Toupét Fundoplication for Gastroesophageal Reflux in Childhood

Weber TR. — Thu, 01 Jul 1999 00:00:00 GMT

Hypothesis

Gastroesophageal reflux (GER) is a common condition in childhood that frequently requires operative treatment. The 360° Nissen fundoplication (NF) has been the standard operation for GER, but is associated with substantial rates of recurrence, "gas bloat," gagging, and dysphagia. I believe that the Toupét fundoplication (TF), a 270° posterior wrap originally described in conjunction with myotomy for achalasia, has fewer complications, and its long-term outcome in children compared with NF is favorable.

Design

Nonrandomized controlled trial.

Setting

Tertiary care children's hospital.

Patients

Two hundred fifty-six children (aged 3 months to 16 years) with GER disease unresponsive to nonoperative therapy who underwent either NF (n=102) or TF (n=154).

Intervention

Operative repair of GER disease by either NF or TF.

Main Outcome Measures

Time to first feeding, time to discharge from the hospital, postoperative dysphagia complications, recurrence, and rehospitalization and reoperation rates for each fundoplication technique.

Results

The 2 fundoplication techniques had equivalent recurrence rates, but TF had significantly lower rates of postoperative dysphagia (P=.008) and rehospitalization/reoperation rates (P=.005) and significantly shorter times to discharge from the hospital (P=.01) and to the first feeding (P=.02).

Conclusions

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 fewer rehospitalizations. In this population, TF seems to be superior to NF.

Esophageal pH Monitoring Abnormalities and Gastroesophageal Reflux Disease in Infants With Intestinal Malrotation

Jolley SG, Lorenz ML, Hendrickson M, et al. — Thu, 01 Jul 1999 00:00:00 GMT

Hypothesis

Infants with rotational abnormalities of the midgut mesentery are at high risk for gastroesophageal reflux disease (GERD) and for sudden infant death (SID) from GERD.

Design

A survey of the prevalence of GERD and the risk factor for SID from GERD in a case series of infants treated for congenital anomalies that include intestinal malrotation. Eighty-one (89%) of the infants studied for GERD had a mean follow-up of 23.2 months (median, 12 months).

Setting

Patients treated in 2 tertiary care centers consisting of a children's hospital and a university medical center.

Patients

Two hundred eighty-six consecutive infants were treated for congenital anomalies from September 1, 1985, through May 31, 1998. The patients selected for study were 91 infants who had 18- to 24-hour esophageal pH monitoring performed and no prior operation on the stomach or esophagus. The studied infants had intestinal malrotation either alone (n=55) or associated with a repaired abdominal wall defect (n=23) or congenital diaphragmatic hernia (n=13). Of the 91 infants, 34 were asymptomatic at the time of esophageal pH monitoring.

Interventions

Eighteen- to 24-hour esophageal pH monitoring was used to determine the presence of GERD (abnormal pH score >2 hours postcibal) and the risk factor for SID from GERD (type I or III reflux pattern in combination with a prolonged mean duration of sleep reflux).

Main Outcome Measures

The prevalence of GERD and the risk factor for SID from GERD. The follow-up of GERD was reported as a combination of clinical outcome and subsequent extended esophageal pH monitoring.

Results

Of the 91 infants studied, 80 (88%) had GERD and 26 (29%) had the risk factor for SID from GERD. Of 55 infants with intestinal malrotation alone, 52 (95%) had GERD, and 20 (36%) had the risk factor for SID from GERD. Although GERD was found in 19 (83%) of 23 patients with repaired abdominal wall defects, the prevalence of the risk factor for SID from GERD was significantly lower (13% [3 patients]; P=.03) than in patients with intestinal malrotation alone. The prevalence of GERD in infants with repaired congenital diaphragmatic hernia was significantly lower (69% [9/13]; P=.02) than in infants with intestinal malrotation alone but not for the prevalence of the risk factor for SID from GERD (23% [3/13]; P=.19). Both symptomatic and asymptomatic patients had similar prevalences of GERD (91% [52/57] vs 82% [28/34]; P=.17) and for the risk factor for SID from GERD (31% [18/57] vs 24% [8/34]; P=.28). On follow-up, the prognosis for GERD in infants with intestinal malrotation was better in the infants who were asymptomatic than in those who were symptomatic at the initial extended esophageal pH monitoring.

Conclusions

The prevalence of GERD in infants with intestinal malrotation is high, and the prevalence of the risk factor for SID from GERD is a significant concern. The prevalence of GERD is lower in infants with congenital diaphragmatic hernia. Infants with repaired abdominal wall defects have a lower prevalence of the risk factor for SID from GERD. We recommend careful evaluation and follow-up of infants with intestinal malrotation for problems, such as SID, from GERD.

JAMA Surgery: Pediatric Otolaryngology Topic Collection

Toupét Fundoplication for Gastroesophageal Reflux in Childhood

Esophageal pH Monitoring Abnormalities and Gastroesophageal Reflux Disease in Infants With Intestinal Malrotation