The effects and efficacy of antireflux surgery in children

Abstract

Gastroesophageal reflux disease (GERD) frequently occurs in the pediatric population. In severe GERD resistant to medical treatment, laparoscopic antireflux surgery (LARS) may be indicated. The overall aim of the studies presented in this thesis is to assess the effects and efficacy of LARS in children, to identify predictors for success and to determine which type of fundoplication is the best technique in pediatric GERD patients. The efficacy of LARS in controlling GERD symptoms after short-term follow-up is high (88%), however after 10-to-15 years follow-up only 57% of patients were symptom free. In contrast to previous published studies debating a possible inferior effectiveness of LARS in children with impaired neurodevelopment (NI), we demonstrate in this thesis that LARS is equally effective in NI children compared to children with normal neurodevelopment. Acid reflux as measured by 24-hour multichannel intraluminal impedance pH (MII-pH) monitoring significantly decreased after LARS from 8.5% to 0.8%. Next to acid reflux also weakly acidic reflux was significantly reduced after short-term follow-up. However, similarly as to GERD symptoms, pathological acid exposure to the esophagus recurred in 43% of the children after 10-to-15 years follow-up. Assessing gastroesophageal motility identified that the lower esophageal sphincter (LES) resting pressure significantly increased after LARS from 10 mmHg to 24 mmHg, but complete LES relaxation, peristaltic contractions and gastric emptying time were not different after LARS. New-onset dysphagia was seen in only 12% of patients after LARS. One of the newer applications of MII-pH monitoring is the assessment of mucosal integrity by calculating the baseline impedance. Distal baseline impedance significantly increased after LARS. This increase in baseline impedance is likely to reflect recovery of mucosal integrity and thereby mucosal healing after LARS. Furthermore, to better assess the impact of LARS from the perspective of the pediatric patient and their caregivers health-related quality of life (HRQoL) questionnaires were completed. HRQoL total score improved significantly after LARS, both from a parental and child’s perspective. HRQoL before and after LARS was significantly lower in NI children. However, neurodevelopment itself did not influence the effect of LARS on HRQoL. One of the aims was to identify predictors for success of therapy. Age at the time of operation is a significant predictor for improvement in HRQoL after LARS, showing that in older children LARS results in more pronounced improvement of HRQoL. Furthermore, in children with a higher total number of reflux episodes on MII-pH monitoring before operation the effect of LARS on reflux reduction was significantly higher. Various types of fundoplication (i.e. complete Nissen or partial Thal and Toupet fundoplication) can be performed in pediatric GERD patients. After an extensive systematic review of the literature, meta-analysis and a prospective study comparing complete fundoplication to partial fundoplication in children with GERD we found that short-term and long-term postoperative reflux control, and postoperative dysphagia were similar after complete and partial fundoplication, however complete fundoplication often resulted in more postoperative dysphagia complaints than partial fundoplication.