Other Medical Issues
- GI Anatomy and Disease
- Nissen Fundoplication
- Pediatric Tube Feeding
Surgical Treatment for Esophagitis
Intensive medical therapy will heal the vast majority of cases of gastroesophageal reflux disease (GERD) and other forms of esophagitis, but symptoms often tend to recur within one year after the cessation of medication. When it is a chronic condition, therapy involving acid suppression or pro-motility agents may be required indefinitely. Mucosal damage or other changes may persist despite the control of symptoms, and the long-term effect of some medications is uncertain. Surgical treatment can be an attractive option.
Fundoplication is a surgical procedure in which the upper part of the stomach (gastric fundus) is wrapped (plicated) around the lower (inferior) part of the esophagus, restoring the function of the lower esophageal sphincter (LES). The LES normally functions to allow masticated food (bolus) to pass into the stomach, while preventing gastric contents (chyme) from returning back up into the esophagus (reflux). Various conditions may result in failure of the LES to allow swallowing or to prevent reflux.
There are three basic types of fundoplication:
- Dor (partial anterior) fundoplication, in which the fundus is laid over the top of the esophagus.
- Toupet (partial posterior) fundoplication, in which the fundus is wrapped to the back of the esophagus.
- Nissen (complete) fundoplication, in which the fundus is wrapped all the way around to the front of the esophagus.
Either of the two partial fundoplications are generally used to surgically correct achalasia, a disorder in which the esophagus has impaired muscular ability to move the food bolus down into the stomach (peristalsis) and the LES fails to relax properly in response to swallowing (deglutition).
However, even if the swallowing and peristaltic functions are otherwise normal, but the LES fails to prevent reflux by contracting properly, a complete fundoplication may be indicated.
It is rare for children suffering from GERD to require surgery. They will usually respond to dietary changes and an adjustment of feeding techniques or eating habits, but when surgery is required, Nissen fundoplication is the most commonly performed operation.
Nissen (complete) fundoplication is a surgical procedure used to treat GERD and hiatal hernia. For paraesophageal hiatal hernia, it is normally the primary treatment, but for GERD it is usually an elective procedure after other therapy has failed.
The goal of surgery for GERD is to re-establish the anti-reflux barrier without creating an obstruction to the food bolus.
During a Nissen procedure, the fundus of the stomach (to the left of the esophagus and above the main part of the stomach) is wrapped around the back of the esophagus. The portion of the fundus that now comes around the right side of the esophagus is sutured down the front to the portion remaining on the left. This fundoplication resembles a buttoned shirt collar, with the sutures as the buttons, the fundus wrap as the collar, and the esophagus as the neck protruding up through the buttoned collar.
A Nissen fundoplication is usually done via laparoscopic surgery, but is also done by traditional open surgery. When used to alleviate GERD, it is often accompanied by modification of the pylorus by pyloromyotomy or pylorplasty to relieve delayed gastric emptying due to pyloric stenosis.
The effect of the procedure is the re-establishment of a functional one-way valve in the esophagus, allowing food to pass into the stomach, but preventing stomach contents from flowing back up into the esophagus, thereby relieving GERD.
After a Nissen procedure, complications that may occur include:
- Gas bloat syndrome, or the inability to belch leading to an accumulation of gas in the stomach or small intestine, caused by tightness of the wrap (plication) or swallowing of air (aerophagia)
- Dysphagia, or trouble with swallowing
- Dumping syndrome, or rapid gastric emptying
- Excessive scarring
- Achalasia (rarely)
Risks and Prognosis
The comparative incidence of complications and failure rates vary slightly between laparoscopic Nissen fundoplication (LNF) and open Nissen fundoplication (ONF), but in both cases, the presence of pre-existing conditions is associated with a tendency for higher reoperation rates.
Subsets of children with increased fundoplication failure rates include:
- Chronic respiratory conditions
- Neurological impairment
- Repaired esophageal atresia (EA)
- Infants less than one year of age
LNF has a shorter hospital stay and shorter time to initiation of regular feeding than ONF does. Overall, LNF is superior to ONF in terms of cost, patient outcome, and acute complications. There is a somewhat higher incidence of eventual reoperations for LNF compared to ONF, but reoperation rates for both procedures are considered quite low, and the procedures are considered safe and effective.
A Closer Look
Paraesophageal hiatal hernia is a condition in which a portion of the stomach protrudes upward into the chest, through the opening in the diaphragm, generally as a result of a weakening of the supporting tissue.
Symptoms of hiatal hernia can include:
- Heartburn, especially when bending or lying down
- Difficulty swallowing (dysphagia)
- Chest pain
Pain and discomfort are due to reflux of gastric contents or air; hiatal hernia is not the only possible cause of reflux, but reflux does happen more easily in the presence of hiatal hernia. Hiatal hernia may be detected and confirmed by upper GI series, barium swallow x-ray, or esophago-gastro-duodenoscopy (EGD).
Causes and contributing factors can include:
- Frequent coughing
- Straining due to constipation
- Congenital weakness of the lower esophageal sphincter (LES) and supporting tissue
Children with this condition usually have it from birth (congenital), and it is often associated with GERD in infants. Nissen fundoplication is used to correct this condition surgically, commonly performed laparoscopically, and has low complication rates and a quick recovery.
The defining element of this surgery is the use of a laparoscope, a telescopic rod, and lens system connected to a video camera or other viewing device. An associated fiber optic cable system channels illumination from a cold (halogen or xenon) light source to the operative field.
Laparoscopic surgery is also described as minimally invasive surgery, bandaid surgery, keyhole surgery, or pinhole surgery.
The advantages of laparoscopic surgery versus a traditional open procedure include:
- Reduced blood loss
- Smaller incisions, with less scarring, less pain, and shorter recovering
- Slightly longer procedure time, but much shorter hospitalization
- Reduced exposure to infection
Infantile hypertrophic pyloric stenosis, or gastric outlet obstruction, is a narrowing of the opening from the stomach to the intestines, due to spasm and hypertrophy of the muscle surrounding the pyloric antrum. This condition is most commonly evidenced by severe vomiting in the first few months of life.
Symptoms of pyloric stenosis generally begin about three weeks of age and can include:
- Vomiting, persistent or projectile, especially after feeding
- Constipation or infrequent small stools over a couple of days
- Dehydration, including several hours between wet diapers, wrinkly or doughy appearance of skin, sunken soft spot on head, and jaundice
- Failure to thrive and lethargy
Diagnosis includes a reliable and consistent history, and description of vomiting. An external physical exam may reveal a pyloric mass—a firm, movable lump in the belly (like an olive). An enlarged, thickened pylorus can be seen by ultrasound. Barium swallow x-ray can reveal any narrowing or obstruction. Blood tests will reveal electrolyte imbalances resulting from dehydration that must be corrected.
Pyloric stenosis is typically managed with surgery by pyloromyotomy, which involves cutting through thickened muscles of the pylorus to relieve the obstruction. This is commonly done laparoscopically.
After successful surgery, most infants return to normal feeding relatively quickly. Because of swelling at the surgical site, there may still be vomiting for a day or so. As long as there are no complications, most infants resume regular feeding and can be sent home within 48 hours. If symptoms recur weeks after surgery, it may suggest other associated problems such as GERD or gastritis, or that the pyloromyotomy was incomplete.
Links to Key Digestive Disorder Sites
- Collins III JB, Georgeson KE, et al. Comparison of Open and Laparoscopic Gastrostomy and Fundoplication in 120 Patients. J Ped Surg 1995: 30 (7): 1065-1071.
- Curet MJ, Josloff RK, Schoeb O, Zucker KA (1999). Laparoscopic reoperation for failed antireflux procedures. Archives of Surgery 134 (5): 559-563.
- Humphrey GME and Najmaldin AS. Laparoscopic Nissen Fundoplication in Diabled Infants and Children. J Ped Surg 1996: 31 (4): 596-599.
- Minjarez RC, Jobe BA. Surgical therapy for gastroesophageal reflux disease. GI Motility online.
- Nissen R (1961). Gastropexy and fundoplication in surgical treatment of hiatal hernia. The American Journal of Digestive Diseases 6: 954-961.
- O’Neill JA, Rowe MI et al. Gastroesophageal Reflux. Pediatric Surgery Fifth Education, 1998: 1007-1028.
- Rice H, Seashore JH, Touloukian RJ. Evaluation of Nissen Fundoplication in Neurologically Impaired Children. J Ped Surg 1991: 26 (6): 697-701.
- Rothenburg, SS. Experience with 220 Consecutive Laparoscopic Nissen Fundoplications in Infants and Children. J Ped Surg. 1998: 33 (2): 274-278.