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Interposition of a jejunal segment between esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux
Interposition of a Jejunal Segment Between Esophagus and Pylorus for Treatment of Multirecurrent Gastroesophageal Reflux By Eric W. Fonkalsrud and Joaquim Los Angeles, California
Bustorff-Silva
Here the authors report the clinical experience with placement of an isolated jejunal segment between the esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux (GER) in a child. A B-year-old neurologically normal girl experienced severe symptomatic GER after 3 previous well-constructed Nissen fundoplications that failed over a 4-year period. The gastric cardia was closed, and a 16-cm isolated segment of proximal jejunum was placed in an isoperistaltic direction between the distal esophagus and an incision through the pylorus, extending onto both the antrum and duodenum. A gastrostomy was used for 3 months. The patient recovered from the operation without complications and has been completely relieved of reflux
symptoms during the 15 months postoperation. She has gained over 6.5 kg in weight and 3.2 cm in height during this period and has not experienced difficulty swallowing solid foods. Esophagogastric dissociation with placement of an isolated jejunal segment between the esophagus and pylorus may have a useful role in the surgical management of multirecurrent symptomatic GER as a “rescue procedure” with low risk compared with other options. J Pediatr Surg 34:7563-1566. Copyright Q 7999 by W.B. Saunders Company.
URGICAL CORRECTION of gastroesophageal reflux (GER) is one of the most frequently performed abdominal operations performed on infants and children in the United States.’ Although the incidence of recurrent symptomatic reflux in neurologically normal children is less than 5%, the frequency increases to 12% in neurologitally impaired children. For those patients who have well-documented recurrent symptomatic reflux that is refractory to medical therapy, a redo fundoplication is commonly recommended. Correction of the frequently associated paraesophageal hernia and suture approximation of the crura of the diaphragm posterior to the esophagus are standard. In addition, several surgeons recommend performance of a simultaneous gastric emptying procedure because the vagus nerves are easily damaged during redo esophageal surgery.2 Although redo fundoplication is successful in preventing further GER in more than 60% of patients, a small group of children may experience a third, or even a fourth recurrence despite meticulous attention to surgical detail. The majority of children with multiple recurrences of reflux have neurological impairment with seizure disorder or chronic lung disease.3,4The surgical management of multirecurrent GER has been a frustrating and complex surgical undertaking, with a variety of surgical techniques being recommended. The current report describes a new modification of the jejunal interposition technique, which preserves gastric function while enhancing gastric emptying and completely relieving symptomatic GER. The operation was performed on a 6-year-old girl who had 4 recurrences of symptomatic GER and had chronic lung disease from
recurrent aspiration as well as failure-to-thrive. She has experienced no further reflux, the lung disease is markedly improved, and her growth has returned to the 60th percentile during the 15 months after operation.
S
Journal
of Pediatric
Surgery,
Vol34,
No 10 (October),
1999: pp 1563-l
566
INDEX jejunal
WORDS: interposition,
Multirecurrent gastroesophageal gastric bypass.
CASE
reflux,
REPORT
A female infant was delivered in a community hospital by cesarean section to a primigravida mother after a 2%week gestation for premature rupture of membranes. Her birth weight was 1,300 g. She experienced respiratory distress and required mechanical ventilation for 4 days. No congenital malformations were identified. She received parenteral nutrition for 3 weeks and was gradually advanced to oral feedings. She was discharged from the hospital at 2% months of age, at which time she weighed 2,150 g. By the age of 4 months, she began to experience emesis after feedings with increasing frequency. A variety of formulas were tried, including goat’s milk and thickening of feedings. Semiupright positioning was used intermittently, when practical, for several weeks. Episodes of fever, coughing, and wheezing, developed and she received intermittent courses of antibiotics. She was hospitalized with aspiration pneumonia on one occasion. At the age of 25 months, the patient was first examined and evaluated at the UCLA Medical Center. Her weight was 9 kg and the height was 78.5 cm, both below the fifth percentile for age, even after subtracting 2 months for prematurity. Neurological development was normal for age, and no other anomalies or disorders were identified. A contrast esophagram showed intermittent GER with features of esophagitis and gastritis. Twenty-four-hour esophageal pH monitoring showed 81
From the Division of Pediatric Surgery, UCLA School of Medicine, Los Angeles, CA. Address reprint requests to Eric II? Fonkalsrud, MD, Department of Surgery, UCLA School of Medicine, Room 72-126 CHS, L.os Angeles, CA 90095-l 749. Copyright o 1999 by WB. Saunders Company 0022-3468/99/3410-0032$03.00/O
1563
1564 reflux episodes (26 with more than 5 minutes duration), the longest lasting 44 minutes. The time in which the pH was 4.0 or lower, was 36.5% of the total time monitored. Results of a gastric emptying study showed 53% retention of an isotope-labeled meal at 90 minutes (50% retention at 90 minutes considered abnormal). At the age of 26 months, the patient underwent a loose Nissen fundoplication, gastropyloric antroplasty,5 and placement of a gastrostomy tube. She was discharged on the sixth postoperative day and progressed well for the first few weeks. She then experienced increasing difhculty swallowing oral feedings and was gradually fed primarily through the gastrostomy. An esophagram showed narrowing at the site of the timdoplication with a paraesophageal hernia. Esophageal dilatations were unsuccessful in relieving the symptoms. At 30 months of age she underwent a redo Nissen fundoplication with esophageal dilatation and revision of the gastrostomy. During the ensuing 3 years, the patient took feedings orally and progressed well clinically except for a chronic cough and continued failure-to-thrive. At age 5% years, she experienced increasing dysphagia and emesis. An esophagram showed lower esophageal stenosis, recurrent GER, and a paraesophageal hernia. She underwent laparotomy with reconstruction of the Nissen fundoplication and repair of the paraesophageal hernia with closure of the crura posterior to the esophagus, both secured with dacron pledgets. In view of the 2 previous operations and the risk of vagal injury with a third reconstruction, the antroplasty was revised with a wide incision. The postoperative recovery was uneventful; however, within 3 months (age 6 years), she experienced repeated emesis with daily pulmonary aspiration. An esophagram showed severe GER and a large paraesophageal hernia. Esophagascopy showed extensive esophagitis. A gastric emptying study showed 49% retention of the isotope meal in the stomach at 90 minutes. She remained symptomatic despite receiving cisapride and omeprazole. At the age of 6% years because of persistent reflux symptoms and failure to gain weight (16% kg), the patient underwent her fourth antireflux operation. The fundoplication had separated widely, and the crural repair also was open widely. In view of the breakdown of 3 fundoplications together with cmral disruption, it was elected to perform a jejunal interposition procedure as a “rescue operation” (Fig 1). The esophagus was divided at the esophagogastric junction, removing a short segment of the cardia. The cardia was closed in 2 layers with interrupted Maxon sutures. A 16-cm segment of jejunum was then isolated approximately 15 cm distal to the ligament of Treitz and was brought through an opening in the transverse mesocolon, placed behind the stomach, and extended up to the esophagus in an isoperistaltic direction. A 2-layer esophagojejunal anastomosis was performed with interrupted Maxon sutures. The crura of the diaphragm were approximated posterior to the esophagus 1.5 cm cephalad to the esophagojejunal anastomosis. The distal end of the jejunal segment was then sutured to a 4-cm incision extending from distal antrum, across the pyloms, and onto the duodenum. TWO layers of interrupted Maxon were used for the anastomosis. The jejunum at the site at which the isolated segment was removed was similarly reconstructed in 2 layers. A tube gastrostomy was constructed. Results of an upper gastrointestinal radiographic contrast study performed 7 days postoperation showed rapid flow of the contrast through the jejunal interposition segment into both the gastric antrum and duodenum with no anastomotic stenosis or leaks. She was discharged from the hospital 9 days after operation at which time she was taking a regular diet without gagging or emesis. The gastrostomy was vented every 8 hours. During examination 4 months postoperation she was swallowmg a regular diet without emesis and had gained 2% kg weight. She had no evidence of dumping or diarrhea. The cough and nocturnal respiratory distress had almost completely resolved. A tine-esophagram showed prompt flow of contrast through the jejunal segment with minimal dilatation and no reflux into the esophagus.
FONKALSRUD
AND
BUSTORFF-SILVA
Fig 1. Cardia of stomach is transected from esophagus and closed. A 16-cm segment of jejunum is placed posterior to the stomach in an isoperistaltic direction and anastomosed to the distal end of the esophagus and to the widely opened pylorus (extending on to antrum and to duodenum). The jejunum is reconstructed, and a gastrostomy tube is placed on the mid portion of the greater curveture.
Upper gastrointestinal radiographs showed that a small portion of ingested feedings refluxed into the stomach but then rapidly emptied into the duodenum. Repeated aspiration of the gastrostomy tube showed no bile reflux; the gastrostomy was removed 3 months postoperation. During examination 15 months postoperation, the patient was able to swallow a regular diet almost normally, was free of emesis and respiratory symptoms, and weighed 23 kg, a gain of almost 7 kg over a 15-month period. There has been no clinical evidence of acid or bile reflux into the esophagus.
DISCUSSION
For children who experience recurrent symptomatic reflux months after undergoing a fundoplication, and who are unresponsive to vigorous medical therapy, reoperaAssuming that the operative tion often is necessary.3*4,6,7 technique was satisfactory, a variety of factors have been implicated in the failure of a fundoplication. Recurrent GER is most likely to occur within the first 2 postoperative years and is most frequent in neurologically impaired children and those with chronic pulmonary disease, poor
GASTRIC
BYPASS
FOR RECURRENT
1565
GER
nutritional status, and a variety of other anatomic or functional disorders that place excessive stress on the fundoplication, eg, gastric atony, seizure disorders, esophageal dysmotility, and esophageal atresia.‘~3~4~6~7 It is helpful to define the anatomy of the gastroesophageal junction by tine-esophagrams and to measure gastric emptying by an isotope feeding study before reoperation. A redo fundoplication generally is recommended for the first recurrence, although the failure rate is reported as high as 15% to 25%.1,3,4,6Because extensive scar tissue often is present at the site of the previous wrap, placing the vagus nerves at risk, a concomitant gastric emptying procedure often is recommended. l For neurologically impaired children with one or more failed fundoplications, some investigators have recommended a feeding jejunostomy and decompressing gastrostomy to avoid major reconstructive surgery.4 In the occasional patient with recurrent GER after 2 or more antireflux operations, more complex reconstruction may be advisable.*y9 The benefits and risks of major reconstruction of the esophagus and stomach to prevent multirecurrent reflux should be weighed against the increasingly difficult and complex technical aspects of further redo fundoplication and the high risk of further recurrence. The Collis-Nissen or Collis-Belsey reconstructions have been used with moderate success in adults and also in some children with failed fundoplications by some investigators.‘OJ1 Combined vagotomy, antrectomy, and Roux-en-Y diversion was performed for recurrent GER by Ellis and Gibbs with 85% of 39 adult patients experiencing improvement, although major complications occurred in 9 patients. Esophagectomy with colonic or jejunal interposition and in some cases with partial gastrectomy, has been recommended by several investigators for patients with failed fundoplications.4Jz-‘6
Good results were reported by Bianchi” in 4 neurologitally impaired children with failed fundoplications who underwent a “rescue procedure” consisting of total esophagogastric dissociation with Roux-en-Y esophagojejunal anastomosis and jejunojejunostomy. This operation has considerable surgical appeal for the child who has undergone 2 or more failed fundoplications because it is less extensive and has fewer complications than esophagectomy with colonic or jejunal replacement operations, while completely assuring against GER. The operation described in the current report has similar advantages to the procedures reported by Bianchi,” and by Danielson and Emmens’* for neurologically impaired children, but additionally has the benefits of placing ingested feedings into the gut proximal to the ampulla of Vater, and also opens the gastric outflow widely to prevent gastric stasis. In previous studies, Pecora19 reported that a pylorojejunostomy produces excellent gastric drainage without altering gastric acid production. The length of the jejunal segment was selected to be 16 cm because this provided a length that was not redundant and was considered sufficiently long to minimize bile or acid reflux. The gastric emptying procedure (antroplasty) had no apparent benefit in preventing recurrent reflux in this patient, in whom gastric dysmotility was believed to be present. The gastrostomy tube, which had been used in the current patient since the age of 26 months, was no longer necessary and was removed 3 months after operation. The weight gain (almost 7 kg in 15 months), combined with the increase in height (3.2 cm in 12 months) after operation, have been very gratifying. The present operation also may be helpful for children with severe neurological impairment and pharyngeal discoordination who may be safely fed through the gastrostomy tube.
REFERENCES 1. Fonkalsrud EW, Ament ME: Gastroesophageal reflux in childhood. Curr Prob Surg 33:1-170,1996 2. Fonkalsrud EW, Ashcraft KW, Coran AG, et al: Surgical treatment of gastroesophageal reflux in children: A combined hospital study of 7467 patients. Pediatrics 101:419-422, 1998 3. Wheatley MJ, Coran AG, Wesley JR, et al: Redo fundoplication in infants and children with recurrent gastroesophageal reflux. J Pediatr Surg 26:758-761, 1991 4. Dalla Vecchia LK, Grosfeld JL, West KW, et al: Reoperation after Nissen fundoplication in children with gastroesophageal reflux: Experience with 130 patients. Ann Surg 226:315-321,1997 5. Fonkalsrud EW, Ament ME, Vargas J: Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children. Am J Surg 153:177-183, 1992 6. Dedinksy GK, Vane DW, Black CT, et ah Complications and reoperation after Nissen fundophcation in childhcod. Am J Surg 153:177-183,1987 7. Kimber C, Kiely EM, Spitz L: The failure rate of surgery for gastro-oesophageal reflux. J Pediatr Surg 33&I-66,1998 8. Ellis FH Jr, Gibb SP: Vagotomy, antrectomy, and Roux-en-Y
diversion for complex reoperative gastroesophageal reflux disease. Ann Surg 220:536-542,1994 9. Stein HJ, Feussner H, Siewert JR: Failure of antireflux surgery: Causes and management strategies. Am J Surg 171:36-40, 1996 10. Stirling MC, Orringer MB: Surgical treatement after the failed antireflux operation. J Thorac Cardiovasc Surg 92:667-672, 1986 11. Cameron BH, Co&ran WJ, McGill CW: The uncut CollisNissen fundophcation: Results for 79 consecutively treated high-risk children. J Pediatr Surg 32:887-891, 1997 12. Ferrer JM Jr, Bruck HM: Jejunal and colonic interposition for non-malignant disease of the esophagus. Ann Surg 169:533-543, 1969 13. Pasch AR, Putnam T: Jejunal interposition for recurrent gastroesophageal reflux in children. Am J Surg 150:248-251, 1985 14. Ring WS, Varco RL, L’Heureux PR, et al: Esophageal replacement with jejunmn in children: An 18 to 33 year follow-up. J Thorac Cardiovasc Surg 83:918-927,1982 15. Mansour KA, Bryan FC, Carlson GW: Bowel interposition for esophageal replacement: Twenty-five-year experience. Ann Thorac Surg 64~752-756, 1997
1566
16. Gadenstatter M, Hagen JA, DeMeester TR, et al: Esophagectomy for unsuccessful antireflux operations. .I Thorac Cardiovasc Surg 115:296-301, 1998 17. Bianchi A: Total esophagogastric dissociation: An alternative approach. J Pediatr Surg 32:1291-1294,1997
FONKALSRUD
AND
BUSTORFF-SILVA
18. Danielson PD, Emmens RW: Esophagogastric disconnection for gastroesophageal reflux in chddren with severe neurological impairment. J Pediatr Surg 34:84-87, 1999 19. Pecora DV: Pylorojejunostomy as an alternative to pyloroplasty. Arch Surg 106:83-85,1973
Bustorff-Silva
Here the authors report the clinical experience with placement of an isolated jejunal segment between the esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux (GER) in a child. A B-year-old neurologically normal girl experienced severe symptomatic GER after 3 previous well-constructed Nissen fundoplications that failed over a 4-year period. The gastric cardia was closed, and a 16-cm isolated segment of proximal jejunum was placed in an isoperistaltic direction between the distal esophagus and an incision through the pylorus, extending onto both the antrum and duodenum. A gastrostomy was used for 3 months. The patient recovered from the operation without complications and has been completely relieved of reflux
symptoms during the 15 months postoperation. She has gained over 6.5 kg in weight and 3.2 cm in height during this period and has not experienced difficulty swallowing solid foods. Esophagogastric dissociation with placement of an isolated jejunal segment between the esophagus and pylorus may have a useful role in the surgical management of multirecurrent symptomatic GER as a “rescue procedure” with low risk compared with other options. J Pediatr Surg 34:7563-1566. Copyright Q 7999 by W.B. Saunders Company.
URGICAL CORRECTION of gastroesophageal reflux (GER) is one of the most frequently performed abdominal operations performed on infants and children in the United States.’ Although the incidence of recurrent symptomatic reflux in neurologically normal children is less than 5%, the frequency increases to 12% in neurologitally impaired children. For those patients who have well-documented recurrent symptomatic reflux that is refractory to medical therapy, a redo fundoplication is commonly recommended. Correction of the frequently associated paraesophageal hernia and suture approximation of the crura of the diaphragm posterior to the esophagus are standard. In addition, several surgeons recommend performance of a simultaneous gastric emptying procedure because the vagus nerves are easily damaged during redo esophageal surgery.2 Although redo fundoplication is successful in preventing further GER in more than 60% of patients, a small group of children may experience a third, or even a fourth recurrence despite meticulous attention to surgical detail. The majority of children with multiple recurrences of reflux have neurological impairment with seizure disorder or chronic lung disease.3,4The surgical management of multirecurrent GER has been a frustrating and complex surgical undertaking, with a variety of surgical techniques being recommended. The current report describes a new modification of the jejunal interposition technique, which preserves gastric function while enhancing gastric emptying and completely relieving symptomatic GER. The operation was performed on a 6-year-old girl who had 4 recurrences of symptomatic GER and had chronic lung disease from
recurrent aspiration as well as failure-to-thrive. She has experienced no further reflux, the lung disease is markedly improved, and her growth has returned to the 60th percentile during the 15 months after operation.
S
Journal
of Pediatric
Surgery,
Vol34,
No 10 (October),
1999: pp 1563-l
566
INDEX jejunal
WORDS: interposition,
Multirecurrent gastroesophageal gastric bypass.
CASE
reflux,
REPORT
A female infant was delivered in a community hospital by cesarean section to a primigravida mother after a 2%week gestation for premature rupture of membranes. Her birth weight was 1,300 g. She experienced respiratory distress and required mechanical ventilation for 4 days. No congenital malformations were identified. She received parenteral nutrition for 3 weeks and was gradually advanced to oral feedings. She was discharged from the hospital at 2% months of age, at which time she weighed 2,150 g. By the age of 4 months, she began to experience emesis after feedings with increasing frequency. A variety of formulas were tried, including goat’s milk and thickening of feedings. Semiupright positioning was used intermittently, when practical, for several weeks. Episodes of fever, coughing, and wheezing, developed and she received intermittent courses of antibiotics. She was hospitalized with aspiration pneumonia on one occasion. At the age of 25 months, the patient was first examined and evaluated at the UCLA Medical Center. Her weight was 9 kg and the height was 78.5 cm, both below the fifth percentile for age, even after subtracting 2 months for prematurity. Neurological development was normal for age, and no other anomalies or disorders were identified. A contrast esophagram showed intermittent GER with features of esophagitis and gastritis. Twenty-four-hour esophageal pH monitoring showed 81
From the Division of Pediatric Surgery, UCLA School of Medicine, Los Angeles, CA. Address reprint requests to Eric II? Fonkalsrud, MD, Department of Surgery, UCLA School of Medicine, Room 72-126 CHS, L.os Angeles, CA 90095-l 749. Copyright o 1999 by WB. Saunders Company 0022-3468/99/3410-0032$03.00/O
1563
1564 reflux episodes (26 with more than 5 minutes duration), the longest lasting 44 minutes. The time in which the pH was 4.0 or lower, was 36.5% of the total time monitored. Results of a gastric emptying study showed 53% retention of an isotope-labeled meal at 90 minutes (50% retention at 90 minutes considered abnormal). At the age of 26 months, the patient underwent a loose Nissen fundoplication, gastropyloric antroplasty,5 and placement of a gastrostomy tube. She was discharged on the sixth postoperative day and progressed well for the first few weeks. She then experienced increasing difhculty swallowing oral feedings and was gradually fed primarily through the gastrostomy. An esophagram showed narrowing at the site of the timdoplication with a paraesophageal hernia. Esophageal dilatations were unsuccessful in relieving the symptoms. At 30 months of age she underwent a redo Nissen fundoplication with esophageal dilatation and revision of the gastrostomy. During the ensuing 3 years, the patient took feedings orally and progressed well clinically except for a chronic cough and continued failure-to-thrive. At age 5% years, she experienced increasing dysphagia and emesis. An esophagram showed lower esophageal stenosis, recurrent GER, and a paraesophageal hernia. She underwent laparotomy with reconstruction of the Nissen fundoplication and repair of the paraesophageal hernia with closure of the crura posterior to the esophagus, both secured with dacron pledgets. In view of the 2 previous operations and the risk of vagal injury with a third reconstruction, the antroplasty was revised with a wide incision. The postoperative recovery was uneventful; however, within 3 months (age 6 years), she experienced repeated emesis with daily pulmonary aspiration. An esophagram showed severe GER and a large paraesophageal hernia. Esophagascopy showed extensive esophagitis. A gastric emptying study showed 49% retention of the isotope meal in the stomach at 90 minutes. She remained symptomatic despite receiving cisapride and omeprazole. At the age of 6% years because of persistent reflux symptoms and failure to gain weight (16% kg), the patient underwent her fourth antireflux operation. The fundoplication had separated widely, and the crural repair also was open widely. In view of the breakdown of 3 fundoplications together with cmral disruption, it was elected to perform a jejunal interposition procedure as a “rescue operation” (Fig 1). The esophagus was divided at the esophagogastric junction, removing a short segment of the cardia. The cardia was closed in 2 layers with interrupted Maxon sutures. A 16-cm segment of jejunum was then isolated approximately 15 cm distal to the ligament of Treitz and was brought through an opening in the transverse mesocolon, placed behind the stomach, and extended up to the esophagus in an isoperistaltic direction. A 2-layer esophagojejunal anastomosis was performed with interrupted Maxon sutures. The crura of the diaphragm were approximated posterior to the esophagus 1.5 cm cephalad to the esophagojejunal anastomosis. The distal end of the jejunal segment was then sutured to a 4-cm incision extending from distal antrum, across the pyloms, and onto the duodenum. TWO layers of interrupted Maxon were used for the anastomosis. The jejunum at the site at which the isolated segment was removed was similarly reconstructed in 2 layers. A tube gastrostomy was constructed. Results of an upper gastrointestinal radiographic contrast study performed 7 days postoperation showed rapid flow of the contrast through the jejunal interposition segment into both the gastric antrum and duodenum with no anastomotic stenosis or leaks. She was discharged from the hospital 9 days after operation at which time she was taking a regular diet without gagging or emesis. The gastrostomy was vented every 8 hours. During examination 4 months postoperation she was swallowmg a regular diet without emesis and had gained 2% kg weight. She had no evidence of dumping or diarrhea. The cough and nocturnal respiratory distress had almost completely resolved. A tine-esophagram showed prompt flow of contrast through the jejunal segment with minimal dilatation and no reflux into the esophagus.
FONKALSRUD
AND
BUSTORFF-SILVA
Fig 1. Cardia of stomach is transected from esophagus and closed. A 16-cm segment of jejunum is placed posterior to the stomach in an isoperistaltic direction and anastomosed to the distal end of the esophagus and to the widely opened pylorus (extending on to antrum and to duodenum). The jejunum is reconstructed, and a gastrostomy tube is placed on the mid portion of the greater curveture.
Upper gastrointestinal radiographs showed that a small portion of ingested feedings refluxed into the stomach but then rapidly emptied into the duodenum. Repeated aspiration of the gastrostomy tube showed no bile reflux; the gastrostomy was removed 3 months postoperation. During examination 15 months postoperation, the patient was able to swallow a regular diet almost normally, was free of emesis and respiratory symptoms, and weighed 23 kg, a gain of almost 7 kg over a 15-month period. There has been no clinical evidence of acid or bile reflux into the esophagus.
DISCUSSION
For children who experience recurrent symptomatic reflux months after undergoing a fundoplication, and who are unresponsive to vigorous medical therapy, reoperaAssuming that the operative tion often is necessary.3*4,6,7 technique was satisfactory, a variety of factors have been implicated in the failure of a fundoplication. Recurrent GER is most likely to occur within the first 2 postoperative years and is most frequent in neurologically impaired children and those with chronic pulmonary disease, poor
GASTRIC
BYPASS
FOR RECURRENT
1565
GER
nutritional status, and a variety of other anatomic or functional disorders that place excessive stress on the fundoplication, eg, gastric atony, seizure disorders, esophageal dysmotility, and esophageal atresia.‘~3~4~6~7 It is helpful to define the anatomy of the gastroesophageal junction by tine-esophagrams and to measure gastric emptying by an isotope feeding study before reoperation. A redo fundoplication generally is recommended for the first recurrence, although the failure rate is reported as high as 15% to 25%.1,3,4,6Because extensive scar tissue often is present at the site of the previous wrap, placing the vagus nerves at risk, a concomitant gastric emptying procedure often is recommended. l For neurologically impaired children with one or more failed fundoplications, some investigators have recommended a feeding jejunostomy and decompressing gastrostomy to avoid major reconstructive surgery.4 In the occasional patient with recurrent GER after 2 or more antireflux operations, more complex reconstruction may be advisable.*y9 The benefits and risks of major reconstruction of the esophagus and stomach to prevent multirecurrent reflux should be weighed against the increasingly difficult and complex technical aspects of further redo fundoplication and the high risk of further recurrence. The Collis-Nissen or Collis-Belsey reconstructions have been used with moderate success in adults and also in some children with failed fundoplications by some investigators.‘OJ1 Combined vagotomy, antrectomy, and Roux-en-Y diversion was performed for recurrent GER by Ellis and Gibbs with 85% of 39 adult patients experiencing improvement, although major complications occurred in 9 patients. Esophagectomy with colonic or jejunal interposition and in some cases with partial gastrectomy, has been recommended by several investigators for patients with failed fundoplications.4Jz-‘6
Good results were reported by Bianchi” in 4 neurologitally impaired children with failed fundoplications who underwent a “rescue procedure” consisting of total esophagogastric dissociation with Roux-en-Y esophagojejunal anastomosis and jejunojejunostomy. This operation has considerable surgical appeal for the child who has undergone 2 or more failed fundoplications because it is less extensive and has fewer complications than esophagectomy with colonic or jejunal replacement operations, while completely assuring against GER. The operation described in the current report has similar advantages to the procedures reported by Bianchi,” and by Danielson and Emmens’* for neurologically impaired children, but additionally has the benefits of placing ingested feedings into the gut proximal to the ampulla of Vater, and also opens the gastric outflow widely to prevent gastric stasis. In previous studies, Pecora19 reported that a pylorojejunostomy produces excellent gastric drainage without altering gastric acid production. The length of the jejunal segment was selected to be 16 cm because this provided a length that was not redundant and was considered sufficiently long to minimize bile or acid reflux. The gastric emptying procedure (antroplasty) had no apparent benefit in preventing recurrent reflux in this patient, in whom gastric dysmotility was believed to be present. The gastrostomy tube, which had been used in the current patient since the age of 26 months, was no longer necessary and was removed 3 months after operation. The weight gain (almost 7 kg in 15 months), combined with the increase in height (3.2 cm in 12 months) after operation, have been very gratifying. The present operation also may be helpful for children with severe neurological impairment and pharyngeal discoordination who may be safely fed through the gastrostomy tube.
REFERENCES 1. Fonkalsrud EW, Ament ME: Gastroesophageal reflux in childhood. Curr Prob Surg 33:1-170,1996 2. Fonkalsrud EW, Ashcraft KW, Coran AG, et al: Surgical treatment of gastroesophageal reflux in children: A combined hospital study of 7467 patients. Pediatrics 101:419-422, 1998 3. Wheatley MJ, Coran AG, Wesley JR, et al: Redo fundoplication in infants and children with recurrent gastroesophageal reflux. J Pediatr Surg 26:758-761, 1991 4. Dalla Vecchia LK, Grosfeld JL, West KW, et al: Reoperation after Nissen fundoplication in children with gastroesophageal reflux: Experience with 130 patients. Ann Surg 226:315-321,1997 5. Fonkalsrud EW, Ament ME, Vargas J: Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children. Am J Surg 153:177-183, 1992 6. Dedinksy GK, Vane DW, Black CT, et ah Complications and reoperation after Nissen fundophcation in childhcod. Am J Surg 153:177-183,1987 7. Kimber C, Kiely EM, Spitz L: The failure rate of surgery for gastro-oesophageal reflux. J Pediatr Surg 33&I-66,1998 8. Ellis FH Jr, Gibb SP: Vagotomy, antrectomy, and Roux-en-Y
diversion for complex reoperative gastroesophageal reflux disease. Ann Surg 220:536-542,1994 9. Stein HJ, Feussner H, Siewert JR: Failure of antireflux surgery: Causes and management strategies. Am J Surg 171:36-40, 1996 10. Stirling MC, Orringer MB: Surgical treatement after the failed antireflux operation. J Thorac Cardiovasc Surg 92:667-672, 1986 11. Cameron BH, Co&ran WJ, McGill CW: The uncut CollisNissen fundophcation: Results for 79 consecutively treated high-risk children. J Pediatr Surg 32:887-891, 1997 12. Ferrer JM Jr, Bruck HM: Jejunal and colonic interposition for non-malignant disease of the esophagus. Ann Surg 169:533-543, 1969 13. Pasch AR, Putnam T: Jejunal interposition for recurrent gastroesophageal reflux in children. Am J Surg 150:248-251, 1985 14. Ring WS, Varco RL, L’Heureux PR, et al: Esophageal replacement with jejunmn in children: An 18 to 33 year follow-up. J Thorac Cardiovasc Surg 83:918-927,1982 15. Mansour KA, Bryan FC, Carlson GW: Bowel interposition for esophageal replacement: Twenty-five-year experience. Ann Thorac Surg 64~752-756, 1997
1566
16. Gadenstatter M, Hagen JA, DeMeester TR, et al: Esophagectomy for unsuccessful antireflux operations. .I Thorac Cardiovasc Surg 115:296-301, 1998 17. Bianchi A: Total esophagogastric dissociation: An alternative approach. J Pediatr Surg 32:1291-1294,1997
FONKALSRUD
AND
BUSTORFF-SILVA
18. Danielson PD, Emmens RW: Esophagogastric disconnection for gastroesophageal reflux in chddren with severe neurological impairment. J Pediatr Surg 34:84-87, 1999 19. Pecora DV: Pylorojejunostomy as an alternative to pyloroplasty. Arch Surg 106:83-85,1973