The management of gastroesophageal reflux in infants

Journal VOL.

VIII.

of Pediatric

OCTOBER

NO. 5

The Management Reflux By M. Carcassonne,

T

Surgery

HIS REPORT

of Gastroesophageal in Infants A. Bensoussan.

and J. Aubert

with gastroesophageal reflux (GER) due to in infants. The aim of the Pediatric surgeon should be, not to try to repair a hernia that may not even exist, but to treat the reflux itself a cause of a variety of symptoms and devastating complications. 1 have been involved in this problem for 20 yr; 10 yr in adults where I could use the various procedures in more than 100 patients. For the last IO yr. I have been concerned only with children. Among them, I selected the infant cases, because they are more frequently diagnosed in this age group and chiefly because their management is still much debated. any

kind

WILL

1973

DEAL

of hiatal

hernia

MATERIALS

AND

METHODS

We reviewed 154 cases of GER in infants from October I, 1964 to September 30. 1972. Fortyrequired operation (3(Y),,). We shall concern ourselves only with these 46 patients.

six patients There

were

lost after

26 boys

and

a year when

patients

had clinical

patients

are alive

20 girls.

they and

and

radiologic

available

first year if the last x-ray

Two

returned

were

lost

to Algeria. examination,

for

3. 6. and

follow-up.

examination

I

to follow-up Follow-up

Radiologic

was normal,

yr after

eight

from

6 mo to 8 yr.

I2 mo

after

operation.

examination

the child

operation:

ranged

was not

asymptomatic,

and

were

The

46

Thirty-three done

after

the weight

the gain

adequate.

CLINICAL

FEATURES

Age at onset of symptoms ranged from I day to I5 mo (Fig. I). Thirty-two cases (69:,,) were recognized before 3 mo of age and treated first conservatively then surgically before that age. Ten patients had clinically proved esophagitis at admission; four had a stricture present at the time of operation. The ages of the patients with stricture when they were admitted were I, 6, 12, and I5 mo. Age at operation ranged from I5 days to 18 mo.

From the University Presenled Phoenix.

be/&e

Ari;..

April

M. Carcassonne, Surgery.

University

o/‘Marseille. The Founh

Meeting

oJ ‘The American

Pediarric

Surgical

A .w~w~~on.

Lkparrmenr

(I/ Pedialr/c.

12.-14, 1973. M.D.:

Prq/essor

of Marseille,

Universify

of’ Marseille.

Marseille.

France.

Address Jar reprim

France. Annual

France.

rryurtrs:

G 1473 hv Grune & Srrallon,

oJ Pediarric France.

A.

J. Aubert,

Surgery;

Surgeon-in-Chief

Bensoussan, M.D.:

M. Carca~.~onnr.

Assislanr

M.D.: in

Assistam Pediatric

2.5 Rue ROKY de Brignolr\

in

Pedialric,

Surgery. 13006.

Surgery,.

Universir),

o/

Mor.veillc~. trunC’c.

Inc.

Journal of Pediafric Surgery. Vol. 8. No. 5 (October).

1973

575

576

CARCASSONNE,

Fig. 1.

‘iL*.

BENSOUSSAN,

AND AUBERT

Age at onset.

Vomiting was present in 44 cases. It had commenced during the first week of life in 70”,, of cases, during the first month in 90”.. Some were treated, some not, by conservative management either at home or in pediatric wards from 15 to 365 days(!). Medical admissions were long enough for the diagnosis of GER to be made in 40 cases. However, six patients were admitted, twice for sepsis, twice for milk allergy, and twice for tracheoesophageal fistula without atresia. Hematemesis occurred in ten cases.

Fig. 2.

Weight at operation.

MANAGEMENT

OF GASTROESOPHAGEAL

REFLUX

577

Anemia was the next most frequent clinical feature and was more related to malnutrition than to esophagitis and ulceration. Failure ru thrive. As shown in Fig. 2, all patients were undersized, some with very severe malnutrition due to prolonged ineffective medical treatment. Ten infants presented a history of recurrent and severe Ptleuttlot~itis. respiratory tract infections with aspiration pneumonitis. Two had cardiac arrest after tracheal aspiration during postural treatment in medical wards. They were operated upon and cured after a short period of intensive respiratory care. Esophagitis or stricture was diagnosed by either x-ray examination or esophagoscopy prior to operation. DIAGNOSIS

Frequently, a permanent hernia may be demonstrated on plain films, but contrast medium is necessary to find the GER. Cineradiography has been helpful in confirming the diagnosis and checking the result of treatment. Our cases can be divided in three types according to the Duhamel and Sauvegrain classitication.’ Minor form of hiatus hernia: chalasia. relaxation of cardia, intermittent mediastinal hernia, 24; permanent mediastinal hernia, 13: right thoracic hernia, upside down stomach, 9: permanent stenosis, 4. All patients presented reflux, but what is more interesting is that the importance of reflux was not related to the size of the hernia. The smaller hernias had more severe reflux than the large hernias: a suhicient reason to speak of reflux rather than of hernia and to treat the reflux. In this series, there was no paraesophageal hernia or congenital short esophagus. Esophagoscopy was the best method of assessing the presence and importance of esophagitis and stricture. It was used preoperatively in all patients. The new Olympus device that we used only for the last 6 mo will probably broaden the endoscopic examination. Gastric acidity studies according to Lister’ have been carried on in our 13 first cases. As the results were not significant we canceled this examination in the cases without stenosis. In our material, as in Randolph’s3 there is no evidence of association of gastric hyperacidity with hiatal hernia. lntraluminal pressure and esophageal motility were recorded in I2 patients without any clear-cut correlation between esophageal motor activity and clinical symptoms. We are less confident about these manometric studies than is Bettex.’ The gradient that exists between the stomach and the intrathoracic esophagus is not found in all manometric studies. When it exists, it indicates a tonic gastroesophageal sphincter, a physiologic barrier against the reflux. But this barrier does not represent the only mechanism of cardial continence. The crura and the level of the high pressure zone are other important factors in the cardiac continence that manometry cannot demonstrate. Associated

Congenital

Anot~~~lies

We recorded three congenital pyloric stenoses, two left diaphragmatic hernias, two congenital heart diseases, two Downs syndromes, one omphalocele, one inguinal hernia, and one hypospadias.

578

CARCASSONNE.

BENSOUSSAN,

AND

AUBERT

TREATMENT All patients in this series except those presenting with stricture and up-side down stomach were observed for a period of at least 3 wk of nonoperative therapy. This consisted of being placed in the upright position at an angle of 60”, and thickening of feedings. Antispasmodic and anticholinergic drugs were not used in our department, but are frequently prescribed by pediatricians. Indications for surgical therapy have been: major hiatal hernia, esophagitis recognizable at esophagoscopy, stricture, and persistence of vomiting, malnutrition, anemia, loss of weight after an adequate but moderate trial of nonoperative therapy. Age. Thirty-seven infants were operated upon before 6 mo, five between 6 and I2 mo, three between 12 and 15 mo, and one was operated upon at I8 mo. One hundred and eight patients were not operated upon. The results of the nonoperative treatment are not analyzed in this report. They are satisfactory but far from good and seven children had to be operated upon later after infancy. Two secondary stenoses occurred in these cases.

Surgery

(Table I )

Fifty-nine operations were performed upon the 46 patients in this series. In 43 cases, the following procedure was used: Abdominal approach through a left pararectal or left transverse subcostal incision, exposure of the esophagogastric junction after easy reduction of the hernia, small peritoneal incision in front of the hiatus, no division of hepatophrenic or hepatogastric ligament, but moderate mobilization of the lower esophagus. The cardia was then pulled down with a sling; no herniorraphy, nor any repair of the hiatus was carried out. Nissen’s fundoplication with one layer of three or four stitches of 4-O silk around the lower esophagus just above the Table

1.

Surgical

Procedures No Cases

Procedure Primary Gastroesophageal

47

reflux

Nissen-Boerema

43

pyloroplasty

Gastrostomy

2

Pylorotomy

1

Thoracic

1

Nissen

Gastroesophageal Colomc

reflux

+ stenosis

4 1

transplant

Thai-Nissen

1

Nissen

+ gastrostomy

2

resection

1

Reoperatlons Secondary 1

Nissen Intestinal Abdominal

2

closure

2

Pylorotomy Late

1

Boerema Closure

left-diaphragmattc

herma

1

MANAGEMENT

OF

GASTROESOPHAGEAL

579

REFLUX

cardia was then performed’s’ (A tube of appropriate caliber must be inserted by the anesthesiologist down to the stomach). Then Boerema’s’ fixation of the lesser curvature to the right anterior abdominal wall under considerable tension, with three stitches of 3-O silk was carried out. Finally, a small HeineckeMickulicz’ pyloroplasty closed by one layer of stitches of 5-O silk’ completed the procedure. one case, a patient with a large associated omphalocele, a Nissen fundoplication was done through a thoracic approach.

in

Results of Surgical

Treatment (Table 2)

Three deaths occurred postoperatively, none later. One patient died of a superior vena cava thrombosis, produced by a central catheter used for hyperalimenta$ion. She was operated upon 45 days before, at 3 mo of age, with a weight of 2 kg, a severe aspiration pneumonia, and gross malnutrition. A gastrostomy and fundoplication were performed under local anesthesia, too late, after 2 mo of failure of conservative treatment. One infant died 60 days after the cure of a large omphalocele using the Schusier” technique. A severe GER followed the closure. Conservative management failed and the baby died from septicemia 4 days after the fundoplication was performed transthoracically. The third patient died 21 days after a secondary operation done for an intestinal strangulation due to faulty gastric fixation. This last case alone may be related to the technique. There were eight postoperative complications. In the immediate postoperative period there were four patients with enterocolitis, one case of wound dehiscence, one fundoplication too tight. Later on there was one thoracic Herniation of the fundoplication and the appearance of one left-diaphragmatic hernia. Table

2.

Results

Result Gastroesophageal

of Surgery No Cases 47

reflux

3

Deaths Wound

dehiscence’

Septlcemla lntestmal

obstructton’

PostoperatIve

compllcatlons

Secondary

4

Enterocolms

1

Wound

dehlscence

Late Fundopllcation

thoraclc

Left diaphragmatic Follow-up Good

6 mo to 8 yr

cases.

29

6 mo to 6 yr 2

results

Satisfactory ’ Reoperated

1

4

Stenosis

Good

1

29

results

Follow-up

herma

herma

results

2

580

CARCASSONNE.

BENSOUSSAN,

AND AUBERT

6

Fig. 3.

Weight after operation. :,

Of the ten patients lost to follow-up, from 1 to 8 yr after surgery, the last examination we recorded showed a good result. Of the 33 remaining patients, all have a good result. This is defined as an absence.of all symptoms, a weight at least above the 25th percentile (Fig. 3) and a normal postoperative x-ray examination. The weight improvement was faster and higher in the patients operated on early and not too malnourished. Films were done 1, 3, and 6 mo after the patients for barium the initial procedure. Later on, we would consider swallow investigation, only if some clinical symptom might appear. If they were doing well clinically, the children were assessed once a year. We performed I2 postoperative manometric studies without significative findings.4 Postoperative control esophagoscopies were carried out only in patients with stenosis. The results of the surgical treatment of the four stenoses observed in infants were satisfactory in the first two: Case 1 is doing well 6 yr after a colon transplant. He swallows well, in spite of a certain degree of colitis of the inferior part of the transplant. Case 2 was operated upon when she was I5 mo old with a Thal-Nissen procedure. She had some swallowing problems for I yr after operation and needed six dilatations. She now grows normally and swallows perfectly. Her last fluoroscopy done in January 1973 shows good esophageal motility in an esophagus of normal size, with no retlux. Cases 3 and 4 were cured by gastrostomy and fundoplication alone. In 2 mo, the stenosis disappeared without any dilatation. Now, I and 2 yr respectively. after closure of the gastrostomy they are still completely free of clinical, endoscopic, or radiologic abnormalities (Fig. 4).

MANAGEMENT

Fig. 4. Peptic

Case

stenosis

OF

GASTROESOPHAGEAL

3. (Al before

Peptic surgery.

stenosis (D)

581

REFLUX

before

Peptic

surgery.

stenosis

after

(El

Peptic

surgery.

stenosis

after

surgery.

Case

4.

(C)

582

CAACASSONNE.

BENSOUSSAN.

AND

AUBERT

DISCUSSION

When we started our experience in adults, we used the technique designed by Allison” in more than 70 patients, with an over-all recurrence of 36”,,. Since we imported into France Nissen’s fundoplication,” we did not see recurrence, first in adults, and now for 10 yr in children and infants. That quality of long-term results is confirmed by Pellerin,14 Genton,15 Bettex,6 Rohatgi,16 and ListerZ as being more satisfactory than the results of other antireflux procedures such as published by Waterston” and Belsey.18 From the experimental point of view, Butterfield” stressed that the Nissen and Hill repairs were the most successful ones in preventing reflux. Weitzmann2’,raised the interesting problem of the impossibility of vomiting after a Nissen operation. It is true that during the immediate postoperative period the child cannot vomit. But if the fundoplication is not too tight, the child quickly learns to vomit, as evidenced by in our case of postoperative bowel obstruction. Why are we performing a gastropexy? First of all, because we never do any repair of the hiatus itself. We did it once and the child had a recurrent leftdiaphragmatic hernia. We do not think that the repair of the hiatus has any merit because of the physiologic weakness of the right crus. Allison, however, was impressed by the modifications Cincotti 2’ designed to reinforce the crural butressing. As we do not close the hiatus, we are obliged to anchor the stomach somewhere to avoid secondary herniation of the fundoplication as numerous cases were reported in the French Pediatric Surgery Society report,in 1968.22 The technique designed by Boerema is for us the simplest one. The abdominal wall is the most secure anchoring site for the lesser gastric curvature. We report one strangulation when we altered the technique. WaterstonI and Lister: after Boerema23 himself, tried gastropexy alone to eliminate reflux. The results are encouraging, but as we think the CER is produced by different factors: abdominal, diaphragmatic, and gastric, we try to deal with them all. In their excellent report, Lilly and Randolph’ did not recommend pyloroused it in 32 cases, Rohatgi et al.16 plasty, as a routine procedure. Cahill et al.” in seven cases. Of course, we take great care of the vagus, and try not to dissect the hiatal area too widely. One never knows what is the importance of preserving the tiny nerve fibers. Pyloroplasty is a simple procedure that always improves the gastric emptying and thus fights against another factor of GER. The abdominal approach is the easiest for this kind of repair. With a short left subcostal incision, avoiding any useless dissection, we can perform easily and quickly the complete procedure even upon the most malnourished infants. Lister’ advocated gastrostomy, not only for patients with esophageal stenosis. It is true that gastrostomy does fix the stomach to the abdomen. But gastrostomy could never by itself cure GER. Gastrostomy thus is for us not a primary procedure, but a secondary one to be used in low-weight and malnourished infants, or in esophageal stenosis. Our tendency to use multiple procedures is shared by a great majority of authors especially CahillJ7 and Rohatgi.16 We record only four cases of severe, narrow, and chronic strictures. Three of them were secondary to minor forms of hiatal hernia, as shown by Berenberg

MANAGEMENT

OF GASTROESOPHAGEAL

REFLUX

583

The last two cases had a rather rapid course (less than 3 mo of evolution). That rapid an evolution should alert the pediatricians to be very careful with the follow-up of conservative treatment. in infants. we are more and more reluctant to perform esophageal resection followed by colonic transplant. We prefer to use a very conservative managcment. the aim of which is to cure the refux. by the procedures already described. A gastrostomy is used for feeding. X-ray examination is done I mo after surgery to check the progressive disappearance of the stenosis. Not too early. generally 6 wk after surgery and only if the x-ray findings are satisfactory, the baby is fed by mouth. If not, it is necessary to wait a little bit longer. II necessary, bouginage might be done. It should be moderate in size and in frequency. If not. it could produce recurrence of the reflux. We share this conservative view with a majority of pediatric surgeons. Rohatgi et al.1° reported 24 cases of stricture with only one transplant. Ekesparre2s used a gastrostomy and a threaded dilator according to Rehbein technique in I:! patients. He was obliged to operate upon I I patients. Cahill et al. recorded five secondary colon interpositions in 15 strictures. The small number of patients prevents any conclusion but we think it is because we are dealing only with infants that conservative treatment appears to be of such value. We have not tried the vagotomy associated with.pyloplasty in the treatment of severe GER without stenosis as advocated by Rickham. We have no experience, but we think vagotomy may be a severe mutilation, and the procedure should be supported by significant studies on the effects of hyperacidity in GER. One hundred fifty-four patients in our series were observed for a period of nonoperative therapy; 42 were operated upon secondarily, four primarily for strictures. This ratio of 30”,, is nearly the same in comparable series. Larger series, but not statistically comparable because of collecting children from I day to 20 yr, various approaches of various surgeons, report different ratios (Cahill” 4 I”,, Rohatgi” 15” ar In some series it was impossible to know the ratio of surgical cases. However, Carre’s series reported 90”. success with postural means only.” It is interesting to note that postural treatment is not easy to control. Failures range from IO”, to 50”,, in the medical series. Severe complications, especially recurrent aspiration pneumonitis, malnutrition, sepsis, even fatality, may occur.3.‘5.‘7 That is why we agree with Lilly and Randolph3 when they wrote: “With this potentially devastating disease, further time should not be squandered in useless experimentation with antispasmodics and formula changes while the infants languish.” The symptomatic response to medical therapy must be prompt and positive after 3 wk of good care. If vomiting continues, if there is no weight gain after 3 wk, the time for surgery has come. We do not think it is rewarding to wait at least 3 mo as Cahill et al.” do. The fear of potential stenosis, the excellent long-term results of a simple, quickly performed surgical procedure that may be used in any infant should urge pediatricians and surgeons to choose surgery after a fair trial of medical and postural treatment. and Neuhauser.“’

584

CARCASSONNE.

SUM

BENSOUSSAN.

AND AUBERT

MARY

Among the 154 infants admitted for gastroesophageal reflux with a hiatus hernia during the period January 1, 1965 through June 30, 1972, an operative procedure was required in 46 (18.5”,,). The surgical procedure used in most patients was the simple one of adding gastropexy to fundoplication and pyloroplasty by an abdominal approach. In patients with esophageal stricture, we are becoming more conservative after experience with a variety of esophageal reconstructions. The indications for operative intervention remain rather stringent in spite of the quality of the surgical results and the danger of ineffective medical management. All of our patients were assessed postoperatively by endoscopy and radiographic tine studies. The follow-up ranges from 7 no to 8 yr. We believe that selected cases of gastroesophageal reflux in infants are well managed by a simple surgical procedure. REFERENCES I. Duhamel malformations

B. Sauvegrain M. Bader JP: Les oesophago-cardio-tuberositaires

chez Ii: nourrisson et Congres des PCdiatres Baillitre Edit. 1957

chez l’enfant Sei&me de Langue Francaise-

2. Lister J: Personal communication, Marseille, 197 I 3. Lilly JR, Randolph JG: Hiatal hernia and gastro-esophageal reflux in infants and children. J Thorac Cardiovasc Surg 55: I-42, 1968 4. Kehrer B. Oesch A. Bettex M: Manometric studies of esophageal motility in infants with hiatus hernia. J Pediatr Surg 7:5 499, 1972 5. Nissen R. Rossetti M: Treatment of hiatus hernia and reflux esophagitis with gastropexie and fundoplication. Stuttgart, Georg Thieme, 1959 6. Bettex M, Kugger F: Long term results of fundoplication in hiatus hernia and cardioesophageal chalasia in infants and children. J Pediatr Surg 4:526, 1969 7. Boerema I. Germs R: Fixation of the lesser curvature of the stomach to the anterior wall after reposition of the hernia through the esophageal hiatus. Arch Chir Neerl 7:35 I, 1955 8. Johnston W, Snyder WH: Vagotomq and pyloroplasty in infancy and childhood. J Pediatr Surg 3:2-238. 1968 9. Waterston D: Hiatus hernia, in Benson C, Mustard W, Ravitch H. Snyder W, Welch D (eds): Pediatric Surgery, vol. I. Chicago, Year Book 1962 10. Wise WS. Rivarola CH, William GD, Fink WJ, Read DC: Experience with the Thal gastro-esophagoplasty. Ann Thorac Surg 10: 213, 1970

I I. Schuster SR: A new method for the staged repair of large omphaloceles. Surg Gynecol Obstet 125:837, 1967 12. Allison PR: Reflux oesophagitis, sliding hiatal hernia and the anatomy of repair. Surg Gynecol Obstet 92:419, 1951 13. Carcassonne M, Dor V. Guerinel G: A propos de deux hernies hiatales traittes par la technique de Nissen. Mars Chir 5:369, 1960 14. Pellerin D, Nihoul-Fekete Cl: Evolution dans le traitement chirurgical de la hernie hiatale de I’enfant. Sem M&d Hap Paris 43: 2794. 1967 15. Nussle D. Genton N, Philippe P: Clinical and radiological fate of nonoperated malpositions of esophagus in infants. Helv Paediatr Acta 24:145, 1969 16. Rohatgi M. Shandling B, Stephens CA: Hiatal hernia in infants and children: results of surgical treatment. Surgery 69:456. 1971 17. Cahill JL, Aberdeen E, Waterston DJ: Results of surgical treatment of esophageal hiatal hernia in infancy and childhood. Surgery 66:597. 1969 IS. Orringer HB, Skinner DB, Belsey RH: Long term results of the mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 63:25, 1972 19. Butterfield WC: Current hiatal hernia repairs: similarities, mechanisms and extended indications: an autopsy study. Surgery 69:910, 1971 20. Weitrmann JJ: Discussion of Kehrer, Oesch. Bettex, ref. 4. J Pediatr Surg 7:503. 1972 21. Cincotti JJ: Discussion of Lilly and

MANAGEMENT

OF GASTROESOPHAGEAL

Randolph, 5553,

ref.

3. J Thorac

585

REFLUX

Cardiovasc

25.

Surg

22.

Borde

hiatales

Ekesparre

suiting

1968 J:

Symposium

de I‘enl‘ant.

sur

Ann

Chir

for

WV:

hiatus

hernies 8:249.

26.

Rickham

Vos A. Boerema

Long

term

6:lOl.

I: Surgical

reflux

results

Treatment

in infants

24.

Berenberg

vomiting

W,

relax in infants.

Dr.

I

necessarily

Lilly

and

failure understand

to thrive,

and we were seeing so little Frank

Guttman

Canada,

of

mothers

may be accustomed

babies on the stomach,

With

this background.

very

experience,

skeptical

Belsey

procedure

not corrected ing,

and

with

a young

for

approach period

aspiration

baby is literally measurement

of the

what

might

was a normal

about.

large

and

And

number

their

I

problems.

spent

8 yr

operation

phenomenon

tn

if we found

so we were

of patients

article

this

my own

requiring

hernia,

it, UC

surprised

upon

appeared

to

stricture.

be

and

whom

excellent

esophagitrs.

in Washington.

last

August

backs

to allow

reflux.

about

first

patient at

to Salt

Lake

involved

of

and the child

gain

D.C

We also

pressure

with

and

fortune

consideration

had

quantitatron

The was

become

which

with

a rigorous a minimum

the daytime,

The

manometry

with

esophageal of reflux

posttional

involved

during

vomrtassociated

conservative.

just

in the study

8 lb. Reflux

retardatton.

to

been

a previous

weighed

of surgery.

not

a completely we had

of time.

growth

protocol

position,

included

she still a period

and

European

and less often

to discover having

ditference States

and

in something

the so-called

We set up a study before

for

my good

with

the

United

English

was a child

continued

It was also

24 hr in a semierect

City

age because

was a weight

management

perhaps the

in the bassinette

getting referred

I yr

that

side of the ocean, rest in the fact that

was discouraged

sphincter

concerning

know.

reflux

reflux

in

in moving

such as this.

in a chair.

intrinsic

of you

hiatal

on their

and there

who

involved

strapped

comment

for

babies

stricture

or medical

This

01

Paldiatr

Lecture

felt

less likely

pneumonitis.

problems

of preoperative

for

gastroesophageal

on this

cautious

however,

gastroenterologist

of 6 wk initially.

that

in Pediarrics

their

The

and

by the operation.

to treating

be asked

respiratory

reflux

I was surprised

reflux

management

Philadelphia.

a position

had been done,

recurrent

with

recurrent

to placing

of in Philadelphia.

Belsey procedure

Guest

to do anything

and England

I was very

and

X:404.

have been asked to do this because

1968 a Fairly

suggested

Europe

position different

in

of it in nearby

with

to

I

very hard

had

gastroesophageal

as compared

Infant

in children.

how they were seeing so much of this problem

Montreal

between

197 I

radiologists

you

procedures

really

in incidence

Our

surgical

namely,

Padal 6:247.

the last 2 yr. As many

there

we looked reported

indications.

Univ

I think

within

something

performed

Chir

Conservative stomach

feel honored

subject.

Randolph

had

We couldn’t

I

CityI:

think

IJ:

thoracic

for Overseas

recognized.

don‘t

et de

chirurgical

1950

so dramatically

we rarely

felt it wasn’t they

Lake

re-

9:317.

of

and it was our experience

all babies. Drs.

5:414,

important

has changed

was an entity

when

(Salt

but highly

in Philadelphia, virtually

cause

Ann

partial Cardio-

a

le traitement

hiatale.

27. Carre

Surg

Discussion

D. Johnson

experience

ED: as

Pediatrics

Invited controversial

Neuhauser

(chalasia)

Chir

I968

1971

esophageal

dans

de la hernie

ol

and children.

in 28 cases. J Pediatr

stenosts

Klin

P: Place de la vagotomre

la pyloroplastie

23.

Z

1971

les Infant

I967 gastro-esophageal

Esophageal

hernia.

with

a pH

probe

rn

the esophagus. The first patient has illustrated

with

a Belsey procedure

periodically

through

cooperation

the

operated

upon

to thrive

The second

had been performed

being dilated patients

severe failure

in his presentation.

previously

for over a year. of in

Well.

a gastroenterologist

I8 mo.

responded patient

an incidence

dramatically,

was one with

without

correction

the summary interested which

as Professor a severe

of the reflux.

of our

experience.

in

problem,

exceeds,

the

I-believe,

that

Carcassonne

stricture

and

again

The child gleaned

is a total reported

was

largely of by

25 Pro-

586

CAACASSONNE.

BENSOUSSAN.

AN0

AUBERT

fessor Carcassonne today. I just talked to Dr. Randolph, and their IO-yr period involves approximately 45 cases. It sounds as if we’re operating when we shouldn’t be operating. We have tried to study each case very critically. Six patients were operated upon for either esophagitis or stricture. Three had significant stricture and another presented with a hemoglobin of 4 after massive hematemesis secondary to esophagitis. This child had a history of previous massive bleeding with an ineffective Belsey operation for treatment. Twelve of our patients had severe failure to thrive, and two out of the I2 were still near their birth weight at I yr of age. We feel it is hard to argue with indications which have been so obvious. Our growth curves after operation have shown a significant improvement. Six children had severe recurrent pulmonary problems. Some had been diagnosed as having basic pulmonary disease and the children had been seen in consultation by the adult respiratory disease group at the University. The conclusion that the recurrent pneumonitis was indeed an aspiration problem allowed subsequent surgical correction. I believe Professor Carcassone has called to our attention an important problem in children that somehow we haven’t been recognizing, I think, as often as we might, Our surgical approach is similar to that Professor Carcassonne has described and in our hands it has proved an efficient way of handling this problem.