 Feb. Abstract Recurrent gastroesophageal reflux (GER) after antireflux procedures (ARP) has been correlated with significant neurological impairment (NI). Other major risk factors for recurrent GER have not been extensively characterized. The authors reviewed their experience with ARPs in children to better characterize the risk factors for recurrent GER and identify successful management strategies for these patients. The charts of 281 consecutively treated children who had an ARP at our institution (1985 to 1992) were reviewed. The neurological status of each child was assessed as normal or impaired (cerebral palsy, seizures, mental retardation, spasticity), and other medical diagnoses such as chronic pulmonary disorders (eg, interstitial disease, cystic fibrosis, bronchopulmonary dysplasia, asthma, etc), and congenital malformations and syndromes were identified. The average follow-up period was 3 years (range, 1 to 7.5 years). Patients with symptoms of recurrent GER were evaluated with an upper gastrointestinal study. Patients with a radiologically intact fundoplication and suspected GER were further evaluated with a 24-hour pH probe. Statistical analyses were performed using the Fisher's Exact Test. Of the 281 patients who underwent ARP, 39 had documented recurrent GER (average, 16 months after surgery). Twenty-five (64%) of these children had chronic pulmonary disease (CPD). Thirty-two percent of all children with CPD had recurrent GER after ARP, versus 7% of those without CPD (P < .0001). For children with NI and CPD there was an increased risk (P < .0001) of failure when compared with the risk in the normal subgroup (children without CPD or NI) who underwent ARP.(ABSTRACT TRUNCATED AT 250 WORDS) <22> Unique Identifier 95267741 Authors Schier F. Waldschmidt J. Institution Department of Paediatric Surgery, University Medical Centre Steglitz, Berlin, Germany. Title Laparoscopic fundoplication in a child. Source European Journal of Pediatric Surgery. 4(6):338-40, 1994 Dec. Abstract A case of laparoscopic fundoplication is described in a child weighing 25 kg. The patient had severe skeletal deformities. Five trocars were used. The view was excellent. A complete posterior wrap was achieved without transsecting the short gastric vessels. Operating time and expenses were greater than with the conventional technique. No complications occurred. The cosmetic result was good. <24> Unique Identifier 95074716 Authors Fleisher DR. Institution Department of Child Health, University of Missouri School of Medicine, Columbia 65212. Title Functional vomiting disorders in infancy: innocent vomiting, nervous vomiting, and infant rumination syndrome. [Review] Source Journal of Pediatrics. 125(6 Pt 2):S84-94, 1994 Dec. Abstract Pediatric gastroenterologists have tended to view gastroesophageal reflux (GER) as a disease in and of itself--a disease that can be diagnosed "objectively" with use of numerical data from esophageal pH monitoring and cured with pharmacologic or surgical treatment. What is often forgotten is that the data derived from esophageal pH monitoring and other techniques may identify the presence of abnormal GER but tell nothing about its pathogenesis. The usual approach to infants who feed poorly, vomit, or fail to gain weight is to identify the presence of abnormal GER, rule out underlying organic causes of vomiting, and then diagnosis primary GER disease. The baby is then treated with pharmacologic, dietary, or positional therapy and, ultimately, if these therapies fail to eradicate the symptoms attributed to GER, surgical fundoplication, which stops vomiting regardless of its causes. The pediatric literature on infant vomiting and GER is almost devoid of research into the nature and possible relationships among infant stress, vomiting, feeding difficulties, and failure to grow. Clinically, the quality of the maternal-infant relationship is frequently approached superficially, with psychosocial aspects treated as less important in infants considered to have primary organic disease amenable to medical or surgical treatment. Psychosocial factors in the pathogenesis of the infant's symptoms are often not pursued beyond assessment for possible abuse or neglect. It has been known for centuries that stress or excitement affects gastrointestinal function and symptoms. Although the field of infant psychiatry has produced a substantial literature on the nature of stresses that affect both infants and mothers, the pediatric literature on vomiting and failure to thrive seldom acknowledges the existence or importance of these contributions. In clinical practice, failure to explore psychosocial aspects that may contribute to vomiting, feeding difficulties, or failure to thrive may result in missed opportunities for less invasive, more effective therapy at best, and countertherapeutic treatment at worst. This article describes three functional vomiting disorders of infancy, their distinguishing characteristics, hypotheses regarding their pathogenesis, and principles of comprehensive management. [References: 55] <25> Unique Identifier 95074713 Authors Hyman PE. Institution Department of Pediatrics, University of California, Los Angeles. Title Gastroesophageal reflux: one reason why baby won't eat. [Review] Source Journal of Pediatrics. 125(6 Pt 2):S103-9, 1994 Dec. Abstract Gastroesophageal reflux (GER) is the movement of gastric contents retrograde into the esophagus. Sometimes the refluxate is seen as emesis, but often reflux is "silent," meaning that there are no discrete symptoms during an episode. In adults, the most common symptom of GER is heartburn, whereas in infancy excessive crying and malaise are symptoms that prompt investigation for GER, with or without esophagitis. Symptoms of esophagitis in infancy may include arching (hyperextension) of the torso and refusal of feedings. Tube feedings may be required to treat infants with failure to thrive who refuse oral feedings. Paradoxically, tube feedings increase the number of GER episodes. A hypothetical explanation for refusal of food in infancy is that pain with swallowing (odynophagia) or heartburn are consequences of peptic esophagitis. As a result, infants will learn to refuse food if it hurts or if they fear that it will hurt to eat. Another possible mechanism is visceral hyperalgesia, a neuropathic condition in which prior experience changes sensory nerves so that previously innocuous stimuli are perceived as painful. Some infants may have especially sensitive sensory nerves in the upper gastrointestinal tract, which predisposes visceral hyperalgesia to develop. Thus pain occurs from luminal distension or acid reflux in the absence of tissue damage. The evaluation of babies who won't eat includes a careful history and physical examination to exclude the possibility of chronic systemic illness. Refusal to feed is an unusual manifestation of a common condition: GER disease. The initial tests for GER usually include a barium swallow study to assess the upper gastrointestinal anatomy, endoscopy and esophageal biopsy to assess esophagitis, and an intraesophageal pH study, which is useful in "silent" reflux to quantitate the duration of esophageal acid exposure and to correlate discrete symptom episodes with periods of reflux. The treatment of infants and toddlers who refuse to eat because of pain resulting from visceral hyperalgesia or reflux esophagitis involves removing the pain associated with eating and making eating a pleasurable experience. Treatment for esophagitis may include maintaining an upright posture after meals and thickened feeds, medication to improve gastrointestinal motility or to decrease acid secretion, or fundoplication. [References: 41] <27> Unique Identifier 95054863 Authors Bliss D. Hirschl R. Oldham K. Chey J. Cilley R. Blane C. Olson A. Shulkin B. Coran A. Institution Section of Pediatric Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI 48109-0245. Title Efficacy of anterior gastric fundoplication in the treatment of gastroesophageal reflux in infants and children. Source Journal of Pediatric Surgery. 29(8):1071-4; discussion 1074-5, 1994 Aug. Abstract Anterior gastric fundoplication (AGF) has been performed at the University of Michigan since 1988. To objectively evaluate the long-term efficacy of the AGF, the authors performed a study of children who had undergone AGF between June 1988 and June 1990 (n = 46). Six of them died of unrelated causes. Twenty-two consented to follow-up evaluation that included parental interview, physical examination, upper gastrointestinal series (UGI), 24-hour esophageal pH probe monitoring (EpH), and a liquid-phase gastric emptying study. Twenty patients (74%) remained asymptomatic, and only one child required reoperation. Four asymptomatic patients exhibited gastroesophageal reflux (GER) by UGI, and three others by EpH. Three children were noted to have delayed gastric emptying. These results compare favorably with data previously reported from this institution of a 5-year follow-up of children after Nissen fundoplication. There is a trend toward improved efficacy (87% v 74%; P = .12), decreased reoperation rate (4% v 14%; P = .11), and less severe complications. The present study shows that AGF is effective treatment for GER when evaluated by objective studies and is comparable in therapeutic efficacy and safety to the Nissen fundoplication. <28> Unique Identifier 94257302 Authors Veit F. Heine RG. Catto-Smith AG. Institution Department of Gastroenterology, Royal Children's Hospital, Parkville, Victoria, Australia. Title Dumping syndrome after Nissen fundoplication. Source Journal of Paediatrics & Child Health. 30(2):182-5, 1994 Apr. Abstract Dumping syndrome is infrequently reported in children, but has significant morbidity. It may be difficult both to diagnose and manage. Two children are reported who developed dumping syndrome after Nissen fundoplication. Symptoms occurred soon after the operation and included post-prandial pallor, sweating, lethargy and diarrhoea. Failure to thrive was a prominent feature. Typical biochemical changes included hyperglycaemia shortly after meals, followed by hyperinsulinaemia and reactive hypoglycaemia. Effective treatment was only achieved with continuous enteral feeding. Children undergoing fundoplication should be closely monitored for episodes of hypoglycaemia and unresponsiveness. The incidence of dumping syndrome after fundoplication may be underestimated, particularly in children. <30> Unique Identifier 93360035 Authors Albanese CT. Towbin RB. Ulman I. Lewis J. Smith SD. Institution Department of Pediatric Surgery, Children's Hospital of Pittsburgh, PA 15213-2583. Title Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux. Source Journal of Pediatrics. 123(3):371-5, 1993 Sep. Abstract To determine the optimal method of providing enteral feeding to neurologically impaired children with gastroesophageal reflux, Nissen fundoplication with simultaneous gastrostomy tube placement (NGT) was compared with anterograde percutaneous gastrojejunostomy (APGJ), a nonsurgical procedure performed under fluoroscopic guidance. The records of 112 neurologically impaired children with gastroesophageal reflux were retrospectively reviewed; 68 had undergone NGT and 44 APGJ. Follow-up data were available for 45 NGT patients (mean age, 6.4 years) and 34 APGJ patients (mean age, 7.9 years). Mean follow-up was 1.8 years in the NGT group and 2.5 years in the APGJ group. Complications resulting from either procedure were classified either as major, which included treatment failures or morbidity resulting in prolonged hospitalization, or as minor, those requiring outpatient treatment only or not directly caused by the procedure. The NGT group had a significantly higher incidence of major complications in comparison with the APGJ group (33.3% vs 11.8%, p < 0.05). Ten patients (22.2%) in the NGT group required reoperation for complications; six required a second NGT for wrap hernia, failure, and continued gastroesophageal reflux. Two patients (5.9%) in the APGJ group required surgery for complications; one of these eventually required an NGT, and the other had an intussusception that necessitated a small-bowel resection. Minor complications were more common in the APGJ group than in the NGT group (44.1% vs 6.6%); the majority of complications were related to the jejunostomy tube. Premature replacement or reinsertion of the jejunostomy tube was necessary in 14 APGJ patients (32%). The mortality rate was 8.8% in the NGT group and 5.9% in the APGJ group (p = not significant). No death occurred within 30 days of either procedure. We conclude that APGJ is a safe alternative method for feeding the neurologically impaired child with gastroesophageal reflux. <31> Unique Identifier 94087439 Authors DeCou JM. Shorter NA. Karl SR. Institution Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756. Title Feeding Roux-en-Y jejunostomy in the management of severely neurologically impaired children. Source Journal of Pediatric Surgery. 28(10):1276-9; discussion 1279-80, 1993 Oct. Abstract Feeding problems are legion in severely neurologically impaired children. Many patients do well with a gastrostomy with or without fundoplication. Unfortunately, fundoplication is not without complication, emphasizing the need for other options in the management of these difficult patients. Since 1990 six patients (age range, 2 months to 6 years) have been treated by the creation of a permanent Roux-en-Y end-jejunostomy and a gastrostomy. The Roux limb is closed tightly around a mushroom catheter. The gastrostomy is left for gastric decompression, and the jejunostomy tube is used for all nutrition and most medications. One patient died in the postoperative period. All the others have done well, without significant complication and with a high level of parent satisfaction (average follow-up, 12 months). Previously four other patients were treated with a Roux-en-Y jejunostomy in which, rather than closing the Roux limb around the catheter, it was brought out as a catheterizable stoma. Frequent leakage and prolapse make this approach less desirable. <32> Unique Identifier 94084485 Authors Weerts JM. Dallemagne B. Hamoir E. Demarche M. Markiewicz S. Jehaes C. Lombard R. Demoulin JC. Etienne M. Ferron PE. et al. Institution Department of Surgery of GI Tract, Clinique Saint-Joseph, Liege, Belgium. Title Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Source Surgical Laparoscopy & Endoscopy. 3(5):359-64, 1993 Oct. Abstract With the world-wide use of laparoscopy, new applications have been found, particularly in the field of esophageal and gastric surgery. From January 1991 through April 1992, 132 patients underwent laparoscopic Nissen fundoplication. The indication for laparoscopic intervention was symptomatic gastroesophageal reflux disease (GERD) not responding to medical treatment. The preoperative assessment included esophagogastroscopy, barium meal, esophageal manometry, and, in selected cases, 24 h pH studies. There was no operative-related mortality. The overall morbidity was 7.5%. Ninety-eight patients were seen 3 months after surgery and evaluated for control of reflux symptoms. One patient complained of mild recurrence of reflux symptoms; however, endoscopic examination revealed no evidence of recurrent esophagitis. Three complained of occasional dysphagia and two, of mild dysphagia. One individual required reoperation for persistent, severe dysphagia. The excellent results observed so far with this procedure have led us to believe that laparoscopic Nissen fundoplication is the procedure of choice for patients with intractable GERD. <33> Unique Identifier 94063614 Authors Varty K. Evans D. Kapila L. Institution Department of Paediatric Surgery, Queens Medical Centre, Nottingham. Title Paediatric gastro-oesophageal reflux: prognostic indicators from pH monitoring. Source Gut. 34(11):1478-81, 1993 Nov. Abstract The original diagnostic 24 hour pH monitoring data in 57 children with gastro-oesophageal reflux (GOR) were retrospectively reviewed after a minimum of one year follow up. The tracings of children who responded to medical treatment were compared with those who failed to respond and required a fundoplication. Children with GOR secondary to oesophageal atresia/tracheo-oesophageal fistula and neurological conditions (n = 12) were analysed separately from those with primary GOR (n = 45). Children with primary GOR requiring a fundoplication (n = 9) had increased daytime reflux. The percentage time pH < 4 was the best discriminator (21% v 7%) with a threshold of 18% giving a 92% specificity and a 70% sensitivity. For children with secondary GOR the percentage time pH < 4 at night was significantly higher (29% v 3.7%) in those requiring a fundoplication (n = 5). A threshold of 18% gave an 80% specificity and an 86% sensitivity. These results show that both daytime and night time pH monitoring data can be of prognostic value in different subgroups of children with GOR. A percentage time pH < 4 of greater than 18% was a useful threshold to apply when evaluating the pH monitoring data. <34> Unique Identifier 94119659 Authors Georgeson KE. Institution Children's Hospital of Alabama, Birmingham 35233. Title Laparoscopic gastrostomy and fundoplication. [Review] Source Pediatric Annals. 22(11):675-7, 1993 Nov. Abstract Laparoscopic gastrostomy and fundoplication are a useful alternative to open fundoplication and gastrostomy in pediatric patients. Laparoscopic fundoplication appears to decrease the length of hospital stay and allow a more rapid recovery. [References: 18] <40> Unique Identifier 93221175 Authors Spitz L. Roth K. Kiely EM. Brereton RJ. Drake DP. Milla PJ. Institution Department of Surgery, Hospital for Sick Children, London. Title Operation for gastro-oesophageal reflux associated with severe mental retardation. Source Archives of Disease in Childhood. 68(3):347-51, 1993 Mar. Abstract One hundred and seventy six children with severe mental retardation underwent a fundoplication for considerable gastro-oesophageal reflux. There were six 'early' (3%) deaths and five 'late' deaths. Major complications developed in 17 (10%) children whereas 86 (49%) had 'minor' complications. A revision operation was required in 27 patients. Overall 142 (81%) children achieved a good result. In spite of the high complication rate and the need for a secondary operation in 15% of the patients, the quality of life for these children and their parents and carers is greatly improved by antireflux surgery. <41> Unique Identifier 93225018 Authors Lobe TE. Schropp KP. Lunsford K. Institution University of Tennessee, Memphis. Title Laparoscopic Nissen fundoplication in childhood [see comments]. Source Journal of Pediatric Surgery. 28(3):358-60; discussion 360-1, 1993 Mar. Abstract An obese, 10-year-old boy presented with symptoms of pain and apnea due to gastroesophageal reflux that was unresponsive to medication. A laparoscopic Nissen fundoplication was performed, and the child was discharged from the hospital within 36 hours of the operation. The rationale and technique of a laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux in childhood is described. <45> Unique Identifier 93386254 Authors Moir CR. Institution Department of Surgery, Mayo Foundation, Rochester, MN 55905. Title Laparoscopy and thoracostomy in children. [Review] Source Current Opinion in Pediatrics. 5(3):333-40, 1993 Jun. Abstract The laparoscopic and thoracoscopic revolution is sweeping through pediatric surgery. The current literature has detailed numerous reports of laparoscopic approaches to traditional operations. The most commonly performed and currently most accepted operations are diagnostic laparoscopy, gynecologic laparoscopy, and laparoscopic cholecystectomy and appendectomy. Few, if any, of these procedures have been subjected to a prospective, randomized trial, but initial reports indicate improved postoperative outcome by decreasing hospital stay and an earlier return to normal activities. Thoracoscopic lung biopsy, tumor excision, and treatment of empyema are well-established procedures. Other operations soon to be introduced are laparoscopic fundoplication, laparoscopic-aided intestinal surgery, thoracoscopic excision of mediastinal masses, spinal surgery, and chest wall surgery. The early enthusiasm for minimally invasive surgery must be tempered by an appreciation for its limitations and complications. How surgeons handle this new innovation will determine whether the promise of laparoscopy is another step towards eliminating the negative factors that have made surgery such a dichotomy of fear and hope. [References: 80] <47> Unique Identifier 93353344 Authors Dellert SF. Hyams JS. Treem WR. Geertsma MA. Institution Department of Pediatrics, Hartford Hospital, Connecticut 06115. Title Feeding resistance and gastroesophageal reflux in infancy. Source Journal of Pediatric Gastroenterology & Nutrition. 17(1):66-71, 1993 Jul. Abstract Resistance to oral feedings occurring during the course of chronic gastroesophageal reflux (GER) in infants has received little attention in the literature. Accordingly, we reviewed the clinical courses of 600 infants of < 24 months of age with GER seen over an 8-year period to determine the prevalence and course of this problem. After excluding infants with severe neurologic disease, craniofacial disorders, or a history of esophageal surgery, 25 infants were found to have resistance to oral feedings that was severe enough to warrant tube feedings for nutritional support. Sixteen of these 25 infants had a history of resistance to oral feeding antedating a diagnosis of GER, whereas nine developed resistance to feeding during the course of therapy. Gestational age, age at onset of GER symptoms, severity of GER, presence/severity of esophagitis, type of medical therapy, need for fundoplication, or postfundoplication complications were similar in these two groups. When the clinical records of these 25 infants were compared to an age- and sex-matched infant population with GER but without feeding resistance, no differences were noted in severity of GER or the presence/severity of esophagitis. However, failure to thrive and the need for fundoplication were significantly more common in the feeding resistance group (p < 0.001). Among those infants with neurodevelopmental evaluation, mild delay was seen more commonly in the infants with feeding resistance but fell short of statistical significance (p = 0.08). Our observations suggest that resistance to oral feedings is an uncommon but severe problem associated with GER in infancy.(ABSTRACT TRUNCATED AT 250 WORDS) <48> Unique Identifier 93310555 Authors Bauer ML. Figueroa-Colon R. Georgeson K. Young DW. Institution Department of Pediatrics, University of Alabama, Birmingham. Title Chronic pulmonary aspiration in children. [Review] Source Southern Medical Journal. 86(7):789-95, 1993 Jul. Abstract According to established diagnostic and therapeutic guidelines for chronic pulmonary aspiration, clinical suspicion is raised by coughing and choking with feeding, coughing during sleep, recurrent pneumonia, failure to thrive, and radiologic signs of chronic lung injury. The upper gastrointestinal series accurately defines anatomy and function, can differentiate between direct and reflux aspiration, and identifies conditions that predispose to aspiration. Gastroesophageal scintigraphy lacks anatomic detail but increases observation time, may differentiate between direct and reflux aspiration, and identifies delayed gastric emptying and gastroesophageal reflux. The lipid-laden macrophage index improves identification of aspiration, but cannot differentiate between direct and reflux aspiration. The esophageal pH probe identifies gastroesophageal reflux. Treatment options include medical therapy (thickened feedings, prone positioning, and metoclopramide) and surgical intervention (gastrostomy, fundoplication, and definitive correction of predisposing conditions). Therapy is determined by severity of illness and results of diagnostic evaluation. [References: 24] <50> Unique Identifier 93155873 Authors Wheatley MJ. Coran AG. Wesley JR. Institution Department of Surgery, University of Michigan Medical School, Ann Arbor. Title Efficacy of the Nissen fundoplication in the management of gastroesophageal reflux following esophageal atresia repair. Source Journal of Pediatric Surgery. 28(1):53-5, 1993 Jan. Abstract From January 1974 to December 1988, 80 patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) were treated at the C.S. Mott Children's Hospital with division of their TEF and esophagoesophagostomy. Thirty-four in this group developed gastroesophageal reflux (GER). After an unsuccessful trial of medical management, 21 underwent Nissen fundoplication, and an additional child with refractory GER died intraoperatively before completion of her fundoplication. Following fundoplication, only eight patients had an uncomplicated course with elimination of reflux and no postoperative dysphagia. Wrap disruption and recurrent reflux occurred in 7 of the 21 (33%), a markedly higher incidence than the 10% figure seen in 220 children without EA who have undergone fundoplication at this institution. Upward tension on the wrap due to the presence of a shortened esophagus probably predisposes to an increased frequency of fundoplication failure in the EA child. In addition, postoperative dysphagia requiring prolonged gastrostomy feedings complicated eight otherwise successful initial or redo-fundoplications. Prolonged dysphagia in this group is likely related to the inability of the dyskinetic esophagus, common in EA, to overcome the increased resistance caused by the Nissen fundoplication. Three deaths (14%) from complications related to antireflux surgery occurred in the series. Although 15 of the 21 children (71%) eventually had excellent long-term results following initial or redo-fundoplication with elimination of reflux and normalization of oral intake, morbidity and mortality were clearly significant. Due to the high incidence of postoperative dysphagia and recurrent reflux, the transabdominal Nissen fundoplication may not be appropriate in EA patients. <51> Unique Identifier 93222106 Authors Hanimann B. Sacher P. Stauffer UG. Institution Department of Surgery, University Children's Hospital Zurich. Title Complications and long-term results of the Nissen fundoplication. Source European Journal of Pediatric Surgery. 3(1):12-4, 1993 Feb. Abstract The Nissen fundoplication is the operative therapy of choice in children with symptomatic gastroesophageal reflux. In recent years several reports on specific complications of the Nissen fundoplication have been published. This report summarizes the complications in 45 patients on whom a Nissen fundoplication was performed in our clinic between 1979 and 1989. 18 patients (40%) showed early or late complications. In 10 patients (22%) reoperation was necessary. However, at follow-up with a mean period of 4 1/2 years after surgery, 36 patients (92%) showed good results without any residual symptoms. The Nissen fundoplication had in our hands a rather high rate of complications. However, late results were excellent and our healing rate (92%) was higher than reported in other series with different techniques. <54> Unique Identifier 94340329 Authors Lobe TE. Institution Section of Pediatric Surgery, LeBonheur Children's Medical Center, Memphis, TN. Title Laparoscopic fundoplication. Source Seminars in Pediatric Surgery. 2(3):178-81, 1993 Aug. Abstract For many years Nissen fundoplication has been the standard for surgical correction of gastroesophageal reflux. Fundoplication now can be performed laparoscopically as well. Advantages to the laparoscopic approach may include decreased complications, such as adhesive bowel obstruction, wound complications, and postoperative pulmonary complications. Moreover, there appears to be a shorter hospitalization time and an earlier return to enteral alimentation and unrestricted activities. <56> Unique Identifier 93036222 Authors Fonkalsrud EW. Ament ME. Vargas J. Institution Division of Pediatric Surgery, UCLA School of Medicine 90024. Title Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children. Source American Journal of Surgery. 164(4):327-31, 1992 Oct. Abstract Operative correction of symptomatic gastroesophageal reflux (GER) was undertaken in 530 children during a 21-year period. Gastroesophageal fundoplication (GEF) alone was performed in 415 children; 83 had simultaneous GEF and pyloroplasty; 13 had pyloroplasty alone; and 19 had GEF with later pyloroplasty. Of the last 355 children with reflux, 110 (31%) had pyloroplasty. Pyloroplasty was performed for persistent symptoms despite medical therapy when more than 60% of the isotope meal was retained in the stomach at 90 minutes. Children with central nervous system disorders and GER often had delayed gastric emptying (DGE). A modified Heineke-Mikulicz pyloroplasty was used for the first 59 children; the last 56 patients had a more simplified antroplasty with a 2.5- to 3.5-cm vertical incision through the antral muscularis down to the duodenum without mucosal incision; the muscularis was reapproximated in a transverse direction with sutures. With a mean follow-up of 5.8 years, only three patients experienced mild transient dumping. None had pyloroplasty leak or clinical evidence of alkaline reflux. Antroplasty is a helpful, simple adjunct to GEF with low morbidity in children with GER and DGE. <57> Unique Identifier 93036223 Authors Udassin R. Seror D. Vinograd I. Zamir O. Godfrey S. Nissan S. Institution Department of Pediatric Surgery, Hadassah University Hospital, Mount Scopus, Jerusalem, Israel. Title Nissen fundoplication in the treatment of children with familial dysautonomia. Source American Journal of Surgery. 164(4):332-6, 1992 Oct. Abstract Thirty-four children with familial dysautonomia (FD) underwent Nissen fundoplication and gastrostomy. The indications for operation were persistent cyclic vomiting that resulted in repeated aspiration pneumonia (94% of the patients), chronic dehydration (82%), failure to thrive (97%), and frequent hospitalizations (76%). There was no operative or early postoperative mortality. Long-term follow-up for up to 12 years was available. Eight patients died during this period from 7 months to 7.5 years postoperatively. In 5 patients (15% of the operated patients), the fundoplication ceased to function 16 months to 5 years postoperatively, which was attributed mainly to repeated severe dysautonomic crises with vigorous retching. Vomiting ceased in 85% of the symptomatic patients; pulmonary deterioration was halted, and the frequency of aspiration pneumonia was reduced in 68%; nutritional improvement was seen in 44%; the hydration status improved in 88%; and the frequency of hospital admissions decreased in 74%. These long-term findings resulted in a significant improvement in the quality of life for the majority of the patients. The absence of operative mortality and the low postoperative morbidity, together with the long-term beneficial results of this surgical procedure, should encourage early surgical intervention in selected FD patients. <61> Unique Identifier 92337478 Authors Smith CD. Othersen HB Jr. Gogan NJ. Walker JD. Institution Department of Surgery, Medical University of South Carolina, Charleston 29425. Title Nissen fundoplication in children with profound neurologic disability. High risks and unmet goals. Source Annals of Surgery. 215(6):654-8; discussion 658-9, 1992 Jun. Abstract Anti-reflux procedures have been advocated in children with profound neurologic disability referred for feeding gastrostomy when gastroesophageal reflux is present. Facilitation of care, reduction in pneumonia and vomiting, and improvement in the general health and survival of these children have been major goals of fundoplication and gastrostomy. In large pediatric series, these procedures have been reported to have low risk and negligible mortality rates. Recent reports, however, document an increased incidence of sequelae of fundoplication in children with profound neurologic disability. This paper retrospectively reviews a series of 35 nonverbal, nonambulatory pediatric patients undergoing a total of 39 fundoplications (37 Nissen, 1 Thal, and 1 Belsey) over an 11-year period. Neurologic impairment of 17 (49%) patients was acquired, 13 (37%) congenital, and 5 (14%) due to a syndrome. Perioperative complications occurred in six (17%). Three additional complications led to early postoperative death. A fourth early death was unexplained. Fourteen (40%) had recurrent pneumonia, 11 (31%) recurrent vomiting, 8 (23%) choking-gagging-retching complex, and 3 (9%) bowel obstruction requiring laparotomy. Recurrent gastroesophageal reflux was documented in seven (20%) patients. A second ARP was performed in six (17%). There were 14 (40%) late deaths. Although the major goals of anti-reflux procedure are clearly achieved in many severely impaired children with gastroesophageal reflux, the use of Nissen fundoplication to resolve the complications of swallowing disorders and improve outcome with an acceptably low risk in this complex set of patients does not appear to be established. <63> Unique Identifier 92364783 Authors Friesen CA. Holder TM. Ashcraft KW. Hodge C. Roberts CC. Institution Department of Gastroenterology, Children's Mercy Hospital, Kansas City, MO 64108. Title Abbreviated esophageal pH monitoring as an indication for fundoplication in children. Source Journal of Pediatric Surgery. 27(6):775-7, 1992 Jun. Abstract Intraesophageal pH recordings from 40 patients with abnormal studies who underwent fundoplication during a 1-year period were evaluated. Scores were recalculated for the first 12, 16, and 20 hours, respectively. Five of the recordings were for less than 24 hours, but were grossly abnormal and mathematically could not have normalized at 24 hours. The percentage of studies which were normal at 12, 16, and 20 hours were 20%, 15%, and 0%, respectively. One fifth of the patients would have been denied a fundoplication based on 12-hour results. In addition, 75 consecutive pH recordings were evaluated prospectively. Total scores were determined for the first 12, 16, and 20 hours with accuracies of 85%, 93%, and 92%, respectively. The sensitivity of 12-hour monitoring was only 78%. All abbreviated studies had a low rate of false positives; however, any false positives may be significant when used to determine the need for an operation. Abbreviated studies were associated with high false-negative rates (up to 52% for the 12-hour studies) for the calculated mean duration of sleep reflux, a parameter that has been found to be useful in identifying patients with respiratory symptoms secondary to gastroesophageal reflux. The use of abbreviated pH monitoring is discouraged. <65> Unique Identifier 92181285 Authors McGrath SJ. Splaingard ML. Alba HM. Kaufman BH. Glicklick M. Institution Medical College of Wisconsin, Milwaukee. Title Survival and functional outcome of children with severe cerebral palsy following gastrostomy. Source Archives of Physical Medicine & Rehabilitation. 73(2):133-7, 1992 Feb. Abstract Survival, functional outcome, care setting, early and late complications, and caregiver satisfaction were determined in 61 children with severe cerebral palsy requiring gastrostomies during a six-year period. Fifty-three (87%) of the initial gastrostomies included a Nissen fundoplication. Early and late complications were 32.8% and 39.3%, respectively. Survival after initial surgery was 84.2% at one year, and 67.6% at four years. One child died within one month of surgery. Seventy percent of the children remained totally dependent in self-care, mobility, and communication; an additional 29% had significant limitations in function. Only 4 children (6.5%) ultimately became independent in feeding. Ninety-three percent of the children were cared for at home. Ninety-four percent of the parents/caregivers believed the gastrostomy was beneficial in management of the child. Survival was unexpectedly high compared to studies of adults and mentally retarded children requiring similar surgical procedures. <68> Unique Identifier 92226938 Authors Martinez DA. Ginn-Pease ME. Caniano DA. Institution Department of Surgery, Ohio State University College of Medicine, Columbus. Title Sequelae of antireflux surgery in profoundly disabled children [see comments]. Source Journal of Pediatric Surgery. 27(2):267-71; discussion 271-3, 1992 Feb. Abstract Between 1976 and 1989 an antireflux operation (193 Nissen; 5 Thal) was performed in 198 children with profound neurological impairment (NI). Etiology of the NI was a syndrome in 24%, congenital in 30%, and acquired in 46%. The most frequent symptoms of gastroesophageal reflux (GER), vomiting and pneumonia, were significantly reduced (P less than .05) after the antireflux operation. Postoperatively, 141 children (71%) developed return of one or more symptoms that had been preoperatively associated with GER, whereas 57 patients (29%) remained asymptomatic. Of the children with symptoms, 86 (61%) underwent diagnostic testing to exclude recurrent GER and 55 (39%) had no diagnostic evaluation. Recurrent GER was documented in 31 patients and a mechanical problem with the fundoplication in 18 children, an operative failure rate of 25%. The symptom-free interval following the antireflux operation averaged 11 months postoperatively; return of symptoms showed no statistical relationship to the etiology of NI, presence of seizures, or degree of muscle tone. The majority of children required multiple outpatient or emergency department visits for evaluation of these symptoms or assessment of gastrostomy tube problems. Survival of all children was 71% at an average postoperative follow-up of 3.5 years. <71> Unique Identifier 93020065 Authors Martinez DA. Ginn-Pease ME. Caniano DA. Institution Department of Surgery, Ohio State University College of Medicine, Columbus. Title Recognition of recurrent gastroesophageal reflux following antireflux surgery in the neurologically disabled child: high index of suspicion and definitive evaluation. Source Journal of Pediatric Surgery. 27(8):983-8; discussion 988-90, 1992 Aug. Abstract Multiple symptoms suggestive of gastroesophageal reflux (GER) developed in 181 of 240 children (75%) with profound neurological impairment (NI) following operative management of GER. Diagnostic testing was performed in 102 children, 56% of patients with symptoms. Recurrent GER was evident on one or more diagnostic studies in 46% of children evaluated. Significant differences (P less than .05) were found in the testing protocols of children with studies positive for GER and those individuals with negative tests. Children with study-documented recurrent GER: (1) had testing conducted at a more remote time postoperatively; (2) received a greater number of total tests; (3) were evaluated by more than one type of diagnostic test; and (4) underwent upper endoscopy and pH monitoring more frequently. No single clinical symptom was predictive of study-documented recurrent GER. These results suggest that recognition of recurrent GER after an antireflux operation in a child with profound NI requires a high index of suspicion. Definitive evaluation of children with postoperative symptoms demands repeated testing over time and the use of more than one type of diagnostic test. A contrast study should be used to evaluate the mechanical properties of the fundoplication and esophagoscopy and/or esophageal pH monitoring to assess the physiological control of GER. <73> Unique Identifier 93048204 Authors Borowitz SM. Borowitz KC. Institution Department of Pediatrics, University of Virginia Health Sciences Center, Charlottesville 22908. Title Oral dysfunction following Nissen fundoplication. Source Dysphagia. 7(4):234-7, 1992. Abstract In this case report we describe a child with mild neurologic impairment who developed debilitating gagging and retching, and severe oral-motor dysfunction following Nissen fundoplication and gastrostomy tube placement. All oral intake ceased after the operation. Evaluation for postoperative dumping syndrome was negative, and the child's symptoms failed to improve despite numerous medical and surgical measures. However, immediately following reversal of the Nissen fundoplication, the child's gagging and retching ceased, and his oral-motor function began to improve. This is a previously undescribed complication of Nissen fundoplication, a surgical procedure commonly employed in children with neurologic impairment. <74> Unique Identifier 92005068 Authors Alawadhi A. Chou S. Soucy P. Institution Department of Surgery, Children's Hospital of Eastern Ontario, Ottawa. Title Gastric volvulus--a late complication of gastrostomy. Source Canadian Journal of Surgery. 34(5):485-6, 1991 Oct. Abstract Two cases of gastric volvulus are reviewed. Both patients were nonverbal, mentally handicapped children, who were fed through a gastrostomy. They had intermittent intolerance to bolus feeds through the gastrostomy, accompanied by abdominal distension and vomiting of gastric contents. One had a previous partial fundoplication and gastrostomy, and the other had had two pyloroplasties and gastrostomy. The axis of torsion ran from the esophagogastric junction to the gastrostomy site. Both children were treated by detorsion and gastropexy. It is postulated that the gastrostomy served as a fixed point for the volvulus. This was facilitated by the chronically dilated stomachs induced by bolus feeds. These two cases are reported to alert the clinician to this possibility when a neurologically impaired child with a gastrostomy presents with feeding difficulties and persistent vomiting. <75> Unique Identifier 92088368 Authors Simpson ET. Keating S. Price J. Institution Department of Paediatric Surgery, Royal Canberra Hospital, ACT. Title Caecal volvulus in a child: an unusual postoperative complication. Source Australian & New Zealand Journal of Surgery. 61(11):860-2, 1991 Nov. Abstract A 2.5 year old dysmorphic child with severe gastro-oesophageal reflux was admitted for elective fundoplication. Three days postoperatively, she developed progressive signs of intestinal obstruction. The diagnosis of caecal volvulus was suggested on the plain radiographic appearance, confirmed at laparotomy and treated by right hemicolectomy. The predisposing factors, diagnosis and approach to surgical management are discussed. <76> Unique Identifier 92251544 Authors Robie DK. Pearl RH. Institution Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307. Title Modified Nissen fundoplication: improved results in high-risk children. Source Journal of Pediatric Surgery. 26(11):1268-72, 1991 Nov. Abstract A modified Nissen fundoplication was performed in 29 children (26 neurologically impaired and 3 neurologically normal). The modifications to the Nissen 360 degrees wrap were: (1) deliberate crural repair with pledgets; (2) recreation of the angle of His; and (3) anchoring wrap to the diaphragm. Presenting complaints were respiratory in 66%, nutritional in 28%, and for prophylaxis in 2 patients requiring gastrostomy tubes. Prospective follow-up was obtained in 26 of 29 patients for an average of 19 months. Early postoperative complications occurred in 3 patients, none due to recurrent reflux. Six late deaths occurred due to neurological deterioration, pulmonary disease, and medication overdose. Barium swallows were obtained in 20 of 22 available patients postoperatively and all wraps were intraabdominal. We conclude that the modified Nissen prevents wrap herniation and improves postoperative results in the high-risk neurologically impaired child. <77> Unique Identifier 92054759 Authors Holcomb GW 3d. Ross AJ 3d. O'Neill JA Jr. Institution Children's Hospital of Philadelphia. Title Postoperative intussusception: increasing frequency or increasing awareness?. Source Southern Medical Journal. 84(11):1334-9, 1991 Nov. Abstract Postoperative intussusception in children is a rare but well recognized phenomenon. The diagnosis is often delayed due to the protean manifestations of the disorder (ileus, distention, and nausea and vomiting) which, when encountered shortly after an abdominal operation, usually result in a low index of suspicion because they are common after laparotomy. Experience with two cases of postoperative intussusception within 24 hours heightened our index of suspicion. Review of our records indicated we had diagnosed and treated postoperative intussusception in 14 children during the preceding 4 years. Patient ages ranged from 4 months to 12 years (mean 39 months, median 20 months), and symptoms appeared on postoperative days 3 to 36 (mean 10 days, median 6 days). Initial operations included excision of a retroperitoneal or abdominal tumor (five cases), Nissen fundoplication and gastrostomy (three), ileal resection (two), Ladd procedure (one), Duhamel operation (one), and operative reduction of ileocolic intussusception (the two most recent cases). Eleven patients had appendectomy (five by the inversion technique), and three had placement of a transgastric small bowel feeding tube. Nine children had had either barium enema or upper gastrointestinal studies because of the postoperative suspicion of obstruction; one patient had both. Diagnostic studies were not done in four patients. Operative reduction was successful in all but one child, who required bowel resection. <78> Unique Identifier 91215446 Authors Parikh D. Tam PK. Institution Institute of Child Health, University of Liverpool, UK. Title Results of fundoplication in a UK paediatric centre. Source British Journal of Surgery. 78(3):346-8, 1991 Mar. Abstract Of 55 children (age 3 months to 16 years) who had fundoplication, major complications occurred in nine (16 per cent): paraoesophageal hernia (five cases), prolonged ileus (two cases), recurrent gastro-oesophageal reflux (one case), and accidental perforation (one case). The single most important factor resulting in complications was the omission of crural repair; of seven patients without crural repair, five developed paraoesophageal hernia/recurrence. Four patients required repeat fundoplication for severe recurrent symptoms and one of these developed the unusual complication of pericardiogastric fistula. Thirteen patients had strictures before operation from reflux oesophagitis, six (46 per cent) resolved after fundoplication alone, six responded to dilatation (mean five sessions), and one required colon interposition. Our preliminary experience with balloon dilatation was encouraging: three of three patients responded after one dilatation only. These results confirmed the efficacy of surgery in controlling reflux: 100 per cent in the short-term and 89 per cent on a 1-6 year follow-up. Major complications might well be reduced by routine crural repair. <81> Unique Identifier 92045247 Authors Rice H. Seashore JH. Touloukian RJ. Institution Section of Pediatric Surgery, Yale University School of Medicine, New Haven, CT 06510. Title Evaluation of Nissen fundoplication in neurologically impaired children. Source Journal of Pediatric Surgery. 26(6):697-701, 1991 Jun. Abstract The value of performing Nissen fundoplication in neurologically impaired children is a controversial issue. To evaluate the benefit of fundoplication in these children, hospital records were reviewed for 77 children who underwent fundoplication for gastroesophageal reflux (GER). Fifty-two children were neurologically impaired; 25 children had no neurological impairment. Impaired children had significantly fewer hospital admissions (1.8 v 0.7; P less than .005) and total days of hospitalization (36 v 14; P less than .005) during the first postoperative 6 months, compared with the immediate preoperative 6-month period. Normal children had fewer hospital admissions and days postoperatively, but the difference was not significant. Impaired children with preoperative failure to thrive (FTT had significantly increased average monthly weight gain over the first 6-month period postoperatively, compared with preoperative growth rate (3.0% v 0.9% of total body weight; P less than .05). Average monthly weight gain at 1 and 2 years postoperatively was not significantly different from preoperative values for impaired children. Growth rate of normal children with FTT did not change significantly postoperatively. Symptomatic relief was comparable in the normal and impaired children. Perioperative mortality was 0% in the normal children and 6% in the impaired children. This study demonstrates that Nissen fundoplication in neurologically impaired children with GER can be performed safely, reduces the frequency of hospitalization, and improves short-term weight gain. <82> Unique Identifier 91347608 Authors Treem WR. Davis PM. Hyams JS. Institution Division of Pediatric Gastroenterology and Nutrition, Hartford Hospital, CT 06115. Title Gastroesophageal reflux in the older child: presentation, response to treatment and long-term follow-up. Source Clinical Pediatrics. 30(7):435-40, 1991 Jul. Abstract Much attention has been focused on the natural history of gastroesophageal reflux (GER) in neurologically normal infants which generally resolves by two years of age. In contrast, little is known of the outcome of GER diagnosed in normal older children. The charts of 32 children (21 males) without neurologic or esophageal anatomic abnormalities, age 3.5 to 16 years (mean = 9.8) at the time of diagnosis, were reviewed. Diagnosis was based on suggestive presenting symptoms and evaluation of prolonged intraesophageal pH monitoring. Esophagitis was diagnosed by histologic criteria in 16 of the 32 patients. Medical treatment consisted of prokinetic agents (metoclopramide, bethanechol) and H2-receptor antagonists. After a one to eight year follow-up period (mean +/- SD - 3.4 +/- 2.1), the symptoms in 13 children had resolved or were sufficiently improved to discontinue medication. In 13 patients, symptoms were improved but medication was required for adequate control. Four children were symptomatic without improvement in spite of medical therapy and two others required fundoplication for continued severe symptoms and refractory esophagitis. In summary, less than 50% of otherwise normal older children with GER undergo spontaneous resolution of marked improvement in symptoms and the remainder require continued long-term medical and/or surgical management. <83> Unique Identifier 92014572 Authors Chen PH. Chang MH. Hsu SC. Institution Department of Pediatrics, National Taiwan University Hospital, Taipei, Republic of China. Title Gastroesophageal reflux in children with chronic recurrent bronchopulmonary infection. Source Journal of Pediatric Gastroenterology & Nutrition. 13(1):16-22, 1991 Jul. Abstract To evaluate the role of gastroesophageal reflux (GER) as a possible cause of recurrent bronchopulmonary infection in Chinese children, 23 patients were studied prospectively with 24-h pH monitoring. Their ages ranged from 3 to 25 months. The patients studied were chosen by the criterion of repeated, radiographically documented bronchopulmonary infection with a frequency of two or more episodes in the most recent 6 months, or a single episode with a protracted course longer than 3 months. Twenty-one of the 23 showed abnormal GER on 24-h pH monitoring. Twenty children received medical therapy, 17 of whom were followed regularly for 14-29 months. Eleven had subsidence or improvement of symptoms at follow-up. Follow-up pH monitoring was performed in 5 of the 11 patients, and showed improvement. Six failed to show improvement with medical therapy. Follow-up pH monitoring revealed increased reflux in two of them. Three of the six received fundoplication and had marked improvement of reflux and symptoms postoperatively. Clinical resolution corresponded well to 24-h pH monitoring. GER may be considered one of the possible contributing factors in any child with chronic recurrent bronchopulmonary infection, and antireflux therapy might be beneficial. Twenty-four hour pH monitoring was the best single test for diagnosing GER and determining the severity of the disease. <84> Unique Identifier 91374233 Authors Wheatley MJ. Coran AG. Wesley JR. Oldham KT. Turnage RH. Institution Department of Surgery, University of Michigan Medical School, Ann Arbor. Title Redo fundoplication in infants and children with recurrent gastroesophageal reflux. Source Journal of Pediatric Surgery. 26(7):758-61, 1991 Jul. Abstract The Nissen fundoplication is well established as the surgical treatment for medically refractory gastroesophageal reflux (GER) in childhood. Recurrent GER following fundoplication is a challenging problem with a reported incidence ranging from 0% to 12%. From January 1974 to January 1989, 286 children have been treated for GER with Nissen fundoplication and gastrostomy tube placement at the University of Michigan C.S. Mott Children's Hospital; 242 of these children have been followed for an average of 30 months, the remaining 44 have been lost to follow-up. Twenty-nine children (12%) have developed recurrent reflux following fundoplication. Medical management with thickened upright feelings, gastrostomy feedings, or gastrojejunostomy tube feedings has been successful for 11 children with control of reflux symptoms. Five additional children who were treated nonoperatively died of coexistant medical problems within 2 months following documentation or recurrent reflux. The remaining 13 children have required redo fundoplication for wrap disruption or herniation, and an additional six children, initially treated at other institutions, have also undergone redo fundoplications. One other child treated at this hospital required redo fundoplication for a postoperative partial gastric volvulus causing gastric outlet obstruction. Of the 20 children who have undergone a second Nissen fundoplication, 16 (80%) are doing well without recurrent GER. Four children have developed recurrent GER with wrap disruption; 1 is doing well following a third fundoplication, 2 have been managed successfully with continuous feedings via gastrojejunostomy feeding tubes, and a fourth child died of complications related to a recurrent tracheoesophageal fistula. Conservative management with gastrojejunal tube feedings should be considered in the initial management of children with recurrent GER following fundoplication.(ABSTRACT TRUNCATED AT 250 WORDS) <86> Unique Identifier 91269000 Authors Di Lorenzo C. Flores A. Hyman PE. Institution Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA 90502. Title Intestinal motility in symptomatic children with fundoplication. Source Journal of Pediatric Gastroenterology & Nutrition. 12(2):169-73, 1991 Feb. Abstract Fundoplication alters the anatomy of the lower esophageal sphincter but should have no direct effects on motility distal to the sphincter. Of 55 children referred for evaluation of symptoms consistent with upper gastrointestinal motor dysfunction, 28 had undergone fundoplication 6 months to 4 years earlier to treat severe gastroesophageal reflux that had failed medical management. All 28 children had symptoms that were unchanged or worsened after fundoplication. In all children, we studied fasting and fed antroduodenal motility, and compared results from groups with and without fundoplication. Abnormalities in antroduodenal motility were found in 25 of 28 of the fundoplication group and in 25 of 27 of unoperated children. We found a wide range of abnormalities, but there were no differences in the types of severity of abnormalities between groups. In summary, in children with severe functional gastrointestinal symptoms, antroduodenal manometry uncovered physiological abnormalities, and fundoplication failed to relieve symptoms. These data suggest that preoperative intestinal manometry could identify children unlikely to benefit from fundoplication. <88> Unique Identifier 92134092 Authors Khoshoo V. Reifen RM. Gold BD. Sherman PM. Pencharz PB. Institution Department of Pediatrics, Louisiana State University Medical Center, New Orleans. Title Nutritional manipulation in the management of dumping syndrome. Source Archives of Disease in Childhood. 66(12):1447-8, 1991 Dec. Abstract Two children with Nissen's fundoplication and either gastrocystoplasty or pyloroplasty developed dumping syndrome. Correction of their blood glucose abnormalities, resolution of symptoms, and weight gain were effectively achieved by addition of fats and uncooked corn starch (50 g/l) to their feeds. <90> Unique Identifier 92068600 Authors Justo RN. Gray PH. Institution Department of Neonatology, Mater Misericordiae Hospital, South Brisbane, Queensland, Australia. Title Fundoplication in preterm infants with gastro-oesophageal reflux. [Review] Source Journal of Paediatrics & Child Health. 27(4):250-4, 1991 Aug. Abstract Gastro-oesophageal reflux in preterm infants may result in recurrent pulmonary insult due to aspiration of gastric contents, and intractable obstructive apnoea. Fundoplication is effective in controlling reflux when medical management has failed. Our experience between 1981 and 1990 was reviewed to assess the efficacy of early surgery in the management of 11 such infants. The infants had a median gestational age of 29 weeks and a median birthweight of 1032 g. Nine infants had fundoplication for recurrent aspiration pneumonitis and two for intractable apnoea. The median age at the time of surgery was 100 days and the median weight of the infants was 2640 g. Nine infants were oxygen dependent and two were still ventilated at the time of surgery. The operative procedure was well tolerated by 10 of the 11 infants. Surgery failed to control reflux in two infants, although good control was obtained in the one who had subsequent surgery. Three infants required prolonged ventilation postoperatively; two of them died later from pulmonary failure. The median time to discharge was 24 days (8-113 days). All infants with intractable apnoea were cured by surgery. Fundoplication is an effective method of management when used early in the treatment of chronic gastro-oesophageal reflux in preterm infants. There is minimal morbidity from the surgical procedure. [References: 23] <92> Unique Identifier 91249904 Authors Pittschieler K. Institution Paediatric Gastroenterology, Department of Paediatrics, Bozen, Italy. Title Dumping syndrome after combined pyloroplasty and fundoplication [see comments]. Source European Journal of Pediatrics. 150(6):410-2, 1991 Apr. Abstract Dumping syndrome in infancy is a rare complication following gastric surgery. We describe an 11-month-old infant affected by recurrent peptic oesophagitis who underwent a combined Nissen fundoplication and pyloroplasty. Early dumping symptoms such as irritability, pallor, sweating, abdominal distension and watery diarrhoea were observed postoperatively after bolus feeding. Gastric emptying, measured after the administration of 150 ml of regular cow milk mixed with 200 microCi (8 MBq) of technetium-99m sulfur colloid (99mTc-SC), demonstrated an early rapid and massive emptying of the isotopes into the small intestine, followed by duodenogastric reflux and a second wave of emptying and reflux at 9 min. The initial pattern of gastric emptying and duodenogastric reflux was followed by a slow emptying phase with half-emptying time of 81 min. Isotope studies should be used to investigate motility disorders caused by this type of anti-reflux operation. Medline Search Subject - Fundoplication October 16, 1995 page 38 of 1