Gastroesophageal reflux disease is still one of the most frequent indications for referral to a pediatric surgeon. Gastroesophageal reflux is quite common in all humans but there are certain children for whom reflux is severe and intractable, or associated with complications such as pain, failure to thrive, aspiration pneumonia, or reactive airways disease. It is extremely important to distinguish reflux, which is effortless, and emesis, which is forceful, as fundoplication in the setting of forceful vomiting will always fail eventually. The decision to operate should be based on clinical grounds. Ideally, there should be a consensus among the primary physician, gastroenterologist, pediatric surgeon, and, perhaps most importantly, the parents. Objective testing is useful in some borderline cases, but available tests are insensitive and nonspecific, and therefore cannot be used as the sole factor in making the decision. The only preoperative test considered mandatory by most pediatric surgeons is an upper GI contrast study, which is useful not to confirm or exclude GER but to rule out achalasia, esophageal stricture, gastric anomalies, and malrotation.
Children being considered for fundoplication generally fall into one of two broad categories: neurologically intact and neurologically impaired. Children who are neurologically impaired often need feeding access (gastrostomy), frequently have moderate-to-severe reflux that could be made worse with gastric feeds, and, most importantly, are sometimes unable to protect their airway. This combination strongly supports the use of fundoplication when gastrostomy is felt to be indicated, but some families may choose to proceed only with gastrostomy, especially if the child has been tolerating nasogastric feeds. This might be reasonable, especially considering that these children also have the highest incidence of postoperative complications, retching, feeding intolerance, hiatal hernia, wrap failure, and recurrent reflux.
There are several time-tested surgical principles that should be adhered to when performing a fundoplication in a child: (1) Perform a complete (360°) wrap whenever feasible. Partial wraps are not as effective or as durable, though they are useful in certain situations, such as esophageal atresia, when esophageal motility is known to be poor. (2) Close the hiatus by approximating the crura posterior to the esophagus. Anterior repair of the hiatus is ineffective and these stitches are doomed to pull through and fail. The use of pledgets or mesh is associated with a significant incidence of erosion and esophageal perforation and so should only be used if there is truly no alternative. (3) The wrap should be loose (“floppy”) and care must be maintained to avoid simply twisting the stomach around the lower esophagus, which can cause severe dysphagia. A bougie is very useful to prevent over-tightening of the hiatus and the wrap. There are published guidelines as to how large a bougie should be used based on the weight of the child, but, in general, one should use the largest bougie that the esophagus will comfortably accommodate. (4) Mobilize at least 3 cm of esophagus into the abdomen and make the wrap 2.0–2.5 cm in length. Use at least three stitches (permanent braided are best) and include a bite of esophagus with each stitch. Try to identify and protect both vagus nerves throughout the procedure to prevent gastric emptying problems. (5) It is generally unnecessary to place collar stitches between the esophagus and hiatus, “rip-stop” stitches (fundus to fundus below the lowest wrap stitch), or stitches between the fundus and diaphragm, but these can be potentially useful in certain situations. (6) Always divide at least some of the upper short gastric vessels. This allows more of the fundus to be wrapped and allows the creation of a tension-free wrap, which is very important. (7) Despite the lack of long-term outcome data, the laparoscopic approach is preferable to the open because of the many advantages of minimal-access surgery, but the steps of the operation must be performed exactly how they would be for the open operation. The open approach is preferred by many surgeons for very small infants and patients undergoing re-do fundoplication.
Intra-operative complications are rare but can be serious. One should be wary of an accessory or replaced left hepatic artery. If a particularly large vessel is “in the way” it makes sense to test-clamp it to be sure the liver does not demarcate. Passing the bougie should be considered the most dangerous part of the operation as esophageal perforation has been described. The surgeon and anesthesiologist must agree that the bougie should be advanced slowly and only when both parties are aware of it. Most perforations are low and small and best repaired primarily and covered with the wrap. If it occurs higher in the chest, adequate drainage, a period of bowel rest, and a contrast study 5–7 days post-op are in order. Re-do Nissen fundoplication can be an extremely tedious procedure, mostly due to the dense adhesions typically formed in this region of the body. This is considered by some surgeons to be an added advantage to the laparoscopic approach: revising the wrap is somewhat easier and can often be done again laparoscopically. The vagus nerves are at high risk for injury during revision fundoplasty but performing an empiric pyloroplasty is no longer recommended due to the high risk of producing the dumping syndrome. Finally, when revising a fundoplication, it is important to take it down completely first, rather than simply reinforcing the part that has loosened. This allows proper closure of the hiatus, identification of the reason for failure, and creation of a tension-free and hopefully more durable wrap.
Postoperative dysphagia occurs in approximately 10% of patients after fundoplication, but only about 10% of these persist for more than 6 weeks. Those that persist should be considered for dilatation of the fundoplication, best done using a balloon dilator under fluoroscopic guidance. Refractory dysphagia could require revision, conversion to a partial wrap, or reversal of the wrap, but surgical intervention of any kind is rarely indicated.