Stephen G. Jolley

Patterns of gastroesophageal reflux in children following repair of esophageal atresia and distal tracheoesophageal fistula.

We studied gastroesophageal reflux (GER) in 25 children between 3 and 83 mo post-repair of esophageal atresia and distal tracheoesophageal fistula (EATEF). The incidence of GER was determined by 18-24 hr pH monitoring of the distal esophagus and gastroesophageal scintiscan following the ingestion of 99mTc sulfur colloid in apple juice. Gastric emptying was also assessed in 20 children. Only 17 of 25 (68%) children had significant GER by esophageal pH monitoring, and 13 of 20 (65%) had significant GER by gastroesophageal scintiscan. Significant GER was found in 10 of 12 (83%) patients wih recurrent vomiting, respiratory symptoms or severe esophagitis. Three of these 10 patients required an operation to control GER. Significant GER occurred in continuous, discontinuous and mixed patterns. The discontinuous pattern was seen in 11 of 17 (65%) children, and was associated with slow gastric emptying. The only factor during the repair of EATEF that subsequently was associated with a higher incidence of significant GER (88% vs. 59%) and slow gastric emptying (11.2 +/- 4.2% vs. 25.9 +/- 3.7% gastric emptying at 30 min, p less than 0.05) was excessive tension at the esophageal anastomosis. Many children with EATEF do not have significant GER, but in those with significant GER slow gastric emptying seems to be important.

Surgery in children with gastroesophageal reflux and respiratory symptoms

We reviewed our seven-year experience in 63 children with an operation to control gastroesophageal reflux and respiratory symptoms. The age at operation, sex, major associated disorders, and control of vomiting in this group of children were compared with another group of 72 children without respiratory symptoms who also had an antireflux operation during the same period. Associated central nervous system, pharyngeal, or esophageal disorders were common in both groups. Vomiting was controlled in 96% of patients. Fifty-six of 61 (92%) children had at least partial relief of respiratory symptoms postoperatively. The complete relief of these symptoms was more likely in patients without major associated disorders (97% vs 59% P = 0.0009). Central nervous system disorders were present in most children with incomplete resolution of respiratory symptoms. It appears that a significant number of affected infants and children may have respiratory difficulties unrelated to the presence of GER.

Lower esophageal pressure changes with tube gastrostomy: a causative factor of gastroesophageal reflux in children?

In children, Stamm tube gastrostomy can initiate gastroesophageal reflux (GER) or worsen preexisting GER. We identified a possible mechanism for this problem in 25 children with GER who had esophageal manometry performed in conjunction with an antireflux operation. Intraoperative lower esophageal high pressure zone (LEHPZ) pressure and length were recorded for a simulated gastrostomy in all patients prior to performing the antireflux operation. These same parameters were then recorded for a simulated (11 patients) or real gastrostomy (14 patients) following the antireflux procedure. The LEHPZ pressure decreased with simulated Stamm gastrostomy (7.8 +/- 1.1----6.6 +/- 1.1 mm Hg, NS: Normal = 11.2 +/- 0.9 mm Hg). This decrease was less significant than the decrease in LEHPZ length (1.1 +/- 0.1----0.8 +/- 0.1 cm, P less than .01: Normal = 1.3 +/- 0.1 cm). Following Boerema gastropexy, simulated gastrostomy produced a similar decrease in LEHPZ pressure (20.8 +/- 3.8----17.1 +/- 2.7 mm Hg, NS) and length (3.3 +/- 0.4----2.5 +/- 0.3 cm, P less than .025). The LEHPZ pressure and length were not decreased by real gastrostomy performed with modified Thal fundoplication or with Nissen fundoplication. Thus, a decrease in LEHPZ length may be one mechanism whereby GER is initiated or worsened by tube gastrostomy in children. Tube gastrostomy has a similar effect when performed with a Boerema gastropexy, but not when performed with a Nissen or modified Thal fundoplication.

Imperforate anus: The neurologic implication of sacral abnormalities*

The association of imperforate anus with bony sacral abnormalities and neurologic deficits is well recognized. These neurologic deficits have been considered static rather than progressive. However, recent experience indicates that some patients may develop progressive neurologic problems due to spinal cord lesions that are amenable to neurosurgical correction. To investigate the frequency of such lesions, routine myelography of imperforate anus patients with sacral anomalies was undertaken. The extraordinarily high incidence of unsuspected lesions known to cause progressive bowel, bladder, and musculoskeletal dysfunction is the basis of this interim report. Thirty percent of patients with anorectal abnormalities had sacral dysplasia. Of the nine patients undergoing myelography to date, eight have been abnormal. Six children had a tethered spinal cord, one had narrowing of the bony spinal canal and dural sac stenosis, and one an anterior meningocele. Spinal cord conditions that may cause deterioration of bowel, bladder, and extremity function should be defined and corrected before irreversible damage occurs. Because of the high incidence of spinal cord lesions detected in these patients with coexisting anorectal and sacral anomalies, routine screening for spinal cord lesions is recommended.

Gastroesophageal Reflux in Infants and Children: Recognition and Treatment

Gastroesophageal reflux is common in infants and children and is associated with a broad spectrum of symptoms and disease. The majority of young patients with reflux can be managed nonoperatively because growth and time usually bring maturation of the antireflux mechanisms. We feel that operation is justified and indicated for the child with complications of reflux that are not reversed by a six-week medical trial, and children with stricture or infants with reflux-related apnea should have operation without delay. In our experience, analysis of the 24-hour esophageal pH tracing has proved most useful to correlate respiratory symptoms with reflux. The Nissen fundoplication is the most effective and the most reliable antireflux procedure, but it must be constructed loosely to minimize the side effects of dysphagia and gas bloating. Because the population at risk for reflux disease has approximately a 50 per cent incidence of significant associated medical problems, morbidity and mortality from some of these problems is inevitable. There should be little or no mortality associated with the antireflux operation itself.

Gastric emptying in children with gastroesophageal reflux. I. An estimate of effective gastric emptying

The association of gastroesophageal reflux (GER) and gastric emptying has been observed, but its importance is poorly understood. We compared 18- to 24-hour esophageal pH recordings with gastric emptying of radionuclide in apple juice in 109 children (2 weeks to 16 years old) referred for an evaluation of GER. A pH score and the pattern of GER (type I, II, and III) were obtained by esophageal pH monitoring. Gastric emptying was measured at 30 minutes (%GE30) and at 60 minutes (%GE60). The measured gastric emptying of apple juice was similar for the normal child and for those with GER regardless of pattern type. An inverse linear correlation between postcibal reflex and measured gastric emptying was demonstrated only by the eight asymptomatic children with a normal pH score (%GE30, r = -.9603, P less than .001; and %GE60, r = -.8263, P less than .05). If the contribution of postcibal reflux on gastric emptying was eliminated, then the effective gastric emptying was increased in many children with the type I (44%, P less than .05), type II (46%, P less than .05), or type III (60%, P less than .05) pattern of GER as compared with children with a normal reflux pattern (7%). In conclusion, measured gastric emptying of clear liquids is not necessarily decreased in most children with GER. Furthermore, many children with GER demonstrate an increased effective gastric emptying even though measured gastric emptying may not appear increased.

Patterns of postcibal gastroesophageal reflux in symptomatic infants

Symptomatic infants displayed three patterns of gastroesophageal reflux after drinking apple juice (20 ml/kg or 300 ml/m2 of body surface area). The type I pattern occurred in patients who had continuous postcibal gastroesophageal reflux, large hiatal hernias and frequently required an antireflux operation. A functional motility disorder suggesting delayed gastric emptying appeared to be important in infants with discontinuous reflux (type II pattern). These infants had frequent gastroesophageal reflux for only 2 3/4 hours postcibally, antral-pylorospasm, increased low esophageal sphincter pressures, and a high incidence of pulmonary symptoms and non-specific watery diarrhea. The mixed (type III) pattern of gastroesophageal reflux occurred in a small number of infants and exhibited features of both type I and II patterns.

Gastric emptying in children with gastroesophageal reflux. II. The relationship to retching symptoms following antireflux surgery.

Following antireflux surgery, children with persistent retching symptoms are presumably more likely to have delayed gastric emptying. We report 66 children between 2 weeks and 16 years of age who had an operation to control gastroesophageal reflux (GER). All patients had GER confirmed by 18- to 24-hour esophageal pH monitoring. Preoperative gastric emptying studies were performed in each patient with 99m-Tc sulfur colloid in apple juice. In addition to the percent gastric emptying (%GE), an effective gastric emptying was estimated by correcting the %GE for postcibal reflux (corrected %GE). Repeat 18- to 24-hour esophageal pH monitoring was performed postoperatively in all patients, and a repeat gastric emptying study was performed in 32 patients. After an average postoperative follow up of 6 months (range of 1 to 18 months), persistent retching was present in 12 (18%) patients. The retching was associated with dumping symptoms in six patients. Retching was seen in patients with a preoperative increase in effective gastric emptying (10/34, 29%, P less than .05) or a decrease in effective gastric emptying (2/15, 13%, NS), and not in patients with an effective gastric emptying within the control range (0/17, 0%). Postoperatively, retching with dumping symptoms was associated with an increased effective gastric emptying, and retching without dumping symptoms with a decreased effective gastric emptying. In conclusion, persistent retching followed anti-reflux surgery in children is related to extremes in effective gastric emptying. The preoperative measurement of corrected %GE identifies children at increased risk for this postoperative problem.

Postoperative small bowel obstruction in infants and children: A problem following nissen fundoplication

A serious consequence of antireflux surgery is postoperative small bowel obstruction in an infant who cannot speak and has been rendered unable to vomit. We reviewed the operative rate for small bowel obstruction following all antireflux operations (210 Nissen fundoplications, 16 Hill fundoplications, 12 modified Thal fundoplications, and 3 Boerema anterior gastropexies) performed on children at our institution between January 1977 and July 1984. Eighteen patients (17 Nissen fundoplications, one Hill fundoplication) were operated upon for small bowel obstruction within two years after the primary operation. The most consistent clinical findings in these children were abdominal distention and a decreased frequency of bowel movements. For operations performed between January 1982 and July 1984, reoperation for small bowel obstruction was needed in 6.1% (6/99) of children following Nissen fundoplication as compared to 0.9% (6/649), P less than 0.001) of children following other major laparotomies. A combination of our experience with that reported by others suggests an estimated incidence of postoperative adhesive small bowel obstruction of 5.5% (24/436) for Nissen fundoplication, 0.9% (3/347) for modified Thal fundoplication, and 0.8% (1/126) for Boerema anterior gastropexy. The performance of a Nissen fundoplication has led to a significant rate of reoperation for small bowel obstruction compared with other major laparotomies and antireflux operations performed in children.

The accuracy of abbreviated esophageal pH monitoring in children.

Extended (18 to 24 hour) esophageal pH monitoring establishes the diagnosis of gastroesophageal reflux (GER) utilizing a pH score, and relates respiratory symptoms to GER when the mean duration of sleep reflux (ZMD) is prolonged. A disadvantage of this method is the expense of overnight hospitalization. We performed extended esophageal pH recordings in 66 consecutive children (1 week to 15 years old) being evaluated for GER. Six portions of the 18- to 24-hour esophageal pH recording were compared to the complete record in an attempt to define the relative accuracy of abbreviated monitoring periods. The abbreviated monitoring periods included the 30 minutes after apple juice feedings (30 minutes AJ), the 2 hours after apple juice feedings (2 hours PC AJ), the 2 hours after milk-formula feedings (2 hours PC MF), the 8 hours with two feedings of apple juice (8 hours AJ), the 8 hours with two feedings of milk formula (8 hours MF), and the first 12 hours of recording (1st 12 hours). The accuracy relative to the 18- to 24-hour recording was poor for 30 minutes AJ, 2 hours PC AJ, and 2 hours PC MF periods (30% to 58%). An improved accuracy occurred during 8-hour AJ periods (29/31, 94%) in children without respiratory symptoms. Although the accuracy in patients with respiratory symptoms was best during 8-hour MF (31/35, 89%) and 1st 12-hour (33/35, 94%) periods, a high false-negative rate for the ZMD (31% to 41%) during abbreviated pH monitoring indicates that many patients with reflux-induced respiratory symptoms will be unrecognized.(ABSTRACT TRUNCATED AT 250 WORDS)