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FUNDOPLICATION
AND
THE GASTRO-ESOPHAGEAL REFLUX DISEASE
IN CHILDREN
2008
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1-Nissen fundoplication may induce gastric myoelectrical disturbance in
children; J Pediatric Surg.1998 ( London, England)
 Recurrent vomiting with failure to thrive is a common problem in
neurologically impaired children. Many undergo fundoplication to
control the underlying gastroesophageal reflux but the results of
surgery are not always satisfactory and post-operative retching may be
a major problem.
 Neurologically impaired children with GERD more commonly have a
preexisting gastric dysrhythmia (65% in NIC vs. 20% in NNC) with
gastroesophageal reflux.
 Children who retch preoperatively are three times more likely to retch
postoperatively .
 25% of NIC may start to retch postoperatively for the first time.
 The authors propose that in NIC loss of the central inhibitory
mechanisms may result in inappropriate activation of the emetic
reflex, which may be heightened by anti-reflux surgery.
2-Nissen fundoplication improves gastric myoelectrical activity
characteristics and symptoms in GER patients: evaluation in
transcutaneous electrogastrography; Surg Endosc 2008, (Warsaw,
Poland)
 This study analyzes the impact of NFP on gastric myoelectrical
activity, measured using the transcutaneous electrogastrography
technique (EGG), and change in digestive symptoms in adult with
GERD.
 EGG was recorded before and after the NFP and compared with the
EGG obtained in healthy volunteers.
 EGG showed the NFP influenced and might improve the slow wave
generation in gastric pacemaker. Dyspeptic symptoms were also
improved up to one year post-operative.
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 Some studies have shown that one mechanism by which NFP prevents
reflux is that it decreases both the number and the magnitude of
relaxation during transient lower esophageal sphincter relaxations.
 It has been shown that the number of episodes and degree of LES
relaxation after NFP decrease by as much as 50% in patients with
GERD but without hiatal hernia or hypotensive LES.
3- Dumping syndrome following Nissen Fundoplication, Diagnosis and
Treatment; J Pediatric Gastroenterology & Nutrition 1996.
 Dumping syndrome is a common complication following Nissen
fundoplication .
 The GTT is the most reliable examination for establishing the
diagnosis.
 The technetium gastric emptying scan and HbA1C level do not play
a significant role in the diagnosis.
 Treatment is simple and effective.
4- Dumping syndrome: a common problem following Nissen
fundoplication in young children; Pediatr Surg Int 2001(Munchen,Germany)
 In childhood, DS presents with non-specific symptoms after feeding
in variable severity and frequency.
 The most common symptoms are refusal to eat, postprandial nausea,
retching, tachycardia ,paleness, and lethargy, diaphoresis, and watery
diarrhea.
 Symptoms can be divided into early dumping ,occurring within the
first 30-60 min after a meal and late dumping 90-240 min
postprandially.
 The pathogenesis of early DS following NFP is not yet fully
understood ,and is likely caused by several mechanisms.
 After ingestion ,food is stored in the fundus ,which relaxes
immediately to keep the intragastric pressure constant. This receptive
relaxation may be disturbed after fundoplication either by using part
of the fundus to form the wrap or by inadvertent damage of the vagal
nerve .
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 There is no single diagnostic test available to establish the diagnosis
of early DS. The oral GTT is helpful to evaluate late reactive
hypoglycemia and provoke symptoms of early DS.
 Vagal damage should be suspected in patients with severe and
persisting symptoms of DS.
 Gastric emptying has been reported to be accelerated in some ,but not
all patients with postoperative DS.
 Pyloroplasty accelerates gastric drainage after NFP and may increase
the risk of postoperative DS.
 Pyloroplasty should not be performed simultaneously with the NFP
,but only in patients with proven delayed gastric emptying by
scintigraphy after anti-reflux surgery.
 Studies that specifically designed to evaluate symptoms of DS after
NFP revealed symptomatic DS in 25-30% of the children.
5- Dumping syndrome; PEDIATRIC SURGERY Update May
2000,Puerto Rico Association of pediatric surgeons.
 Fundoplication is the most common cause of DS in children.
 Pyloroplasty is one of the important causes of DS in children.
6- Dumping syndrome after combined pyloroplasty and fundoplication;
Pediatric Gastroenterology depart 1990 (Bozen,Italy).
 Dumping syndrome in infancy is a rare complication following
gastric surgery.
 The majority of cases with dumping syndrome in infancy have been
reported after a Nissen fundoplication.
 It’s well known that the fundoplication accelerates the gastric
emptying of liquid meals leading to the dumping syndrome.
 Pyloromyotomy seems to be the major factor in the genesis of
dumping and it should be concluded that the indication for combined
pyloroplasty and fundoplication must always be carefully evaluated.
 Diagnosis is still based mainly on symptoms and on an abnormal
glucose tolerance test, and radionuclide gastroduodenal
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scintigraphy especially in cases of combined fundoplication and
pyloroplasty.
7- Fundoplication : Friend or Foe ? Journal of Pediatric Gastroenterology and
Nutrition,2002.( Pennsylvania,USA).
 GERD is a relatively benign condition in the younger infant. Most
patients improve during the first 18 months of life. In older children
and adults ,GERD is often a chronic disease , unlikely to resolve
spontaneously.
 Some children , such as those with neurological disorders or chronic
pulmonary disease ,are especially at risk for complications of poorly
controlled GERD.
 Antireflux surgery should not be advised with the expectation that
patients with GERD will no longer need to take antisecretory
medications or that the procedure will prevent cancer among those
with GERD and Barret’s esophagitis.
 Post-fundoplication problems are more common in special categories
of children ,such as those with neurological or respiratory diseases,
with esophageal atresia ,or with a generalized motility disorder. These
children have challenging physiology that makes it difficult for any
intervention to be successful.
 Fundoplication reduces the volume of the stomach and uses most of
the proximal stomach to create a wrap around the lower part of the
esophagus that leads to decreased gastric postprandial relaxation and
subsequent gastric distension.
 The largest review of postfundoplication dumping syndrome estimates
that up to 30% of children who undergo fundoplication will have
symptoms or biochemical evidence of dumping syndrome.
 Octreotide seems to have hypoalgesic effects on the gastrointestinal
tract and is particularly helpful in the subset of children who having
dumping syndrome after fundoplication.
 Fundoplication has led, and continues to lead ,to improved quality and
quantity of life in many carefully selected children.
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8- Long-term outcome of laparoscopic Nissen-Rossetti fundoplication
for neurologically impaired and normal children;Surg Endosc 2008
(Nantes, France).
 Recurrence of GERD symptoms after LNF is high in NIC than NNC.
 Laparoscopic Nissen fundoplication is safe and effective in the longterm for correcting primary reflux in children, but late deterioration
may appear in neurologically impaired children.
 Primary GERD in NNC and GERD in NIC may not have the same
outcome because neurologically impaired children present with
GERD as a consequence of diffuse gastrointestinal dysmotility.
 Diagnosis of GERD in NIC may be delayed because of the possible
confusion between symptoms related to the underlying neurological
disease and symptoms related to GERD.
 NIC should be evaluated more frequently than NNC after NFP
because of the late recurrences secondary to evolving dysmotility
disorders.
9- Nissen Fundoplication in Children with Profound Neurologic
Disability; Division of pediatric surgery 1992 (South Carolina).
 Recent studies have documented the significantly higher morbidity
and mortality rates after fundoplication in NIC as compared with
NNC.
 Conditions that tend to raise intra-abdominal pressure and possibly
contribute to the development and recurrence of GERD in NIC
include; seizure disorder,,, spasticity,,,, pulmonary disease,,,,
chronic constipation ,,,choking-gagging-retching,,,, scoliosis.
 Nissen fundoplication in patients with profound neurological
disability increased risks of death, recurrence of symptoms,
paraesophageal hernia, and small bowel obstruction in these
children as compared with NNC.
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10- Gastroesophageal reflux in neurologically impaired children: partial
or total fundoplication? Langenbeck’s Arch Surg (1998).
 This is a retrospective study compare the short and long term results
of two different procedures in NIC with a documented GERD.
 One group (A) underwent NFP and the other group (B) underwent
Thal fundoplication.
 This study showed that there is no statistical difference between the
two procedures in terms of relative risk of complication and success
rate .
 The duration of surgery and hospital stay were significantly shorter in
group (B) .The Thal fundoplication can therefore be proposed as the
first choice in the management of GERD in NIC.
11- Toupet Fundoplication (TF) for Gastroesophageal Reflux in
Childhood; Arch Surg.1999.
 These data show that both NF and TF are effective procedures for
GER in children ,with acceptable recovery times and low recurrence
rates.
 However ,TF results in earlier feeding and discharge from the hospital
and has a significantly lower incidence of dysphagia,gagging,and gas
bloat , resulting in lower incidence of the need for reoperation and /or
rehospitalizations than NF .
 In most series ,children with moderate to severe neurological
impairment make up most of the patients requiring fundoplication and
the 360 NFP is the most widely used procedure for this group.
 However , for the NNC the NFP procedure has many unpleasant side
effects and complications that make it less than ideal for this
population.
 The partial wrap (Thal procedure) and the Toupet procedure are not
good operations for NIC because they don’t completely prevent
reflux, especially in patients with poor gastric emptying.
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12- Esophagogastric Dissociation versus Fundoplication: Which Is Best
for Severely Neurologically Impaired Children? Journal of Pediatric
Surgery; 2001, ( Milano,Italy).
 Severely NIC often have pharyngeal neuromuscular incoordination
and difficulty with swallowing , severe GER , recurrent respiratory
infection ,and consequently severe malnutrition.
 In the literature ,several reports have been published reporting the
association of fundoplication with a 7% to 35% recurrence of reflux
that required additional surgery in NIC.
 In 1997 Bianchi proposed esophagogastric dissociation (EGD) as a
valid alternative to fundoplication and gastrostomy to totally
eliminate the risk of recurrence of GER.
 Pearl et al reported that in NIC the postoperative morbidity rate was 2
times greater and the mortality rate 4 times greater than in NNC. In
these children significant complication rates are reported in up to
59% of patients ,and a significant risk of failure is seen in up to 25%.
 Esophagogastric dissociation is a more complex procedure than
fundoplication with a potential for more complications.
 Esophagogastric dissociation can have a definitive role as a primary
form of management for severe NIC with pharyngeal neuromuscular
incoordination and GER.
13- Nissen fundoplication and gastrostomy in severely neurologically
impaired children with gastroesophageal reflux; Hong Kong Med J,2006.
 This study indicates in severely NIC with gastroesophageal reflux ,
vomiting ,gastrointestinal bleeding , and indices based on 24-hour
oesophageal pH monitoring were significantly reduced following
fundoplication and gastrostomy.
 The incidence of pneumonia was unchanged. The recurrence rate of
reflux was 30% and mortality rate was 20%.
 The efficacy of fundoplication in severely NIC has been doubted.
Morbidity ,mortality and recurrence rates are higher than reported in
NNC.
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14- Gastrostomy feeding in the disabled child: When is an antireflux
procedure required? Arch Dis Child,1999.
 Children with neurological impairment frequently exhibit clinical
evidence of gastrointestinal dysmotility with oral motor impairment,
gastroesophageal reflux (GER), delayed gastric emptying ,and
constipation.
 Feeding gastrostomy tubes are being used increasingly in this group of
children in an attempt both to improve their nutritional status and to
reduce the amount of time taken over feeding.
 One of the most significant complications is the development of GER
secondary to gastrostomy tube placement.
 Twenty years ago it was common practice for any antireflux operation
to accompany the insertion of a feeding gastrostomy tube. This
attitude has changed over the past decade and the current view is that
a routine antireflux procedure is not always necessary with a
gastrostomy,because:
 The advent of the percutaneous endoscopic gastrostomy (PEG) made
placement of a gastrostomy tube possible without laparotomy. Therefore
the antireflux operation, which previously had been regarded as an adjunct
to gastrostomy formation ,became a separate major abdominal operation
with significant morbidity.
 There was evidence from an increasing number of centers that
gastrostomy tube placement did not consistently promote GER and ,
therefore ,antireflux surgery was not essential in patients who did not have
clinical evidence of GER before gastrostomy.

Nissen fundoplication ,the most widely used procedure for controlling
GER ,relieves symptoms in more that 80% of patients. However, in
disabled patients in particular this is at a cost of high morbidity and
recurrence. Postoperative complications have been reported in up to 59%
of patients.
 Fundoplication ,therefore has a significant risk for failure in NIC ,in
addition to which there is a high risk of other complications developing.
 Objective evidence of recurrent reflux following NFP is reported in 636% of patients. The incidence of repeat fundoplication ranges from 515%.
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15- The use of gastrostomy for feeding in neurologically impaired
children is associated with GER: In what percentage of cases?
PEDIATRIC SURGERY SECRETS,2001.
 Gastrostomy ,either surgically or by percutaneous endoscopic
technique, is associated with an increase in GER due to;
* Opening of the angle of His
* Reduction of LES length.
* Lowering of the LES pressure.

Development of postgastrostomy GER in NIC with normal
preoperative studies has been reported to be as high as 66%.
 The Witzel gastrostomy has been associated with a lower incidence of
postoperative GER than the Stamm gastrostomy.
 Lesser curvature gastrostomy tubes are associated with less reflux
than greater- curvature tubes.
16- Acarbose treatment of postprandial hypoglycemia in children after
Nissen fundoplication; J Pediatr 2001.
 Dumping syndrome and postprandial hypoglycemia have been
reported after NFP. The physiopathologic mechanisms are poorly
understood and a variety of therapies have field to control the
hypoglycemia in these patients.
 Therapies that have been used to treat DS include cornstarch, pectin,
octreotide, and dietary manipulation, but many patients continue to
have severe symptoms.
 Acarbose delays the conversion of oligosaccharides to
monosaccharides and attenuates postprandial increases in blood
glucose.
 GTT has been used as the most reliable diagnostic method for PPH. A
decrease of > 6 mmol/L ( 108 mg/dL) between peak and nadir blood
glucose has been proposed as a diagnostic criterion for DS.
 Gastrointestinal symptoms such as flatulence, abdominal distension,
and diarrhea are the most commonly reported adverse effects for
acarbose.
 For children with documented PPH, this study recommends starting
acarbose at 12.5 mg per feeding and titrating it according to the
glycemic response and occurrence of side effects.
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 Patients should have their liver function monitored because there have
been reports of elevated liver enzymes with acarbose.
 This study describes the use of acarbose in the treatment of PPH in
children who have undergone fundoplication.
17- Nutritional Management of Dumping Syndrome Associated with
Antireflux Surgery; Journal of Pediatric Surgery, 1994.
 Several management strategies have been used to attempt to control
the symptomatology and abnormalities in glucose homeostasis
associated with dumping syndrome. The results have been
inconsistent.
 The choice of the fat emulsion was based on its ability to maximally
delay gastric emptying, to readily mix in the liquid phase, and to be
easily available.
 Microlipid is exclusively composed of long chain triglycerides, and
thus provides a greater delay in gastric emptying than would medium
or short chain triglycerides.
 Uncooked cornstarch was chosen because it produced a consistent
and sustained blood glucose level. It also could be used as a bolus
infusion, eliminating the need for continuous feeding. It is readily
available and inexpensive.
 This method of management was effective in alleviating the
symptomatology and aberration in glucose homeostasis associated
with dumping syndrome. It was non invasive, thus eliminating the
need for pharmacological intervention.
 No complication was encountered with this treatment plan.
18- Nutritional manipulation in the management of dumping syndrome;
Arch Dis Child, 1991.
 Dumping syndrome in children has been described almost
exclusively as a postoperative complication of Nissen’s
fundoplication.
 In this study, effective control of symptoms and nutritional
rehabilitation was achieved by dietary manipulations alone.
 Nutritional management was designed in accordance with the
underlying altered physiology.
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 Fats were used to delay gastric emptying and uncooked corn starch
was used to deliver small amounts of glucose at a steady rate over a
relatively longer time period.
 Microlipid was chosen as the fat source for several reasons:
 Firstly , it is a commercially available fat emulsion that is
readily miscible in a liquid phase and thus it’s appropriate for
use in tube feeding.
 Secondly, as microlipid is composed of long chain
triglycerides , it will delay the gastric emptying more than
medium chain triglycerides.
 Microlipid also provides a nutritionally balanced fat source with
essential fatty acids.
 The choice of uncooked corn starch was based on several factors: it
produces a slow and sustained blood glucose concentration.
 Other commonly used and commercially available glucose
polymers ( for example, Polycose, Ross Laboratories) have a shorter
chain length and produce a sharper and less sustained blood glucose
response.
 The management of dumping syndrome should be aimed at
resolving
clinical
symptoms
and
improving
nutrition
simultaneously.
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