Last Update: October 16, 1996

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Search for: (nissen or fundoplication) and (pediatric) for the last 24 months yields the following:

Database: Medline <1991 to October 1996> 
Gastroesophageal reflux in children.
Bagwell CE
Division of Pediatric Surgery, Medical College of Virginia, Richmond,
Surg Annu, 27:1995, 133-63
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.
Care of the infant with gastroesophageal reflux and respiratory
disease: after the Nissen fundoplication.
Parrish RS; Berube MC
J Pediatr Health Care, 9: 5, 1995 Sep-Oct, 211-7
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.
Gastroesophageal reflux in childhood.
Fonkalsrud EW; Ament ME
Pediatric Surgery, UCLA School of Medicine, USA.
Curr Probl Surg, 33: 1, 1996 Jan, 1-70
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.
Laparoscopic Thal fundoplication in severely scoliotic children.
van der Zee DC; Bax NM
Department of Pediatric Surgery, University Children's Hospital
Wilhelmina, Utrecht, The Netherlands.
Surg Endosc, 9: 11, 1995 Nov, 1197-8
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.
Gastroesophageal reflux. Diagnostic and therapeutic approaches.
Hillemeier AC
Division of Pediatric Gastroenterology, University of Michigan, Ann
Arbor, Michigan 48109-0200, USA.
Pediatr Clin North Am, 43: 1, 1996 Feb, 197-212
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.
Unique Identifier 
Heine RG. Reddihough DS. Catto-Smith AG. 
Department of Gastroenterology, Royal Children's Hospital, 
Parkville, Victoria, Australia. 
Gastro-oesophageal reflux and feeding problems after 
gastrostomy in children with severe neurological 
Developmental Medicine & Child Neurology. 37(4):320-9, 
1995 Apr. 
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. 
Unique Identifier 
Veit F. Schwagten K. Auldist AW. Beasley SW. 
Department of Surgery, Royal Children's Hospital, 
Parkville, Victoria, Australia. 
Trends in the use of fundoplication in children with 
gastro-oesophageal reflux. 
Journal of Paediatrics & Child Health. 31(2):121-6, 1995 
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. 
Unique Identifier 
Fonkalsrud EW. Ellis DG. Shaw A. Mann CM Jr. Black TL. 
Miller JP. Snyder CL. 
Department of Surgery, University of California Los Angeles 
School of Medicine, USA. 
A combined hospital experience with fundoplication and 
gastric emptying procedure for gastroesophageal reflux in 
Journal of the American College of Surgeons. 
180(4):449-55, 1995 Apr. 
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. 
Unique Identifier 
Hallerback B. Glise H. Johansson B. 
Dept. of Surgery, NAL, Trollhattan, Sweden. 
Laparoscopic Rosetti fundoplication. 
Scandinavian Journal of Gastroenterology - Supplement. 
208:58-61, 1995. 
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 
Unique Identifier 
Bagwell CE. 
Division of Pediatric Surgery, Medical College of Virginia, 
Richmond, USA. 
Gastroesophageal reflux in children. [Review] 
Surgery Annual. 27:133-63, 1995. 
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] 
Unique Identifier 
Bensoussan AL. Yazbeck S. Carceller-Blanchard A. 
Division of Pediatric General Surgery, Hopital 
Sainte-Justine, Montreal, Quebec, Canada. 
Results and complications of Toupet partial posterior wrap: 
10 years' experience. 
Journal of Pediatric Surgery. 29(9):1215-7, 1994 Sep. 
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 
Unique Identifier 
Krishnamoorthy M. Mintz A. Liem T. Applebaum H. 
Kaiser Permanente Medical Center, Los Angeles, California. 
Diagnosis and treatment of respiratory symptoms of 
initially unsuspected gastroesophageal reflux in infants. 
American Surgeon. 60(10):783-5, 1994 Oct. 
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) 
Unique Identifier 
Lelli JL. Ashcraft KW. 
Department of Surgery, University of Michigan Medical 
School, Ann Arbor. 
Gastroesophageal reflux. [Review] 
Seminars in Thoracic & Cardiovascular Surgery. 6(4):240-6, 
1994 Oct. 
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] 
Unique Identifier 
Khoshoo V. Roberts PL. Loe WA. Golladay ES. Pencharz 
Children's Hospital, New Orleans, LA 70118. 
Nutritional management of dumping syndrome associated with 
antireflux surgery. 
Journal of Pediatric Surgery. 29(11):1452-4, 1994 Nov. 
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. 
Unique Identifier 
Kazerooni NL. VanCamp J. Hirschl RB. Drongowski RA. 
Coran AG. 
Section of Pediatric Surgery, Mott Children's Hospital, Ann 
Arbor, MI. 
Fundoplication in 160 children under 2 years of age. 
Journal of Pediatric Surgery. 29(5):677-81, 1994 May. 
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) 
Unique Identifier 
Maxson RT. Harp S. Jackson RJ. Smith SD. Wagner CW. 
Department of Surgery, University of Arkansas for Medical 
Sciences, Little Rock. 
Delayed gastric emptying in neurologically impaired 
children with gastroesophageal reflux: the role of 
Journal of Pediatric Surgery. 29(6):726-9, 1994 Jun. 
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 
Unique Identifier 
Watanabe Y. Catto-Smith AG. 
Department of General Surgery, Royal Children's Hospital, 
Parkville, Melbourne, Australia. 
The clinical significance of a prolonged stable pH around 
4.0 in 24-h pH monitoring. 
Journal of Pediatric Gastroenterology & Nutrition. 
19(1):50-7, 1994 Jul. 
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 
Unique Identifier 
Buchmiller TL. Curr M. Fonkalsrud EW. 
Division of Pediatric Surgery, University of California Los 
Angeles School of Medicine. 
Assessment of alkaline reflux in children after Nissen 
fundoplication and pyloroplasty [published erratum appears 
in J Am Coll Surg 1994 Apr;178(4):416]. 
Journal of the American College of Surgeons. 178(1):1-5, 
1994 Jan. 
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. 
Unique Identifier 
Mira-Navarro J. Bayle-Bastos F. Frieyro-Segui M. 
Garramone N. Gambarini A. 
Servicio de Cirugia Infantil, Hospital General de Alicante, 
Long-term follow-up of Nissen fundoplication. 
European Journal of Pediatric Surgery. 4(1):7-10, 1994 
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. 
Unique Identifier 
Taylor LA. Weiner T. Lacey SR. Azizkhan RG. 
Division of Pediatric Surgery, University of North Carolina 
School of Medicine, Chapel Hill 27599-7210. 
Chronic lung disease is the leading risk factor correlating 
with the failure (wrap disruption) of antireflux procedures 
in children. 
Journal of Pediatric Surgery. 29(2):161-4; discussion 
164-6, 1994 Feb. 
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) 
Unique Identifier 
Schier F. Waldschmidt J. 
Department of Paediatric Surgery, University Medical Centre 
Steglitz, Berlin, Germany. 
Laparoscopic fundoplication in a child. 
European Journal of Pediatric Surgery. 4(6):338-40, 1994 
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. 
Unique Identifier 
Fleisher DR. 
Department of Child Health, University of Missouri School 
of Medicine, Columbia 65212. 
Functional vomiting disorders in infancy: innocent 
vomiting, nervous vomiting, and infant rumination syndrome. 
Journal of Pediatrics. 125(6 Pt 2):S84-94, 1994 Dec. 
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] 
Unique Identifier 
Hyman PE. 
Department of Pediatrics, University of California, Los 
Gastroesophageal reflux: one reason why baby won't eat. 
Journal of Pediatrics. 125(6 Pt 2):S103-9, 1994 Dec. 
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: 
Unique Identifier 
Bliss D. Hirschl R. Oldham K. Chey J. Cilley R. Blane 
C. Olson A. Shulkin B. Coran A. 
Section of Pediatric Surgery, C.S. Mott Children's 
Hospital, Ann Arbor, MI 48109-0245. 
Efficacy of anterior gastric fundoplication in the 
treatment of gastroesophageal reflux in infants and 
Journal of Pediatric Surgery. 29(8):1071-4; discussion 
1074-5, 1994 Aug. 
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 
Unique Identifier 
Veit F. Heine RG. Catto-Smith AG. 
Department of Gastroenterology, Royal Children's Hospital, 
Parkville, Victoria, Australia. 
Dumping syndrome after Nissen fundoplication. 
Journal of Paediatrics & Child Health. 30(2):182-5, 1994 
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. 
Unique Identifier 
Albanese CT. Towbin RB. Ulman I. Lewis J. Smith SD. 
Department of Pediatric Surgery, Children's Hospital of 
Pittsburgh, PA 15213-2583. 
Percutaneous gastrojejunostomy versus Nissen fundoplication 
for enteral feeding of the neurologically impaired child 
with gastroesophageal reflux. 
Journal of Pediatrics. 123(3):371-5, 1993 Sep. 
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. 
Unique Identifier 
DeCou JM. Shorter NA. Karl SR. 
Department of Surgery, Dartmouth-Hitchcock Medical Center, 
Lebanon, NH 03756. 
Feeding Roux-en-Y jejunostomy in the management of severely 
neurologically impaired children. 
Journal of Pediatric Surgery. 28(10):1276-9; discussion 
1279-80, 1993 Oct. 
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 
Unique Identifier 
Weerts JM. Dallemagne B. Hamoir E. Demarche M. 
Markiewicz S. Jehaes C. Lombard R. Demoulin JC. Etienne 
M. Ferron PE. et al. 
Department of Surgery of GI Tract, Clinique Saint-Joseph, 
Liege, Belgium. 
Laparoscopic Nissen fundoplication: detailed analysis of 
132 patients. 
Surgical Laparoscopy & Endoscopy. 3(5):359-64, 1993 Oct. 
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. 
Unique Identifier 
Varty K. Evans D. Kapila L. 
Department of Paediatric Surgery, Queens Medical Centre, 
Paediatric gastro-oesophageal reflux: prognostic indicators 
from pH monitoring. 
Gut. 34(11):1478-81, 1993 Nov. 
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 
Unique Identifier 
Georgeson KE. 
Children's Hospital of Alabama, Birmingham 35233. 
Laparoscopic gastrostomy and fundoplication. [Review] 
Pediatric Annals. 22(11):675-7, 1993 Nov. 
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] 
Unique Identifier 
Spitz L. Roth K. Kiely EM. Brereton RJ. Drake DP. 
Milla PJ. 
Department of Surgery, Hospital for Sick Children, London. 
Operation for gastro-oesophageal reflux associated with 
severe mental retardation. 
Archives of Disease in Childhood. 68(3):347-51, 1993 Mar. 
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. 
Unique Identifier 
Lobe TE. Schropp KP. Lunsford K. 
University of Tennessee, Memphis. 
Laparoscopic Nissen fundoplication in childhood [see 
Journal of Pediatric Surgery. 28(3):358-60; discussion 
360-1, 1993 Mar. 
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. 
Unique Identifier 
Moir CR. 
Department of Surgery, Mayo Foundation, Rochester, MN 
Laparoscopy and thoracostomy in children. [Review] 
Current Opinion in Pediatrics. 5(3):333-40, 1993 Jun. 
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] 
Unique Identifier 
Dellert SF. Hyams JS. Treem WR. Geertsma MA. 
Department of Pediatrics, Hartford Hospital, Connecticut 
Feeding resistance and gastroesophageal reflux in infancy. 
Journal of Pediatric Gastroenterology & Nutrition. 
17(1):66-71, 1993 Jul. 
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 
Unique Identifier 
Bauer ML. Figueroa-Colon R. Georgeson K. Young DW. 
Department of Pediatrics, University of Alabama, 
Chronic pulmonary aspiration in children. [Review] 
Southern Medical Journal. 86(7):789-95, 1993 Jul. 
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] 
Unique Identifier 
Wheatley MJ. Coran AG. Wesley JR. 
Department of Surgery, University of Michigan Medical 
School, Ann Arbor. 
Efficacy of the Nissen fundoplication in the management of 
gastroesophageal reflux following esophageal atresia 
Journal of Pediatric Surgery. 28(1):53-5, 1993 Jan. 
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. 
Unique Identifier 
Hanimann B. Sacher P. Stauffer UG. 
Department of Surgery, University Children's Hospital 
Complications and long-term results of the Nissen 
European Journal of Pediatric Surgery. 3(1):12-4, 1993 
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. 
Unique Identifier 
Lobe TE. 
Section of Pediatric Surgery, LeBonheur Children's Medical 
Center, Memphis, TN. 
Laparoscopic fundoplication. 
Seminars in Pediatric Surgery. 2(3):178-81, 1993 Aug. 
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. 
Unique Identifier 
Fonkalsrud EW. Ament ME. Vargas J. 
Division of Pediatric Surgery, UCLA School of Medicine 
Gastric antroplasty for the treatment of delayed gastric 
emptying and gastroesophageal reflux in children. 
American Journal of Surgery. 164(4):327-31, 1992 Oct. 
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. 
Unique Identifier 
Udassin R. Seror D. Vinograd I. Zamir O. Godfrey S. 
Nissan S. 
Department of Pediatric Surgery, Hadassah University 
Hospital, Mount Scopus, Jerusalem, Israel. 
Nissen fundoplication in the treatment of children with 
familial dysautonomia. 
American Journal of Surgery. 164(4):332-6, 1992 Oct. 
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 
Unique Identifier 
Smith CD. Othersen HB Jr. Gogan NJ. Walker JD. 
Department of Surgery, Medical University of South 
Carolina, Charleston 29425. 
Nissen fundoplication in children with profound neurologic 
disability. High risks and unmet goals. 
Annals of Surgery. 215(6):654-8; discussion 658-9, 1992 
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. 
Unique Identifier 
Friesen CA. Holder TM. Ashcraft KW. Hodge C. Roberts 
Department of Gastroenterology, Children's Mercy Hospital, 
Kansas City, MO 64108. 
Abbreviated esophageal pH monitoring as an indication for 
fundoplication in children. 
Journal of Pediatric Surgery. 27(6):775-7, 1992 Jun. 
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. 
Unique Identifier 
McGrath SJ. Splaingard ML. Alba HM. Kaufman BH. 
Glicklick M. 
Medical College of Wisconsin, Milwaukee. 
Survival and functional outcome of children with severe 
cerebral palsy following gastrostomy. 
Archives of Physical Medicine & Rehabilitation. 
73(2):133-7, 1992 Feb. 
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. 
Unique Identifier 
Martinez DA. Ginn-Pease ME. Caniano DA. 
Department of Surgery, Ohio State University College of 
Medicine, Columbus. 
Sequelae of antireflux surgery in profoundly disabled 
children [see comments]. 
Journal of Pediatric Surgery. 27(2):267-71; discussion 
271-3, 1992 Feb. 
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. 
Unique Identifier 
Martinez DA. Ginn-Pease ME. Caniano DA. 
Department of Surgery, Ohio State University College of 
Medicine, Columbus. 
Recognition of recurrent gastroesophageal reflux following 
antireflux surgery in the neurologically disabled child: 
high index of suspicion and definitive evaluation. 
Journal of Pediatric Surgery. 27(8):983-8; discussion 
988-90, 1992 Aug. 
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. 
Unique Identifier 
Borowitz SM. Borowitz KC. 
Department of Pediatrics, University of Virginia Health 
Sciences Center, Charlottesville 22908. 
Oral dysfunction following Nissen fundoplication. 
Dysphagia. 7(4):234-7, 1992. 
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. 
Unique Identifier 
Alawadhi A. Chou S. Soucy P. 
Department of Surgery, Children's Hospital of Eastern 
Ontario, Ottawa. 
Gastric volvulus--a late complication of gastrostomy. 
Canadian Journal of Surgery. 34(5):485-6, 1991 Oct. 
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. 
Unique Identifier 
Simpson ET. Keating S. Price J. 
Department of Paediatric Surgery, Royal Canberra Hospital, 
Caecal volvulus in a child: an unusual postoperative 
Australian & New Zealand Journal of Surgery. 61(11):860-2, 
1991 Nov. 
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. 
Unique Identifier 
Robie DK. Pearl RH. 
Department of Surgery, Walter Reed Army Medical Center, 
Washington, DC 20307. 
Modified Nissen fundoplication: improved results in 
high-risk children. 
Journal of Pediatric Surgery. 26(11):1268-72, 1991 Nov. 
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. 
Unique Identifier 
Holcomb GW 3d. Ross AJ 3d. O'Neill JA Jr. 
Children's Hospital of Philadelphia. 
Postoperative intussusception: increasing frequency or 
increasing awareness?. 
Southern Medical Journal. 84(11):1334-9, 1991 Nov. 
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. 
Unique Identifier 
Parikh D. Tam PK. 
Institute of Child Health, University of Liverpool, UK. 
Results of fundoplication in a UK paediatric centre. 
British Journal of Surgery. 78(3):346-8, 1991 Mar. 
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 
Unique Identifier 
Rice H. Seashore JH. Touloukian RJ. 
Section of Pediatric Surgery, Yale University School of 
Medicine, New Haven, CT 06510. 
Evaluation of Nissen fundoplication in neurologically 
impaired children. 
Journal of Pediatric Surgery. 26(6):697-701, 1991 Jun. 
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. 
Unique Identifier 
Treem WR. Davis PM. Hyams JS. 
Division of Pediatric Gastroenterology and Nutrition, 
Hartford Hospital, CT 06115. 
Gastroesophageal reflux in the older child: presentation, 
response to treatment and long-term follow-up. 
Clinical Pediatrics. 30(7):435-40, 1991 Jul. 
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. 
Unique Identifier 
Chen PH. Chang MH. Hsu SC. 
Department of Pediatrics, National Taiwan University 
Hospital, Taipei, Republic of China. 
Gastroesophageal reflux in children with chronic recurrent 
bronchopulmonary infection. 
Journal of Pediatric Gastroenterology & Nutrition. 
13(1):16-22, 1991 Jul. 
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. 
Unique Identifier 
Wheatley MJ. Coran AG. Wesley JR. Oldham KT. Turnage 
Department of Surgery, University of Michigan Medical 
School, Ann Arbor. 
Redo fundoplication in infants and children with recurrent 
gastroesophageal reflux. 
Journal of Pediatric Surgery. 26(7):758-61, 1991 Jul. 
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 
Unique Identifier 
Di Lorenzo C. Flores A. Hyman PE. 
Department of Pediatrics, Harbor-UCLA Medical Center, 
Torrance, CA 90502. 
Intestinal motility in symptomatic children with 
Journal of Pediatric Gastroenterology & Nutrition. 
12(2):169-73, 1991 Feb. 
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 
Unique Identifier 
Khoshoo V. Reifen RM. Gold BD. Sherman PM. Pencharz PB. 
Department of Pediatrics, Louisiana State University 
Medical Center, New Orleans. 
Nutritional manipulation in the management of dumping 
Archives of Disease in Childhood. 66(12):1447-8, 1991 Dec. 
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. 
Unique Identifier 
Justo RN. Gray PH. 
Department of Neonatology, Mater Misericordiae Hospital, 
South Brisbane, Queensland, Australia. 
Fundoplication in preterm infants with gastro-oesophageal 
reflux. [Review] 
Journal of Paediatrics & Child Health. 27(4):250-4, 1991 
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] 
Unique Identifier 
Pittschieler K. 
Paediatric Gastroenterology, Department of Paediatrics, 
Bozen, Italy. 
Dumping syndrome after combined pyloroplasty and 
fundoplication [see comments]. 
European Journal of Pediatrics. 150(6):410-2, 1991 Apr. 
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 
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