New Insights in Gastroesophageal Reflux, Esophageal Function and Gastric Emptying in Relation to Dysphagia Before and After Anti-Reflux Surgery in Children

Abstract

Introduction Gastroesophageal reflux disease and treatment in childrenGastroesophageal reflux disease (GERD) in children is common, it affects approximately (?)3% of infants and <1% of older children. 1 GERD is clinically diagnosed when gastroesophageal reflux (GER) causes troublesome symptoms, and is a source of stress for both patients and caregivers. In infants, GERD is often mild and short lived, with >90% being free of GERD symptoms at the age of 18 months. 2,3 'Symptomatic GERD', that is a clinical diagnosis of GERD without corroborative evidence such as endoscopic evidence of esophagitis, can be challenging to treat. Standard treatment consists firstly of conservative measures: lifestyle changes, excess weight reduction, no exposure to tobacco smoke. In specific cases allergies are associated with GERD, and avoidance of allergens may relieve symptoms.If pharmacological therapy is considered, acid suppression is the first choice and using proton pump inhibitors (PPIs) is favored above H2-antagonists and on demand buffering agents. 2 However, acid suppression therapy in infants and children is now widely discouraged as PPIs, whilst proven effective in increasing gastric pH, do not reduce GERD symptoms. 4 The lack of therapeutic efficacy of acid suppressive therapy might be explained by the fact that acid suppression does not target the underlying mechanism of reflux which is transient lower sphincter relaxation (TLESR). 3,5 Acid suppression only turns acid GER into weakly acid GER, which may still cause troublesome symptoms. Although other therapeutic agents are being developed for adult GERD treatment (especially GABA(B) agonists and mGLUR5 antagonists), these have many sideeffects and are not yet tested in children. 6,7 Therefore, no pharmacological interventions aimed a reducing TLESRs are available.In patients with objective evidence of acid-related GERD, based on upper endoscopy, pH-metry and/or pH impedance measurement (pHMII), who experience severe symptoms or have esophagitis refractory to optimal medical therapy, anti-reflux surgery (fundoplication) may be a treatment of last resort. 8Indications for fundoplication are poorly defined in children 2,9,10 and there is no uniformity between hospitals in the approach to infants and children with pharmacological therapy resistant GERD. 11 Neurologically impaired children, children with a history of esophageal atresia 12 and children with respiratory alarm symptoms considered GERD-related (e.g. apnea, bronchiectasis, recurrent pneumonia) are more prone to undergo fundoplication. Fundoplication techniquesThe primary goal of anti-reflux surgery is to reduce GER without preventing passage into the stomach of swallowed substances. These conclusions are however based on limited data and uncertainty remains with respect to the optimal fundoplication technique. In addition prospective evidence is limited in terms of efficacy and complication rates between partial and total fundoplication. 19 Efficacy and safety of fundoplicationEfficacy and safety o...

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines

“…They created a Dysphagia Risk Index that seemed better able to predict post-operative dysphagia in both adults supported by an uncontrolled pilot study of 10 children. (65, 66) Additionally, based upon pediatric studies, HRM with or without impedance may be of value to assess for “R waves” and retrograde bolus flow to diagnose rumination, a mimicker of intractable reflux symptoms. (67–71)…”

Does Nissen fundoplication improve deglutition in children?

“…However, no objective method has been defined to identify who are more likely to respond well to NF and no diagnostic tool has been found effective to predict PD preoperatively. Based on pH-impedance studies, the mean number of GER episodes, acid exposure, and impedance baseline values were significantly reduced after surgery 11 . However, none of them were able to predict occurrence of PD after surgery.…”

Textbook of Pediatric Gastroenterology, Hepatology and Nutrition

“…Antireflux procedures in the USA were reported to be most commonly performed in children during a period of life when regurgitation is normal and physiologic and objective measures of GERD are difficult to interpret [236]. In contrast, in Europe, antireflux surgery is considered as a treatment of last resort in children with GERD refractory to pharmacological therapies [237]. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis, which relates bolus movement and pressure generation within the esophageal lumen [237].…”

“…In contrast, in Europe, antireflux surgery is considered as a treatment of last resort in children with GERD refractory to pharmacological therapies [237]. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis, which relates bolus movement and pressure generation within the esophageal lumen [237]. In adults, most benefit from antireflux surgery is observed in patients with typical reflux symptoms well controlled with PPI and patients with demonstrated pathologic esophageal acid exposure [238].…”