Femke A. Mauritz

The Effects and Efficacy of Antireflux Surgery in Children with Gastroesophageal Reflux Disease: A Systematic Review

BackgroundAntireflux surgery (ARS) for gastroesophageal reflux disease (GERD) is one of the most frequently performed major operations in children. Many studies have described the results of ARS in children, however, with a wide difference in outcome. This study aims to systematically review the efficacy of pediatric ARS and its effects on gastroesophageal function, as measured by gastroesophageal function tests. This is the first systematic review comprising only prospective, longitudinal studies, minimizing the risk of bias.MethodsThree electronic databases (Medline, Embase, and the Cochrane Library) were searched for prospective studies reporting on ARS in children with GERD.ResultsIn total, 17 eligible studies were identified, reporting on a total of 1,280 children. The median success rate after ARS was 86% (57–100%). The success rate in neurologically impaired children was worse in one study, but similar in another study compared to normally developed children. Different surgical techniques (total versus partial fundoplication, or laparoscopic versus open approach) showed similar reflux recurrence rates. However, less postoperative dysphagia was observed after partial fundoplication and laparoscopic ARS was associated with less pain medication and a shorter hospital stay. Complications of ARS varied from minimal postoperative complications to severe dysphagia and gas bloating. The reflux index (RI), obtained by 24-h pH monitoring (n = 8) decreased after ARS. Manometry, as done in three studies, showed no increase in lower esophageal sphincter pressure after ARS. Gastric emptying (n = 3) was reported either unchanged or accelerated after ARS. No studies reported on barium swallow x-ray, endoscopy, or multichannel intraluminal impedance monitoring before and after ARS.ConclusionARS in children shows a good overall success rate (median 86%) in terms of complete relief of symptoms. Efficacy of ARS in neurologically impaired children may be similar to normally developed children. The outcome of ARS does not seem to be influenced by different surgical techniques, although postoperative dysphagia may occur less after partial fundoplication. However, these conclusions are bound by the lack of high-quality prospective studies on pediatric ARS. Similar studies on the effects of pediatric ARS on gastroesophageal function are also very limited. We recommend consistent use of standardized assessment tests to clarify the effects of ARS on gastroesophageal function and to identify possible risk factors for failure of ARS in children.

Laparoscopic Thal fundoplication in children: a prospective 10- to 15-year follow-up study.

Objective:To study long-term (10–15 years) efficacy of antireflux surgery (ARS) in a prospectively followed cohort of pediatric patients with gastroesophageal reflux disease, using 24-hour pH monitoring and reflux-specific questionnaires. Background:Studies on short-term outcome of ARS in pediatric patients with gastroesophageal reflux disease have shown good to excellent results; however, long-term follow-up studies are scarce, retrospective, and have not used objective measurements. Methods:Between 1993 and 1998, a cohort of 57 pediatric patients (ages 1 month to 18 years; 46% with neurological impairment) underwent laparoscopic anterior partial fundoplication (Thal). Preoperatively and postoperatively (at 3–4 months and at 1–5 and 10–15 years), reflux-specific questionnaires were filled out, and 24-hour pH monitoring was performed. Results:At 3 to 4 months, at 1 to 5 years, and at 10 to 15 years after ARS, 81%, 80%, and 73% of patients, respectively, were completely free of reflux symptoms. Disease-free survival analysis, however, demonstrated that only 57% of patients were symptom free at 10 to 15 years after ARS. Total acid exposure time significantly decreased from 13.4% before ARS to 0.7% (P < 0.001) at 3 to 4 months after ARS; however, at 3 to 4 months after ARS, pH monitoring was still pathological in 18% of patients. At 10 to 15 years after ARS, the number of patients with pathological reflux had even significantly increased to 43% (P = 0.008). No significant differences were found comparing neurologically impaired and normally developed patients. Conclusions:As gastroesophageal reflux persists or recurs in 43% of children 10 to 15 years after laparoscopic Thal fundoplication, it is crucial to implement routine long-term follow-up after ARS in pediatric patients with gastroesophageal reflux disease.

Complete Versus Partial Fundoplication in Children with Gastroesophageal Reflux Disease: Results of a Systematic Review and Meta-analysis

Complete fundoplication (Nissen) has long been accepted as the gold standard surgical procedure in children with therapy-resistant gastroesophageal reflux disease (GERD); however, increasingly more evidence has become available for partial fundoplication as an alternative. The aim of this study was to perform a systematic review and meta-analysis comparing complete versus partial fundoplication in children with therapy-resistant GERD. PubMed (1960 to 2011), EMBASE (from 1980 to 2011), and the Cochrane Library (issue 3, 2011) were systematically searched according to the PRISMA statement. Results were pooled in meta-analyses and expressed as risk ratios (RRs). In total, eight original trials comparing complete to partial fundoplication were identified. Seven of these studies had a retrospective study design. Short-term (RR 0.64; p = 0.28) and long-term (RR 0.85; p = 0.42) postoperative reflux control was similar for complete and partial fundoplication. Complete fundoplication required significantly more endoscopic dilatations for severe dysphagia (RR 7.26; p = 0.007) than partial fundoplication. This systematic review and meta-analysis showed that reflux control is similar after both complete and partial fundoplication, while partial fundoplication significantly reduces the number of dilatations to treat severe dysphagia. However, because of the lack of a well-designed study, we have to be cautious in making definitive conclusions. To decide which type of fundoplication is the best practice in pediatric GERD patients, more randomized controlled trials comparing complete to partial fundoplication in children with GERD are warranted.

Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis.

Background: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. Methods: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. Results: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. Conclusions: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.

Validation of a Novel 3-Dimensional Sonographic Method for Assessing Gastric Accommodation in Healthy Adults

: A novel automated 3‐dimensional (3D) sonographic method has been developed for measuring gastric volumes. This study aimed to validate and assess the reliability of this novel 3D sonographic method compared to the reference standard in 3D gastric sonography: freehand magneto‐based 3D sonography.

Mo1208 Laparoscopic Gastrostomy Is Safer Than Percutaneous Endoscopic Gastrostomy in Children: Results of a Systematic Review and Meta-Analysis

Background: A gastrostomy is frequently performed in children who require long-term enteral feeding. Nowadays gastrostomy placement is a minimally invasive procedure via either percutaneous endoscopic gastrostomy (PEG) or laparoscopic assisted gastrostomy (LAG). Both procedures are widely used in pediatric patients. However, no consensus exists on which type of approach is best practice in these patients. Aim: The aim of this study was to determine if PEG or LAG is the most effective and safe procedure in pediatric patients requiring a gastrostomy Method: A systematic review and meta-analysis was performed according to the guidelines in the PRISMA-statement. PubMed, EMBASE, and the Cochrane Library were searched to identify eligible articles. Results were pooled in meta-analyses and expressed as risk ratios (RR). Results: Our extensive literature search provided 2,342 articles. After title, abstract and full-text screening five original studies comparing PEG to LAG placement in children were identified. All studies had retrospective study designs. The completion rate (PEG 98%; LAG 100%) and time to full-enteral feeds (PEG 0.7 and LAG 0.8 days) of both procedures were similar. No studies reported data comparing the efficacy of feeding via the gastrostomy or its effect on developing gastroesophageal reflux (GER). Major complications, such as intraperitoneal leakage (RR 0.28; p=0.36; after tube exchange RR 3.14; p=0.28) and persistence of the gastrocutaneous fistula after removal of the gastrostomy tube (RR 0.94; p =0.92 ) were as frequently encountered after both PEG and LAG. However, PEG was associated with significantly more adjacent bowel injury (RR=5.55; p= 0.05), early tube dislodgement (RR=7.44; p=0.02), and complications requiring reintervention under general anesthesia in the operating room (RR=2.79; p=0.0008). The risk of developing minor complications was similar after both PEG and LAG placement. Conclusion: This systematic review and meta-analysis demonstrates a lack in studies comparing the effect of PEG and LAG on the efficacy of feeding via the gastrostomy tube and postoperative GER. However, major complications such as adjacent bowel injury, early tube dislodgements and complications requiring reintervention under general anesthesia in the operating room were significantly less frequent after LAG. Therefore, we conclude that LAG is the safest approach and should be the first choice in children requiring gastrostomy placement.