- Email: [email protected]
Treatment of gastroesophageal reflux in children by Thal fundoplication
J
THORAC CARDIOVASC SURG
82:706-712, 1981
Treatment of gastroesophageal reflux in. children by Thal fundoplication The anterior fundoplication described by Thai has been used in treating gastroesophageal reflux surgically in 362 children at The Children's Mercy Hospital and at St. Luke's Hospital in Kansas City, Missouri, because medical therapy had failed or was inappropriate. Long-term results have been evaluated in regard 10 relief of reflux and relief of symptoms attributed to reflux. Of the 335 patients followed from I to 8 years, 90% had a satisfactory initial result. Five percent required reoperationfor a recurrence of reflux due to failure of the fundoplication or development of a hiatus hernia. All recurrences developed within 5 months of the initial operation. Fifteen of 335 patients (4.5%) had persistent symptoms despite correction (~I' the gastroesophageal reflux; in these patients, attributing the symptoms to reflux was incorrect. There were no deaths in this series of patients as a result (if operation. The success rate (if the ThaI fundoplication in children compares favorably with that 01' the Nissen fundoplication.
Keith W. Ashcraft, M.D., Thomas M. Holder, M.D., and Raymond A. Amoury, M.D. (by invitation), Kansas City, Mo.
T
he symptoms of gastroesophageal reflux in infants and children range from nutritional inconveniences to life-threatening apnea. In most patients a trial of medical management consisting of thickened feeding and marked elevation is certainly warranted. Patients with apnea necessitating resuscitation for no other demonstrated reason than gastroesophageal reflux probably deserve immediate surgical treatment because the failure of nonoperative management is so disastrous. 1 Established esophageal strictures often do not respond to nonoperative therapy. Surgical therapy for other symptoms attributed to gastroesophageal reflux is otherwise reserved for those patients who do not respond to simpler measures or who are so uncooperative as to make medical therapy futile.>" Probably less than 20% of children with gastroesophageal reflux require operative therapy. The 360 degree wraparound described by Nissen is the most popular fundoplication being done today. Alternatives include the partial wraps described by Thai, Belsey, and Hill with all their modifications. Because the ability to belch and to vomit is so important in From the Department of Surgery, Children's Mercy Hospital, and University of Missouri at Kansas City, School of Medicine, Kansas City, Mo. Read at the Sixty-first Annual Meeting of The American Association for Thoracic Surgery, Washington, D.C., May 11-13, 1981. Address for reprints: Keith W. Ashcraft, M.D., Children's Mercy Hospital, 24th and Gillham Rd., Kansas City, Mo. 64108.
706
pediatric patients, we have used the anterior partial wrap fundoplication described by Thai to treat gastroesophageal reflux in pediatric patients. We have performed Thai fundoplications on 362 patients prior to April, 1980, 335 of whom were available for study. The results of this fundoplication with a minimum 1 year follow-up are presented so that they may be compared with other techniques of fundoplication.
Patients and methods Between April, 1973, and April, 1980,362 patients underwent a Thai fundoplication for symptoms referable to gastroesophageal reflux at The Children's Mercy Hospital and St. Luke's Hospital in Kansas City, Missouri. These patients ranged in age from 10 days to 15 years. The diagnosis of reproducible gastroesophageal reflux was established by barium study alone in 267 patients (74%). Reflux of barium was graded from I to V by the radiologist and was correlated with clinical symptoms. Grade I was reflux into the lower esophagus, Grade II into the midesophagus, and Grade III into the upper esophagus. Grade IV reflux resulted in barium in the pharynx, and Grade V was into the nasopharynx and actually outside the mouth. Grades I and II reflux were sufficient to produce esophagitis symptoms but insufficient to produce nutritional or respiratory symptoms. Grade III reflux most often was associated with nutritional symptoms. Grade I V and V reflux were associated with any of the three symptom categories of esophagitis, nutritional disor-
0022-5223/81/110706+07$00.70/0 © 1981 The C. V. Mosby Co.
Volume 82 Number 5 November, 1981
ders, or recurrent respiratory problems. In the patient with recurrent respiratory disorders and Grade I or II reflux, the barium study was considered to be "negative. " A "positive" barium study was combined with other testing, including esophageal biopsy, Tuttle test," and manometries in 44 patients (12%); the diagnosis was established by manometries, Tuttle test, or biopsy without positive barium study in 50 patients (14%). In one patient esophageal pH measurement was not available to us at the time. Even though the repeated barium studies failed to show reflux, his clinical symptoms strongly suggested reflux. A fundoplication was undertaken with the parent's full knowledge that it might be fruitless, and his symptoms were completely relieved. The symptoms of reflux in children are more diverse than they are in the adult, being divided into respiratory, esophageal, or nutritional categories (Table I). Among 203 patients (56%) having respiratory manifestations as the predominant symptom, 80 patients had apneic episodes or aborted crib deaths necessitating resuscitation to one degree or another, 49 had repeated cough, croup, or choking, and 74 had recurrent pneumonitis, some with as many as 20 hospital admissions for this problem. Esophageal manifestations were much less common, being found in 26 patients (7%). Eight of them had esophageal pain, four had bleeding, and 14 had stricture. Nutritional disorders occurred in 126 patients (35%) and included starvation in two patients, significant nutritional failure in 66 patients, and intractable vomiting in 58 patients. There were seven other patients (2%) who, because of central nervous system disorders, required long-term gastrostomy feeding and who were unable to retain gastric content without fundoplication. Two hundred sixty patients (72%) were under 1 year of age and 102 patients were older than 1 year of age at operation. The operative procedure employed consists of transabdominal exposure of the distal esophagus and hiatus (Fig. 1). The esophagus is surrounded with a Teflon tape and retracted downward, so that the hiatus is bluntly dissected away from the esophagus. Placement of a 10 or 18 Fr. nasogastric sump tube facilitates the dissection. At operation 98 patients (27%) were noted to have a hiatus hernia. Radiographic demonstration of hiatus hernia in these patients was uncommon. After 2 to 4 em of esophagus had been mobilized, the esophagus was retracted forward and to the patient's left so that the crura of the hiatus could be approximated. A 2-0 silk figure-of-eight suture was placed to narrow the hiatus. to a point that the esophagus, the nasogastric tube, and the tip of the index finger could pass through the hiatus. Further repair of the hiatus was
Gastroesophageal reflux
707
Table I. Distribution of symptoms by age Total
Symptom Respiratory Apnea Croup, choking, cough Recurrent pneumonitis Esophageal Heartburn, colic Bleeding, anemia Stricture Nutritional Intractable vomiting Nutritional failure Starvation Nervous CNS disorders Totals
73 37 33
7 12 41
80 49 74
3 2 4
5 2 10
8 4 14
42 60 2
16 6 0
58 66 2
4
3
7
260
102
362
Legend: CNS, Central nervous system.
accomplished by placing additional sutures below this "limiting" stitch if necessary. The "limiting" stitch was also used to suture the back wall of the esophagus to the hiatus, to maintain at least a 2 em length of esophagus posteriorly within the abdominal cavity. A running Prolene suture was begun at the lesser curvature side of the gastroesophageal junction and was then run across the gastroesophageal junction to the greater curvature side. At this point, the suture line was turned superiorly on the left side of the esophagus and the anterior free wall of the fundus was sutured so as to create a fundoplication. Short gastric vessels were not divided. No splenic injuries occurred. As the hiatus was reached, the running suture was continued 180 degrees across the esophagus from the patient's left to his right, with the stomach, esophagus, and hiatus being sutured and the anterior vagus nerve avoided. The suture line then was turned inferiorly. The stomach was sutured to the lesser curvature side of the esophagus to the point of origin, where the suture was tied to itself at the lesser curvature side of the gastroesphageal junction. This created a patch of anterior wall of the fundus attached to the anterior half of the intra-abdominal esophagus, 2 em long in the infant and up to 4 em long in the older child. The esophagus was not opened in any patient, as Thai has described in the treatment of the severe esophageal stricture. Only the anterior fundoplication portion of Thal's? procedure was used. Gastrostomy was not done except in those patients who were known
708
The Journal of Thoracic and Cardiovascular Surgery
Ashcraft, Holder, Amoury
A
B ,,'
"I
"
'. 't
iit
w
~!~.
Fig. 1. The anterior fundoplication of Thal. The esophagus is mobilized through an abdominal incision, The hiatus is repaired posterior to the esophagus, and the esophagus is attached to this hiatal repair stitch to fix approximately the lower2 ern of the posterioresophagus within the abdominal cavity. The anteriorfundoplication is then carried out with either running or interrupted sutures to attach the free fundic portion of the stomach anteriorly to the lower 2 to 4 cm of esophagus. The uppermost stitches at the hiatus incorporate stomach, esophagus, and hiatus. The vagusnervebranches are protected carefully. It is not necessary to divideshortgastric vessels to produce this fundoplication.
to require tube feeding for extended periods, i.e., children with damage to the central nervous system. Nasogastric drainage was used overnight. Liquids were started on the first postoperative day and a regular diet on the second postoperative day. Most patients were dismissed on the third postoperative day on a regular diet and doing well. The rapid recovery, short hospitalization, and reduced cost are distinct advantages of this simple procedure. Most of the patients were in the hospital less than 72 hours. Follow-up evaluation was by clinical history, physical examination, evaluation of weight and growth curves, and by barium examination. Two hundred nineteen patients (65%) had follow-up barium studies demonstrating the absence of reflux in 207 and minimal reflux in 12. Postoperative Tuttle testing and long-term pH determinations and manometries were used rarely when symptoms persisted but reflux by barium study was not demonstrable. In several patients this prompted reoperation, with relief of symptoms.
Results Of the 362 patients operated upon, 335 were available for follow-up from 1 year to 8 years postoperative-
Iy. The results of fundoplication were assessed from two points of view. First, was the fundoplication successful in stopping the reflux? Second, if the reflux was stopped, did the symptoms attributed to the reflux also cease? Table II lists the indications for operation. The column listing errors in diagnosis contains those patients whose symptoms persisted even though the reflux was corrected by operation. There were 15 patients in this category (5%). Seventeen patients (5%) had recurrent reflux because of disruption of the fundoplication or because of development of a hiatus hernia postoperatively. These patients underwent reoperation, with complete alleviation of all symptoms the second time. There were 303 (90%) patients who had satisfactory outcome, alleviation of symptoms, after one fundoplication. Ultimately, 320 patients (95%) had a satisfactory "long-term" result from a Thai fundoplication. All recurrences of symptoms developed within 5 months of operation. Most of the patients were able to belch postoperatively and all could vomit when necessary. No patients had the gas bloat syndrome. A transient period of loose stools was the only frequent postoperative gastrointestinal disorder.
Volume 82 Number 5 November, 1981
Gastroesophageal reflux
709
Table II. Results of Thal fundoplication in 335 patients Error in diagnosis No. of patients Apnea Cough, choking, croup Recurrent pneumonitis Esophagitis Intractable vomiting Nutritional failure Starvation CNS disorders
No. followed
No.
80 49 74 26 58 66 2 7
80 42 71 26 54 57 2 7
4 2 6
362
335
15
I
0 2 0 0
Failure of first procedure
I% 5 5 8 4 3
5
No.
I
%
4 2 3 2 3 3 0 0
5 5 4 8 6 5
17
5
Initial good result
I
Ultimately satisfactory
I
%
No.
38 62 23 51 52 2 7
90 90 88 88 94 92 100 100
76 40 65 25 54 55 2 7
95 95 92 96 100 97 100 100
303
90
320
95
No. 72
%
Legend: CNS, Central nervous system.
Discussion Gastroesophageal reflux is very common in neonates and disappears spontaneously in most babies. Of those patients discovered to have reflux within the first 6 months of life, about 80% to 90% will have resolution of their symptoms if treated with thickened feedings in the sitting position. There is some evidence to suggest that some patients are best treated prone without thickened feedings," but for the most part the nonoperative treatment of reflux consists of thickened feedings and keeping the child upright (at least 60 degrees) in an infant seat 24 hours a day. At 6 months of age the infant becomes strong enough physically and independent enough emotionally to make this method of treatment very difficult or impossible for parents and patient. Prone positioning at 30 degrees is better tolerated by the older infant. The medical treatment of gastroesophageal reflux requires considerable patient cooperation. In the small child who is able to be restrained or able to be positioned without expressing his discomfort, medical therapy is possible. In the older patient, the prone positioning of the patient at 30 degrees requires restraint during sleep or the child will tum sideways in bed seeking a horizontal position. Mere elevation of the head of the bed does little or nothing to prevent gastroesophageal reflux or its symptoms in the child. It is important that the disorder be recognized early so that positional treatment may be instituted while it is still tolerated. The mainstay of diagnosis remains the barium study. The skill of the radiologist in dealing with children is exceedingly important. 9 Without special skills, falsenegative results are very frequent. All patients who had reflux demonstrated radiographically and who also had pH or manometric studies were found to have reflux by both modalities. That is to say, the barium study appar-
Table III. Indications for reoperation after Thal fundoplication Fundoplication disrupted Hiatus hernia developed Hiatus hernia recurred Incisional hernia, dehiscence Bowel obstruction
10/335 9/244 2/91 6/335 3/335 30(9%)
ently gave no false-positive information. The patients who had negative barium studies often were subjected to short-term pH and manometric studies as described by Euler and Ament." 10 The pH study was determined to be. the most sensitive and the most reliable. Longterm pH monitoring was not used in any of these patients. Esophagoscopy with estimation of gross esophagitis was used in the one patient who had several negative barium studies prior to the availability of the pH measurement. Most errors made by assuming that demonstrated gastroesophageal reflux was responsible for the symptoms were made in the group of 203 patients having respiratory symptoms attributed to reflux. Included in this group of patients were 80 who had apneic episodes which required some form of resuscitation by the parent, a physician, or trained medical emergency personnel. There were four (of 80) patients in this group who continued to have apneic episodes even though their reflux was surgically corrected. All of the patients with apnea had been evaluated completely by a pediatrician prior to referral for fundoplication. Many had been evaluated by a neurologist or a cardiologist or both, as well. Serum electrolytes, glucose, calcium, phosphorus, blood urea and nitrogen were all within normal limits, so that they could not be considered causes of
The Journal of
710 Ashcraft, Holder, Amoury
Thoracic and Cardiovascular Surgery
the apnea. Electroencephalograms were done in many patients, all of which were normal. Electrocardiography was performed in many patients to exclude the possibility of cardiac dysrhythmia. Only following extensive evaluation, which included barium esophageal studies and/or esophageal pH and manometric measurements, were the patients referred for operative therapy. Re-evaluation in these four symptomatic patients following correction of their gastroesophageal reflux again failed to reveal any other cause for the apneic episodes. Some of these continue. There were four patients in this category as well who had recurrent reflux and recurrent apneic episodes, both of which responded favorably to reoperation. Errors in diagnosis were made in two of 42 patients who had cough, choking, or recurrent croup as a presenting respiratory symptom (5%) and in six of 71 patients with recurrent pneumonitis (8%). Recurrent pneumonitis meant two or more episodes within the first year of life with as many as 20 hospital admissions for pneumonitis over a 4 or 5 year period. Patients with recurrent pulmonary symptoms other than apnea were all evaluated by a pediatrician, and most were referred to an immunologist or allergist for further study. It was only after determination of immune competence, elimination of allergies, and elimination of cystic fibrosis as possible causes that these patients were referred for surgical treatment. Four patients in whom fundoplication "failed" have had only one further hospitalization due to pneumonitis, whereas each had many hospitalizations prior to operation, and their overall state of health is much improved. One of 26 patients (4%) who had esophagitis as the predominant symptom continued to have pain and probably had a minor degree of reflux, although it could not be documented. Perhaps the major disadvantage of the ThaI fundoplication is that minor degrees of reflux can occur at times more easily than with the Nissen fundoplication. In those instances of esophageal pain or bleeding or distal esophageal stricture, a Nissen fundoplication may be the more advisable operative procedure. Two patients had significant recurrent gastroesophageal reflux and responded favorably to reoperation. Two of 57 patients with failure to thrive did not improve following fundoplication. Those with intractable vomiting, starvation, and those who had fundoplication as a preventative measure with gastrostomy for central nervous system disorders were all satisfactorily treated. Reoperation was required in 30 of 335 patients (9%)
because of a variety of complications (Table III). Ten fundoplications (3%) came apart producing recurrent gastroesophageal reflux. All responded favorably to reoperation. Nine of 244 patients developed a postoperative hiatus hernia when one had not been present before, and two of 91 patients had recurrence of a repaired hiatus hernia. Only seven of the 11 patients with postoperative hernias had recurrent gastroesophageal reflux and were symptomatic. Four underwent operation to restore a surgically competent gastroesophageal junction below the diaphragm-a procedure which may have been unnecessary. Nine other patients (3%) required reoperation for such complications as incisional hernias, wound dehiscence, or bowel obstruction. In the last 200 patients there have been no such complications necessitating reoperation, since incidental umbilical herniorrhaphy and appendectomy have been discontinued and since the transverse upper abdominal incision has been used almost exclusively. There were no deaths due to operation. Twenty-two of the 362 patients (6%) died, nine of them in the hospital. One patient with severe central nervous system disease vomited and aspirated, but most died of underlying central nervous system or cardiac disorders. There were 13 late deaths, all due to associated disorders. There were 114 patients with associated disorders in this group. These disorders include severe brain damage in 26, esophageal atresia in 24, and cardiac lesions in 21. Eleven patients had recognizable syndromes and 11 others had subglottic stenosis, which probably resulted from repeated aspiration. The group of patients having esophageal atresia and tracheoesophageal fistula deserve special attention. Recurrent esophageal stricture has been the most common manifestation of reflux in the patient after repair of esophageal atresia. II. 12 Additionally, one patient had a minor extrapleural anastomotic leak but such massive gastroesphageal reflux that gastrostomy feedings were impossible until fundoplication was done. Prompt healing of the leak followed fundoplication. In contrast to the usual neonate with gastroesophageal reflux, in whom a resolution of 80% to 90% could be expected, about two thirds of those patients with esophageal atresia and gastroesophageal reflux required fundoplication. Others have reported similar need for operative therapy of the gastroesophageal reflux in these infants.": 14 The anterior fundoplication described by ThaI allows the patient to belch and vomit postoperatively. In many patients who have had a Nissen fundoplication, vomiting is difficult or impossible." It would appear from
Volume 82
Gastroesophageal reflux
Number 5
711
November, 1981
other data that recurrence rates of gastroesophageal reflux following Nissen's fundoplication in the child are comparable to those in this series. 3-5 The problem of erroneously assuming that demonstrated gastroesophageal reflux is responsible for symptoms continues to be disturbing. Although we did not use long-term pH monitoring, extensive work has been done in this area in Salt Lake City, Utah.": 16 In a recently reported series of patients, the pattern of reflux was determined over a 24 hour period in 93 patients. Seventy-seven of these patients were followed up for an average period of 30 months, 30 of whom had undergone operation for gastroesophageal reflux. Vomiting was controlled by an antireflux operation in each child, but respiratory symptoms were not relieved in four patients and growth retardation did not improve in two patients. We conclude that prolonged pH measurements in determination of the patterns of reflux are of very little benefit either in selecting patients for operation or in predicting which patients will respond favorably to operation. Fortunately, sorting out these patients, which may be impossible with the present state of the art, becomes less of a problem when the mortality remains zero and the complication rate remains low.
2
3
4
5
6
7 8
REFERENCES Herbst JJ, Book LS, Bray PF: Gastroesophageal reflux in the "near miss" sudden infant death syndrome. J Pediatr 92:73-75, 1978 Randolph JG, Lilly JR, Anderson KD: Surgical treatment of gastroesophageal reflux in infants. Ann Surg 180: 479-488, 1974 Leape LL, Ramenofsky ML: Surgical treatment of gastroesophageal reflux in children. Am J Dis Child 134:935938, 1980 Fonkalsrud EW, Ament ME, Byrne WJ, Rachelefsky GS: Gastroesophageal fundoplication for the management of reflux in infants and children. J THORAC CARDIOVASC SURG 76:655-664, 1978 Schatzlein MH, Ballantine TVN, Thirunavukkarasu S, Fitzgerald JF, Grosfeld JL: Gastroesophageal reflux in children. Arch Surg 114:505-510, 1979 Euler AR, Ament MR: Detection of gastroesophageal reflux in the pediatric-age patient by esophageal intraluminal pH probe measurement (Tuttle test). Pediatrics 60:65-68, 1977 Thai AP: A unified approach to surgical problems of the esophagastric junction. Ann Surg 168:542-550, 1968 Ramenofsky ML, Leape LL: Continuous upper esophageal pH monitoring in patients with gastroesophageal reflux pneumonia and apneic spells. J Pediatr Surg (in press)
9 McCauley RGK, Darling DB, Leonidas JC, Schwartz AM: AJR 130:47-50, 1978 10 Euler AR, Ament ME: Value of esophageal manometric studies in the gastroesophageal reflux of infancy. Pediatrics 59:58-61, 1977 11 Pieretti R, Shandling B, Stephens CA: Resistant esophageal stenosis associated with reflux after repair of esophageal atresia. A therapeutic approach. J Pediatr Surg 9:355-357, 1974 12 Ashcraft KW, Goodwin C, Amoury RA, Holder TM: Early recognition and aggressive treatment of gastroesophageal reflux following repair of esophageal atresia. J Pediatr Surg 12:317-321,1977 13 Parker AF, Christie DL, Cahill JL: Incidence and significance of gastroesophageal reflux following repair of esophageal atresia and tracheoesophageal fistula and the need for anti-reflux procedures. J Pediatr Surg 14:5-8, 1979 14 Fonkalsrud EW: Gastroesophageal fundoplication for reflux following repair of esophageal atresia. Arch Surg 114:48-51, 1979 15 Jolley SG, Herbst JJ, Johnson DG, Book LS, Matlak ME, Condon VR: Patterns of postcibal gastroesophageal reflux in symptomatic infants. Am J Surg 138:946-950, 1979 16 Jolley SG, Johnson DG, Herbst JJ, Matlak ME: The significance of gastroesophageal reflux patterns in children. J Pediatr Surg (in press)
Discussion DR. TOM R. DEMEESTER Palos Heights, /II.
I arise to bring to focus two points regarding the paper of Dr. Ashcraft. The first point deals with diagnosis of gastroesophageal reflux, and the second point deals with the evaluation of the operation designed to improve the competence of the cardia. The diagnosis of reflux based on atypical symptoms can be very difficult and often misleading. Because of this, there is a great need to be objective. Eighty of their 362 patients had apnea. There are many causes for apnea besides gastroesophageal reflux. There were 66 patients who had nutritional failure. There are many causes for nutritional failure other than gastroesophageal reflux. Only 26 of their 362 patients had esophagitis, an objective sign of gastroesophageal reflux in most situations. We must remember that chalasia, i.e., an open cardia, is a normal finding in early infancy. It is important, therefore, that the diagnosis of reflux be objectively established in these children and that their atypical symptoms, suspected to be due to reflux, are able to be correlated to the occurrence of reflux episodes. If such a relationship cannot be demonstrated, I do not believe it is wise to proceed with surgical therapy. My second comment has to do with the proposed modified
The Journal of
712 Ashcraft, Holder, Amoury
operation. We are asked to believe on the basis of testimony that the defect in these patients was an incompetent cardia and that the operation proposed has been designed to improve the incompetent cardia. I remind you that operations to correct reflux are different from most other operations that we do. More commonly than not, an operation is performed to remove an organ, and we do not care about the function of an organ when it has been extirpated. However, the postoperative function of an organ is very important if we design an operation to improve the function of an organ and not to extirpate or replace it. Prior to proposing a modified operation designed to improve the function of the cardia, we should know how much cardia was deranged preoperatively and what improvement the operation made on the function of the cardia postoperatively. Simply to rely on symptoms as a measurement of functional improvement is not reliable. I would suggest that if the authors think the problem was due to an incompetent cardia, then studies ought to demonstrate that the cardia was indeed incompetent; if their modified operation is designed to improve an incompetent cardia, then studies should be done to show that the operation indeed does improve an incompetent cardia. This is only a reasonable thing to do before suggesting the operation to others. MR. RONALD BELSEY Chicago. Ill.
We have an antique British principle that diagnosis precedes treatment. Dr. DeMeester has posed many of the questions that I was going to ask the authors of this paper, but from their figures I rather gather that only 27 of their patients had any objective tests being conducted to determine whether there was in fact reflux either before or after the operation. In the surgical treatment of gastroesophageal reflux, we must be very critical regarding indications for operation and in assessing results of operation. It is not sufficient to say that the child no longer has apnea after the operation. He may be terrified of having another operation and doesn't dare not to breathe. We must insist as a society on objective evidence of
Thoracic and Cardiovascular Surgery
the reflux, of the degree of reflux, of the timing of the reflux, and whether after surgical treatment the reflux has been cured. One thing I liked about this paper was the emphasis on 180 or 240 degree fundoplication as opposed to the overaggressive 360 degree fundoplication of the Nissen procedure. I do not think it matters whether it is done through the abdomen or the chest, provided the surgeon has a clear idea of what he is attempting to do. We now know from clinical experience and from some of Dr. DeMeester's experiments that the only sensible way of controlling reflux is to restore the lowest sphincter zone to the high-pressor region under the diaphragm and to retain it there permanently. DR. AS HC RA FT (Closing) Dr. DeMeester and Mr. Belsey imply that the only objective evidence for reflux is long-term pH monitoring, and we differ from them in that respect. Long-term pH monitoring has a great many strong points in its favor, but in point of fact, reflux can be demonstrated very nicely, at least in the child, by barium studies. Radiographic studies are reproducible and, in the opinion of many, are as reliable when positive as are long-term pH determinations. As I pointed out, when long-term pH measurements were done in Salt Lake City by Jolley and his co-workers, they really did not help much. Their diagnostic error rate was 20% compared to 5% with our approach. As to objective evidence of cure postoperatively, the same argument would apply. The relief of symptoms seems to us to be the objective of the operation. The anterior fundoplication, which allows patients to belch and vomit, is of definite value. We did have about 30 patients who underwent the Nissen procedure, many of whom had esophagitis, and probably for these patientsthere is an advantage in the 360 degree wrap in that the cessation of reflux is much more absolute. It is a procedure that is associated with gas bloats and sometimes obstruction, which in the child can be a very serious problem.
THORAC CARDIOVASC SURG
82:706-712, 1981
Treatment of gastroesophageal reflux in. children by Thal fundoplication The anterior fundoplication described by Thai has been used in treating gastroesophageal reflux surgically in 362 children at The Children's Mercy Hospital and at St. Luke's Hospital in Kansas City, Missouri, because medical therapy had failed or was inappropriate. Long-term results have been evaluated in regard 10 relief of reflux and relief of symptoms attributed to reflux. Of the 335 patients followed from I to 8 years, 90% had a satisfactory initial result. Five percent required reoperationfor a recurrence of reflux due to failure of the fundoplication or development of a hiatus hernia. All recurrences developed within 5 months of the initial operation. Fifteen of 335 patients (4.5%) had persistent symptoms despite correction (~I' the gastroesophageal reflux; in these patients, attributing the symptoms to reflux was incorrect. There were no deaths in this series of patients as a result (if operation. The success rate (if the ThaI fundoplication in children compares favorably with that 01' the Nissen fundoplication.
Keith W. Ashcraft, M.D., Thomas M. Holder, M.D., and Raymond A. Amoury, M.D. (by invitation), Kansas City, Mo.
T
he symptoms of gastroesophageal reflux in infants and children range from nutritional inconveniences to life-threatening apnea. In most patients a trial of medical management consisting of thickened feeding and marked elevation is certainly warranted. Patients with apnea necessitating resuscitation for no other demonstrated reason than gastroesophageal reflux probably deserve immediate surgical treatment because the failure of nonoperative management is so disastrous. 1 Established esophageal strictures often do not respond to nonoperative therapy. Surgical therapy for other symptoms attributed to gastroesophageal reflux is otherwise reserved for those patients who do not respond to simpler measures or who are so uncooperative as to make medical therapy futile.>" Probably less than 20% of children with gastroesophageal reflux require operative therapy. The 360 degree wraparound described by Nissen is the most popular fundoplication being done today. Alternatives include the partial wraps described by Thai, Belsey, and Hill with all their modifications. Because the ability to belch and to vomit is so important in From the Department of Surgery, Children's Mercy Hospital, and University of Missouri at Kansas City, School of Medicine, Kansas City, Mo. Read at the Sixty-first Annual Meeting of The American Association for Thoracic Surgery, Washington, D.C., May 11-13, 1981. Address for reprints: Keith W. Ashcraft, M.D., Children's Mercy Hospital, 24th and Gillham Rd., Kansas City, Mo. 64108.
706
pediatric patients, we have used the anterior partial wrap fundoplication described by Thai to treat gastroesophageal reflux in pediatric patients. We have performed Thai fundoplications on 362 patients prior to April, 1980, 335 of whom were available for study. The results of this fundoplication with a minimum 1 year follow-up are presented so that they may be compared with other techniques of fundoplication.
Patients and methods Between April, 1973, and April, 1980,362 patients underwent a Thai fundoplication for symptoms referable to gastroesophageal reflux at The Children's Mercy Hospital and St. Luke's Hospital in Kansas City, Missouri. These patients ranged in age from 10 days to 15 years. The diagnosis of reproducible gastroesophageal reflux was established by barium study alone in 267 patients (74%). Reflux of barium was graded from I to V by the radiologist and was correlated with clinical symptoms. Grade I was reflux into the lower esophagus, Grade II into the midesophagus, and Grade III into the upper esophagus. Grade IV reflux resulted in barium in the pharynx, and Grade V was into the nasopharynx and actually outside the mouth. Grades I and II reflux were sufficient to produce esophagitis symptoms but insufficient to produce nutritional or respiratory symptoms. Grade III reflux most often was associated with nutritional symptoms. Grade I V and V reflux were associated with any of the three symptom categories of esophagitis, nutritional disor-
0022-5223/81/110706+07$00.70/0 © 1981 The C. V. Mosby Co.
Volume 82 Number 5 November, 1981
ders, or recurrent respiratory problems. In the patient with recurrent respiratory disorders and Grade I or II reflux, the barium study was considered to be "negative. " A "positive" barium study was combined with other testing, including esophageal biopsy, Tuttle test," and manometries in 44 patients (12%); the diagnosis was established by manometries, Tuttle test, or biopsy without positive barium study in 50 patients (14%). In one patient esophageal pH measurement was not available to us at the time. Even though the repeated barium studies failed to show reflux, his clinical symptoms strongly suggested reflux. A fundoplication was undertaken with the parent's full knowledge that it might be fruitless, and his symptoms were completely relieved. The symptoms of reflux in children are more diverse than they are in the adult, being divided into respiratory, esophageal, or nutritional categories (Table I). Among 203 patients (56%) having respiratory manifestations as the predominant symptom, 80 patients had apneic episodes or aborted crib deaths necessitating resuscitation to one degree or another, 49 had repeated cough, croup, or choking, and 74 had recurrent pneumonitis, some with as many as 20 hospital admissions for this problem. Esophageal manifestations were much less common, being found in 26 patients (7%). Eight of them had esophageal pain, four had bleeding, and 14 had stricture. Nutritional disorders occurred in 126 patients (35%) and included starvation in two patients, significant nutritional failure in 66 patients, and intractable vomiting in 58 patients. There were seven other patients (2%) who, because of central nervous system disorders, required long-term gastrostomy feeding and who were unable to retain gastric content without fundoplication. Two hundred sixty patients (72%) were under 1 year of age and 102 patients were older than 1 year of age at operation. The operative procedure employed consists of transabdominal exposure of the distal esophagus and hiatus (Fig. 1). The esophagus is surrounded with a Teflon tape and retracted downward, so that the hiatus is bluntly dissected away from the esophagus. Placement of a 10 or 18 Fr. nasogastric sump tube facilitates the dissection. At operation 98 patients (27%) were noted to have a hiatus hernia. Radiographic demonstration of hiatus hernia in these patients was uncommon. After 2 to 4 em of esophagus had been mobilized, the esophagus was retracted forward and to the patient's left so that the crura of the hiatus could be approximated. A 2-0 silk figure-of-eight suture was placed to narrow the hiatus. to a point that the esophagus, the nasogastric tube, and the tip of the index finger could pass through the hiatus. Further repair of the hiatus was
Gastroesophageal reflux
707
Table I. Distribution of symptoms by age Total
Symptom Respiratory Apnea Croup, choking, cough Recurrent pneumonitis Esophageal Heartburn, colic Bleeding, anemia Stricture Nutritional Intractable vomiting Nutritional failure Starvation Nervous CNS disorders Totals
73 37 33
7 12 41
80 49 74
3 2 4
5 2 10
8 4 14
42 60 2
16 6 0
58 66 2
4
3
7
260
102
362
Legend: CNS, Central nervous system.
accomplished by placing additional sutures below this "limiting" stitch if necessary. The "limiting" stitch was also used to suture the back wall of the esophagus to the hiatus, to maintain at least a 2 em length of esophagus posteriorly within the abdominal cavity. A running Prolene suture was begun at the lesser curvature side of the gastroesophageal junction and was then run across the gastroesophageal junction to the greater curvature side. At this point, the suture line was turned superiorly on the left side of the esophagus and the anterior free wall of the fundus was sutured so as to create a fundoplication. Short gastric vessels were not divided. No splenic injuries occurred. As the hiatus was reached, the running suture was continued 180 degrees across the esophagus from the patient's left to his right, with the stomach, esophagus, and hiatus being sutured and the anterior vagus nerve avoided. The suture line then was turned inferiorly. The stomach was sutured to the lesser curvature side of the esophagus to the point of origin, where the suture was tied to itself at the lesser curvature side of the gastroesphageal junction. This created a patch of anterior wall of the fundus attached to the anterior half of the intra-abdominal esophagus, 2 em long in the infant and up to 4 em long in the older child. The esophagus was not opened in any patient, as Thai has described in the treatment of the severe esophageal stricture. Only the anterior fundoplication portion of Thal's? procedure was used. Gastrostomy was not done except in those patients who were known
708
The Journal of Thoracic and Cardiovascular Surgery
Ashcraft, Holder, Amoury
A
B ,,'
"I
"
'. 't
iit
w
~!~.
Fig. 1. The anterior fundoplication of Thal. The esophagus is mobilized through an abdominal incision, The hiatus is repaired posterior to the esophagus, and the esophagus is attached to this hiatal repair stitch to fix approximately the lower2 ern of the posterioresophagus within the abdominal cavity. The anteriorfundoplication is then carried out with either running or interrupted sutures to attach the free fundic portion of the stomach anteriorly to the lower 2 to 4 cm of esophagus. The uppermost stitches at the hiatus incorporate stomach, esophagus, and hiatus. The vagusnervebranches are protected carefully. It is not necessary to divideshortgastric vessels to produce this fundoplication.
to require tube feeding for extended periods, i.e., children with damage to the central nervous system. Nasogastric drainage was used overnight. Liquids were started on the first postoperative day and a regular diet on the second postoperative day. Most patients were dismissed on the third postoperative day on a regular diet and doing well. The rapid recovery, short hospitalization, and reduced cost are distinct advantages of this simple procedure. Most of the patients were in the hospital less than 72 hours. Follow-up evaluation was by clinical history, physical examination, evaluation of weight and growth curves, and by barium examination. Two hundred nineteen patients (65%) had follow-up barium studies demonstrating the absence of reflux in 207 and minimal reflux in 12. Postoperative Tuttle testing and long-term pH determinations and manometries were used rarely when symptoms persisted but reflux by barium study was not demonstrable. In several patients this prompted reoperation, with relief of symptoms.
Results Of the 362 patients operated upon, 335 were available for follow-up from 1 year to 8 years postoperative-
Iy. The results of fundoplication were assessed from two points of view. First, was the fundoplication successful in stopping the reflux? Second, if the reflux was stopped, did the symptoms attributed to the reflux also cease? Table II lists the indications for operation. The column listing errors in diagnosis contains those patients whose symptoms persisted even though the reflux was corrected by operation. There were 15 patients in this category (5%). Seventeen patients (5%) had recurrent reflux because of disruption of the fundoplication or because of development of a hiatus hernia postoperatively. These patients underwent reoperation, with complete alleviation of all symptoms the second time. There were 303 (90%) patients who had satisfactory outcome, alleviation of symptoms, after one fundoplication. Ultimately, 320 patients (95%) had a satisfactory "long-term" result from a Thai fundoplication. All recurrences of symptoms developed within 5 months of operation. Most of the patients were able to belch postoperatively and all could vomit when necessary. No patients had the gas bloat syndrome. A transient period of loose stools was the only frequent postoperative gastrointestinal disorder.
Volume 82 Number 5 November, 1981
Gastroesophageal reflux
709
Table II. Results of Thal fundoplication in 335 patients Error in diagnosis No. of patients Apnea Cough, choking, croup Recurrent pneumonitis Esophagitis Intractable vomiting Nutritional failure Starvation CNS disorders
No. followed
No.
80 49 74 26 58 66 2 7
80 42 71 26 54 57 2 7
4 2 6
362
335
15
I
0 2 0 0
Failure of first procedure
I% 5 5 8 4 3
5
No.
I
%
4 2 3 2 3 3 0 0
5 5 4 8 6 5
17
5
Initial good result
I
Ultimately satisfactory
I
%
No.
38 62 23 51 52 2 7
90 90 88 88 94 92 100 100
76 40 65 25 54 55 2 7
95 95 92 96 100 97 100 100
303
90
320
95
No. 72
%
Legend: CNS, Central nervous system.
Discussion Gastroesophageal reflux is very common in neonates and disappears spontaneously in most babies. Of those patients discovered to have reflux within the first 6 months of life, about 80% to 90% will have resolution of their symptoms if treated with thickened feedings in the sitting position. There is some evidence to suggest that some patients are best treated prone without thickened feedings," but for the most part the nonoperative treatment of reflux consists of thickened feedings and keeping the child upright (at least 60 degrees) in an infant seat 24 hours a day. At 6 months of age the infant becomes strong enough physically and independent enough emotionally to make this method of treatment very difficult or impossible for parents and patient. Prone positioning at 30 degrees is better tolerated by the older infant. The medical treatment of gastroesophageal reflux requires considerable patient cooperation. In the small child who is able to be restrained or able to be positioned without expressing his discomfort, medical therapy is possible. In the older patient, the prone positioning of the patient at 30 degrees requires restraint during sleep or the child will tum sideways in bed seeking a horizontal position. Mere elevation of the head of the bed does little or nothing to prevent gastroesophageal reflux or its symptoms in the child. It is important that the disorder be recognized early so that positional treatment may be instituted while it is still tolerated. The mainstay of diagnosis remains the barium study. The skill of the radiologist in dealing with children is exceedingly important. 9 Without special skills, falsenegative results are very frequent. All patients who had reflux demonstrated radiographically and who also had pH or manometric studies were found to have reflux by both modalities. That is to say, the barium study appar-
Table III. Indications for reoperation after Thal fundoplication Fundoplication disrupted Hiatus hernia developed Hiatus hernia recurred Incisional hernia, dehiscence Bowel obstruction
10/335 9/244 2/91 6/335 3/335 30(9%)
ently gave no false-positive information. The patients who had negative barium studies often were subjected to short-term pH and manometric studies as described by Euler and Ament." 10 The pH study was determined to be. the most sensitive and the most reliable. Longterm pH monitoring was not used in any of these patients. Esophagoscopy with estimation of gross esophagitis was used in the one patient who had several negative barium studies prior to the availability of the pH measurement. Most errors made by assuming that demonstrated gastroesophageal reflux was responsible for the symptoms were made in the group of 203 patients having respiratory symptoms attributed to reflux. Included in this group of patients were 80 who had apneic episodes which required some form of resuscitation by the parent, a physician, or trained medical emergency personnel. There were four (of 80) patients in this group who continued to have apneic episodes even though their reflux was surgically corrected. All of the patients with apnea had been evaluated completely by a pediatrician prior to referral for fundoplication. Many had been evaluated by a neurologist or a cardiologist or both, as well. Serum electrolytes, glucose, calcium, phosphorus, blood urea and nitrogen were all within normal limits, so that they could not be considered causes of
The Journal of
710 Ashcraft, Holder, Amoury
Thoracic and Cardiovascular Surgery
the apnea. Electroencephalograms were done in many patients, all of which were normal. Electrocardiography was performed in many patients to exclude the possibility of cardiac dysrhythmia. Only following extensive evaluation, which included barium esophageal studies and/or esophageal pH and manometric measurements, were the patients referred for operative therapy. Re-evaluation in these four symptomatic patients following correction of their gastroesophageal reflux again failed to reveal any other cause for the apneic episodes. Some of these continue. There were four patients in this category as well who had recurrent reflux and recurrent apneic episodes, both of which responded favorably to reoperation. Errors in diagnosis were made in two of 42 patients who had cough, choking, or recurrent croup as a presenting respiratory symptom (5%) and in six of 71 patients with recurrent pneumonitis (8%). Recurrent pneumonitis meant two or more episodes within the first year of life with as many as 20 hospital admissions for pneumonitis over a 4 or 5 year period. Patients with recurrent pulmonary symptoms other than apnea were all evaluated by a pediatrician, and most were referred to an immunologist or allergist for further study. It was only after determination of immune competence, elimination of allergies, and elimination of cystic fibrosis as possible causes that these patients were referred for surgical treatment. Four patients in whom fundoplication "failed" have had only one further hospitalization due to pneumonitis, whereas each had many hospitalizations prior to operation, and their overall state of health is much improved. One of 26 patients (4%) who had esophagitis as the predominant symptom continued to have pain and probably had a minor degree of reflux, although it could not be documented. Perhaps the major disadvantage of the ThaI fundoplication is that minor degrees of reflux can occur at times more easily than with the Nissen fundoplication. In those instances of esophageal pain or bleeding or distal esophageal stricture, a Nissen fundoplication may be the more advisable operative procedure. Two patients had significant recurrent gastroesophageal reflux and responded favorably to reoperation. Two of 57 patients with failure to thrive did not improve following fundoplication. Those with intractable vomiting, starvation, and those who had fundoplication as a preventative measure with gastrostomy for central nervous system disorders were all satisfactorily treated. Reoperation was required in 30 of 335 patients (9%)
because of a variety of complications (Table III). Ten fundoplications (3%) came apart producing recurrent gastroesophageal reflux. All responded favorably to reoperation. Nine of 244 patients developed a postoperative hiatus hernia when one had not been present before, and two of 91 patients had recurrence of a repaired hiatus hernia. Only seven of the 11 patients with postoperative hernias had recurrent gastroesophageal reflux and were symptomatic. Four underwent operation to restore a surgically competent gastroesophageal junction below the diaphragm-a procedure which may have been unnecessary. Nine other patients (3%) required reoperation for such complications as incisional hernias, wound dehiscence, or bowel obstruction. In the last 200 patients there have been no such complications necessitating reoperation, since incidental umbilical herniorrhaphy and appendectomy have been discontinued and since the transverse upper abdominal incision has been used almost exclusively. There were no deaths due to operation. Twenty-two of the 362 patients (6%) died, nine of them in the hospital. One patient with severe central nervous system disease vomited and aspirated, but most died of underlying central nervous system or cardiac disorders. There were 13 late deaths, all due to associated disorders. There were 114 patients with associated disorders in this group. These disorders include severe brain damage in 26, esophageal atresia in 24, and cardiac lesions in 21. Eleven patients had recognizable syndromes and 11 others had subglottic stenosis, which probably resulted from repeated aspiration. The group of patients having esophageal atresia and tracheoesophageal fistula deserve special attention. Recurrent esophageal stricture has been the most common manifestation of reflux in the patient after repair of esophageal atresia. II. 12 Additionally, one patient had a minor extrapleural anastomotic leak but such massive gastroesphageal reflux that gastrostomy feedings were impossible until fundoplication was done. Prompt healing of the leak followed fundoplication. In contrast to the usual neonate with gastroesophageal reflux, in whom a resolution of 80% to 90% could be expected, about two thirds of those patients with esophageal atresia and gastroesophageal reflux required fundoplication. Others have reported similar need for operative therapy of the gastroesophageal reflux in these infants.": 14 The anterior fundoplication described by ThaI allows the patient to belch and vomit postoperatively. In many patients who have had a Nissen fundoplication, vomiting is difficult or impossible." It would appear from
Volume 82
Gastroesophageal reflux
Number 5
711
November, 1981
other data that recurrence rates of gastroesophageal reflux following Nissen's fundoplication in the child are comparable to those in this series. 3-5 The problem of erroneously assuming that demonstrated gastroesophageal reflux is responsible for symptoms continues to be disturbing. Although we did not use long-term pH monitoring, extensive work has been done in this area in Salt Lake City, Utah.": 16 In a recently reported series of patients, the pattern of reflux was determined over a 24 hour period in 93 patients. Seventy-seven of these patients were followed up for an average period of 30 months, 30 of whom had undergone operation for gastroesophageal reflux. Vomiting was controlled by an antireflux operation in each child, but respiratory symptoms were not relieved in four patients and growth retardation did not improve in two patients. We conclude that prolonged pH measurements in determination of the patterns of reflux are of very little benefit either in selecting patients for operation or in predicting which patients will respond favorably to operation. Fortunately, sorting out these patients, which may be impossible with the present state of the art, becomes less of a problem when the mortality remains zero and the complication rate remains low.
2
3
4
5
6
7 8
REFERENCES Herbst JJ, Book LS, Bray PF: Gastroesophageal reflux in the "near miss" sudden infant death syndrome. J Pediatr 92:73-75, 1978 Randolph JG, Lilly JR, Anderson KD: Surgical treatment of gastroesophageal reflux in infants. Ann Surg 180: 479-488, 1974 Leape LL, Ramenofsky ML: Surgical treatment of gastroesophageal reflux in children. Am J Dis Child 134:935938, 1980 Fonkalsrud EW, Ament ME, Byrne WJ, Rachelefsky GS: Gastroesophageal fundoplication for the management of reflux in infants and children. J THORAC CARDIOVASC SURG 76:655-664, 1978 Schatzlein MH, Ballantine TVN, Thirunavukkarasu S, Fitzgerald JF, Grosfeld JL: Gastroesophageal reflux in children. Arch Surg 114:505-510, 1979 Euler AR, Ament MR: Detection of gastroesophageal reflux in the pediatric-age patient by esophageal intraluminal pH probe measurement (Tuttle test). Pediatrics 60:65-68, 1977 Thai AP: A unified approach to surgical problems of the esophagastric junction. Ann Surg 168:542-550, 1968 Ramenofsky ML, Leape LL: Continuous upper esophageal pH monitoring in patients with gastroesophageal reflux pneumonia and apneic spells. J Pediatr Surg (in press)
9 McCauley RGK, Darling DB, Leonidas JC, Schwartz AM: AJR 130:47-50, 1978 10 Euler AR, Ament ME: Value of esophageal manometric studies in the gastroesophageal reflux of infancy. Pediatrics 59:58-61, 1977 11 Pieretti R, Shandling B, Stephens CA: Resistant esophageal stenosis associated with reflux after repair of esophageal atresia. A therapeutic approach. J Pediatr Surg 9:355-357, 1974 12 Ashcraft KW, Goodwin C, Amoury RA, Holder TM: Early recognition and aggressive treatment of gastroesophageal reflux following repair of esophageal atresia. J Pediatr Surg 12:317-321,1977 13 Parker AF, Christie DL, Cahill JL: Incidence and significance of gastroesophageal reflux following repair of esophageal atresia and tracheoesophageal fistula and the need for anti-reflux procedures. J Pediatr Surg 14:5-8, 1979 14 Fonkalsrud EW: Gastroesophageal fundoplication for reflux following repair of esophageal atresia. Arch Surg 114:48-51, 1979 15 Jolley SG, Herbst JJ, Johnson DG, Book LS, Matlak ME, Condon VR: Patterns of postcibal gastroesophageal reflux in symptomatic infants. Am J Surg 138:946-950, 1979 16 Jolley SG, Johnson DG, Herbst JJ, Matlak ME: The significance of gastroesophageal reflux patterns in children. J Pediatr Surg (in press)
Discussion DR. TOM R. DEMEESTER Palos Heights, /II.
I arise to bring to focus two points regarding the paper of Dr. Ashcraft. The first point deals with diagnosis of gastroesophageal reflux, and the second point deals with the evaluation of the operation designed to improve the competence of the cardia. The diagnosis of reflux based on atypical symptoms can be very difficult and often misleading. Because of this, there is a great need to be objective. Eighty of their 362 patients had apnea. There are many causes for apnea besides gastroesophageal reflux. There were 66 patients who had nutritional failure. There are many causes for nutritional failure other than gastroesophageal reflux. Only 26 of their 362 patients had esophagitis, an objective sign of gastroesophageal reflux in most situations. We must remember that chalasia, i.e., an open cardia, is a normal finding in early infancy. It is important, therefore, that the diagnosis of reflux be objectively established in these children and that their atypical symptoms, suspected to be due to reflux, are able to be correlated to the occurrence of reflux episodes. If such a relationship cannot be demonstrated, I do not believe it is wise to proceed with surgical therapy. My second comment has to do with the proposed modified
The Journal of
712 Ashcraft, Holder, Amoury
operation. We are asked to believe on the basis of testimony that the defect in these patients was an incompetent cardia and that the operation proposed has been designed to improve the incompetent cardia. I remind you that operations to correct reflux are different from most other operations that we do. More commonly than not, an operation is performed to remove an organ, and we do not care about the function of an organ when it has been extirpated. However, the postoperative function of an organ is very important if we design an operation to improve the function of an organ and not to extirpate or replace it. Prior to proposing a modified operation designed to improve the function of the cardia, we should know how much cardia was deranged preoperatively and what improvement the operation made on the function of the cardia postoperatively. Simply to rely on symptoms as a measurement of functional improvement is not reliable. I would suggest that if the authors think the problem was due to an incompetent cardia, then studies ought to demonstrate that the cardia was indeed incompetent; if their modified operation is designed to improve an incompetent cardia, then studies should be done to show that the operation indeed does improve an incompetent cardia. This is only a reasonable thing to do before suggesting the operation to others. MR. RONALD BELSEY Chicago. Ill.
We have an antique British principle that diagnosis precedes treatment. Dr. DeMeester has posed many of the questions that I was going to ask the authors of this paper, but from their figures I rather gather that only 27 of their patients had any objective tests being conducted to determine whether there was in fact reflux either before or after the operation. In the surgical treatment of gastroesophageal reflux, we must be very critical regarding indications for operation and in assessing results of operation. It is not sufficient to say that the child no longer has apnea after the operation. He may be terrified of having another operation and doesn't dare not to breathe. We must insist as a society on objective evidence of
Thoracic and Cardiovascular Surgery
the reflux, of the degree of reflux, of the timing of the reflux, and whether after surgical treatment the reflux has been cured. One thing I liked about this paper was the emphasis on 180 or 240 degree fundoplication as opposed to the overaggressive 360 degree fundoplication of the Nissen procedure. I do not think it matters whether it is done through the abdomen or the chest, provided the surgeon has a clear idea of what he is attempting to do. We now know from clinical experience and from some of Dr. DeMeester's experiments that the only sensible way of controlling reflux is to restore the lowest sphincter zone to the high-pressor region under the diaphragm and to retain it there permanently. DR. AS HC RA FT (Closing) Dr. DeMeester and Mr. Belsey imply that the only objective evidence for reflux is long-term pH monitoring, and we differ from them in that respect. Long-term pH monitoring has a great many strong points in its favor, but in point of fact, reflux can be demonstrated very nicely, at least in the child, by barium studies. Radiographic studies are reproducible and, in the opinion of many, are as reliable when positive as are long-term pH determinations. As I pointed out, when long-term pH measurements were done in Salt Lake City by Jolley and his co-workers, they really did not help much. Their diagnostic error rate was 20% compared to 5% with our approach. As to objective evidence of cure postoperatively, the same argument would apply. The relief of symptoms seems to us to be the objective of the operation. The anterior fundoplication, which allows patients to belch and vomit, is of definite value. We did have about 30 patients who underwent the Nissen procedure, many of whom had esophagitis, and probably for these patientsthere is an advantage in the 360 degree wrap in that the cessation of reflux is much more absolute. It is a procedure that is associated with gas bloats and sometimes obstruction, which in the child can be a very serious problem.