Surgical aspects in GERD in children.ppt

Antireflux surgery (ARS) for gastroesophageal reflux disease (GERD) is one of the most frequently performed
major operations in children. This study aims to review the efficacy of pediatric ARS and its complications and longterm results. ARS in children shows a good overall success rate in terms of complete relief of symptoms.

1. SURGICALSURGICAL ASPECTSASPECTS OFOF GASTROGASTRO--
ESOPHAGEALESOPHAGEAL REFLUXREFLUX DISEASEDISEASE IN IN
CHILDRENCHILDREN
OgnjanOgnjan BrankovBrankov
Department of Pediatric SurgeryDepartment of Pediatric Surgery
Emergency Hospital Emergency Hospital ““NN..II..PirogovPirogov” ”
SofiaSofia

2. DefinitionDefinition
1.1.Gastro-esophageal refluxGastro-esophageal reflux diseasedisease ((GERDGERD) ) –– the complex ofthe complex of
the complications resulting from GER.the complications resulting from GER.
2.2.GastroGastro--esophagealesophageal refluxreflux ((GERGER) –) – spontaneousspontaneous refluxreflux ofof
stomachstomach contentscontents into theinto the esophagusesophagus. .
3.3.CardiohalasiaCardiohalasia – – physiologicalphysiological condition incondition in newborns and newborns and
babiesbabies as a resultas a result ofof immaturity immaturity of the lowerof the lower esophagealesophageal
sphinctersphincter

3. The Montreal Definition - 2006The Montreal Definition - 2006
Esophageal SyndromesEsophageal Syndromes Extraesophageal SyndromesExtraesophageal Syndromes
SymptomaticSymptomatic
SyndromesSyndromes
Syndromes withSyndromes with
Esophageal injuryEsophageal injury
ProposedProposed
AssociationsAssociations
EstablishedEstablished
AssociationsAssociations
1.1.Typical Typical
RefluxReflux
SyndromeSyndrome
22. . IrritabilityIrritability
““Crying babyCrying baby
syndromesyndrome
1. 1. Reflux Reflux
EsophagitisEsophagitis
2. 2. Peptic orPeptic or
fibrous fibrous
stricturestricture
3. 3. Barrett’s Barrett’s
EsophagusEsophagus
1.1.ChronicChronic
pulmopathypulmopathy
2.Reflux Asthma2.Reflux Asthma
SyndromeSyndrome
3. Anemia 3. Anemia
4. 4. Laryngitis Laryngitis
5. Reflux Dental 5. Reflux Dental
Erosion SyndromeErosion Syndrome
1.Pharingitis1.Pharingitis
4.Recurrent4.Recurrent
Otitis mediaOtitis media

4. Pathogenesis of G E R DPathogenesis of G E R D
Cardiohalasia Hiatal herniaCardiohalasia Hiatal hernia
GERGER
Reflux-Reflux-
esophagitisesophagitis
StrictutreStrictutre
HypotrophyHypotrophy ErosionsErosions
Anemia Anemia
AspirationAspiration
PulmopathyPulmopathy
Neurological Neurological
symptomssymptoms
LaryngitisLaryngitis
Dental Dental
dystrophydystrophy

5. PathophysiologyPathophysiology ofof GERGER
“closing versus opening mechanisms”“closing versus opening mechanisms”
Closing mechanismsClosing mechanisms
Leimer’s membraneLeimer’s membrane
Hiatus esophageusHiatus esophageus
Abdominal part of the Abdominal part of the
esophagusesophagus
Hiss’s angle and valveHiss’s angle and valve
High pressure areaHigh pressure area
of the lower esophageal of the lower esophageal
sphincter sphincter ((LESLES))
ООpening mechanismspening mechanisms
Dysmotility andDysmotility and
andand
delayed gastric emptying delayed gastric emptying
IncreasedIncreased abdominalabdominal
pressurepressure
IncreasedIncreased stomachstomach volumevolume

6. Surgical conditionsSurgical conditions leadingleading to GERto GER
Congenital hiatus herniaCongenital hiatus hernia
Large esophagealLarge esophageal hiatus hiatus
andand looseloose phreno-phreno-
esophageal membraneesophageal membrane
withwith dysfunction of the dysfunction of the
LESLES

 Delayed gastric emptying Delayed gastric emptying
and increasedand increased intra-intra-
abdominalabdominal pressurepressure

7. Clinical significance of the hiatal herniaClinical significance of the hiatal hernia

HHiatusiatus herniahernia is not always present but is a concomitant is not always present but is a concomitant
factor forfactor for development ofdevelopment of GERDGERD. .
Total stomachTotal stomach herniashernias are excluded from our presentation. are excluded from our presentation.
They are treated surgicallyThey are treated surgically before occurrence of reflux before occurrence of reflux
diseasedisease because of thoracic compression syndromebecause of thoracic compression syndrome..

TransitoryTransitory (25 %) (25 %)
PermanentPermanent (33 %) (33 %)

8. Clinical symptoms Clinical symptoms 0 – 0 – 22 yearsyears
 VomitingVomiting 9 90 0 %%
 Night cough Night cough 64.1 64.1 %%
 Growth retardation 55.1%Growth retardation 55.1%
 AnemiaAnemia 42.342.3 % %
 HypotrophyHypotrophy 14.1 14.1%%
 Irritability Irritability 116.7 6.7 %%

9. Clinical symptoms Clinical symptoms 3-7 years 3-7 years
 Dysphagia / vomiting 90Dysphagia / vomiting 90 % %
 Recurrent lung infectionsRecurrent lung infections 31.5 31.5 % %
 Chronic anemia 15.4Chronic anemia 15.4 % %
 Heart burnHeart burn 22.8 % 22.8 %
 Chronic laryngitis 20%Chronic laryngitis 20%
 Growth retardationGrowth retardation 8.9 8.9%%

10. Treatment before admissionTreatment before admission
No treatment 21(23.9%)No treatment 21(23.9%)
Treatment of extraesophageal symptoms Treatment of extraesophageal symptoms
15 (17%)15 (17%)
Inadequate treatment 20 (22.7%)Inadequate treatment 20 (22.7%)
Failed treatment 32 (36.4%)Failed treatment 32 (36.4%)

11. DiagnosisDiagnosis
 Radiologic contrast study 88Radiologic contrast study 88 (100 %) (100 %)
 Upper endoscopyUpper endoscopy 78 78 ( (88.688.6 %) %)
 24-24-hourshours рН- рН-monitoringmonitoring 42 42 (4 (47.7 7.7 %)%)
 Reflux-scintigraphyReflux-scintigraphy 19 19 (21, (21,66 %) %)

12. Radiologic contrast studyRadiologic contrast study
CardiohalasiaCardiohalasia
Barret’s esophagusBarret’s esophagus
Fibrous strictureFibrous stricture
Shortened esophagusShortened esophagus
““secondary brachiesophagus”secondary brachiesophagus”

13. Grades of reflux-esophagitits –Grades of reflux-esophagitits – endoscopic criteriaendoscopic criteria
І І gradegrade – – erythemaerythema typetype “fire blades”“fire blades”, , single erosionssingle erosions
ІІ ІІ gradegrade – – erosionserosions, , fibrinousfibrinous coatingcoating
ІІІ ІІІ gradegrade – – oedemaoedema andand desquamationdesquamation, , confluent erosionsconfluent erosions, , fibrinous fibrinous
coatingcoating, , stricture formationstricture formation, , peptic ulcerpeptic ulcer
ІV ІV gradegrade – – peptic peptic or fibrous strictureor fibrous stricture

14. 24-24-hourshours рН – рН – monitoringmonitoring
1.1.Refllux index – percentageRefllux index – percentage ofof episodes withepisodes with рН рН belowbelow 4,0 4,0
2.2.Number ofNumber of reflux episodes > reflux episodes > 5 5 minmin
3.3.The longest reflux episodeThe longest reflux episode
4.4.Clearance timeClearance time
5.5.RegistrationRegistration of postprandial and night episodesof postprandial and night episodes
RISK RatioRISK Ratio
R I 5 – 10 % I degreeR I 5 – 10 % I degree
R I 10 – 20 % R I 10 – 20 % ІІ ІІ degreedegree
R I overR I over 20 % ІІІ 20 % ІІІ degreedegree

15. Indications for surgeryIndications for surgery
 Reflux-esophagitis III -Reflux-esophagitis III - ІV ІV gradegrade
 ManifestedManifested reflux diseasereflux disease ( (lung infectionlung infection,, anemia, growth anemia, growth
retardationretardation))
 R I over 10 %R I over 10 %
Unsuccessful conservative treatment for Unsuccessful conservative treatment for 3 – 6 3 – 6 monthsmonths
 Congenital hiatal herniaCongenital hiatal hernia

16. Surgical methodsSurgical methods
1616 ( (18.218.2%)%)
FundopexyFundopexy
Lortat-Jackob / ThalLortat-Jackob / Thal
7272 ( (81.881.8%)%)
FundoplicationFundoplication
NissenNissen

17. Surgical procedure forSurgical procedure for secondary secondary
shortened esophagusshortened esophagus
Anterior transpositionAnterior transposition 18 18
(Merendino)(Merendino)
Intrathoracic Nissen
3 (3,4 %)

18. Postoperative complicationsPostoperative complications
FundoplicationFundoplication FundopexyFundopexy
Bowel obstructionBowel obstruction 6 (8,3 %) 6 (8,3 %) 2 (12,5 %)2 (12,5 %)
Paraesophageal herniaParaesophageal hernia 4 (5,6 %) /4 (5,6 %) /
Slipped NissenSlipped Nissen 2 (2,8 %) /2 (2,8 %) /
Cardia stenosisCardia stenosis 2 (2,8 %) /2 (2,8 %) /
RELAPSERELAPSE 3 (4,2 %) 3 (4,2 %) 6 (37,5 %)6 (37,5 %)

19. PostoperativePostoperative complicationscomplications
RecurrenceRecurrence – – 99
((10.210.2 %) %)
Slipped Nissen – 2Slipped Nissen – 2
ParaesophagealParaesophageal
herniahernia - - 44
Gas-bloat – 2
IleusIleus / intussusseption / intussusseption – – 88

20. Late resultsLate results
RelaparotomyRelaparotomy 12 (13,6 %)12 (13,6 %)
Redo Nissen Redo Nissen 9 (10,2 %) 9 (10,2 %)
Esophageal dilatationEsophageal dilatation 39 (44,3 %)39 (44,3 %)
Replacement with colon 1 (1,1 %)Replacement with colon 1 (1,1 %)

Mortality Mortality 0 %0 %

21. Causes of complications - Causes of complications -
““immaturity of GITimmaturity of GIT ” ”
 Delayed gastric emptying Delayed gastric emptying ((pyloroplastypyloroplasty, , prokineticsprokinetics))
ImpairedImpaired “m“migratingigrating motor complex” (motor complex” (DeMeester) DeMeester) – – worsened intestinal worsened intestinal
peristalsis peristalsis
 ImpairedImpaired microcirculationmicrocirculation of theof the intestinal wallintestinal wall ( (epidural analgesiaepidural analgesia, ,
Cisapride)Cisapride)
 Incorrect surgical technique Incorrect surgical technique
 Trauma of n.vagusTrauma of n.vagus

22. ConclusionsConclusions
1.Gastro-esophageal reflux disease (GERD) in children is a specific
medical condition with complex etiology and diverse clinical
symptoms - esophageal and extraesophageal.
2.The basic cause leading to GERD is a pathologic relaxation of
LES with permanent acid reflux into the esophagus.
3. The timely evaluation of the clinical symptomatic and an
adequate conservative treatment will avoid late medical
troubles.
4. Operative treatment should be performed early when indicated,
thus preventing serious surgical complications.