Surgical management of the gastroesophageal reflux syndrome in childhood.

Gastroesophageal reflux (GER) is a common cause of repeated emesis, failure to thrive, repeated pulmonary infection, and asthma in infants and children. During a 14-year period 270 children underwent gastroesophageal fundoplication for symptomatic reflux. The 24-hour esophageal pH monitoring is the most accurate test available to verify the presence of GER and is also helpful in evaluating the results of fundoplication. Transabdominal fundoplication may be performed with a low risk of complications. The most frequent complication requiring reoperation is paraesophageal hiatus hernia (6/270 patients), which should be repaired in almost all instances when symptoms develop. Closure of the crura posterior to the esophagus greatly reduces the incidence of this problem. Esophageal motility disorders occur in more than 35% of patients with symptomatic reflux and militate against performing a tight antireflux operation. Approximately 50% of patients with symptomatic reflux have associated gastric motility disorders. Radionuclide studies with 99mTC sulfur colloid in semisolid feedings have determined the magnitude of gastric retention after a feeding and have been helpful in identifying children who require a pyloroplasty with or without fundoplication. Pyloroplasty is performed simultaneously with fundoplication in approximately 10% of patients with symptomatic reflux when the lower esophageal sphincter pressure is low and the esophageal pH monitor shows reflux. The excellent clinical results achieved by fundoplication with or without pyloroplasty and the low morbidity and mortality rates indicate that these procedures should be used early in the management of infants and children who suffer symptomatic GER.