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Gastro-oesophageal Reflux Disease 313

Figure 49.1: Operative intervention for GORD.

dilatation with radiological screening seems to be an inherently safer This is placed endoscopically with the jejunostomy extension passed
approach. Most patients then require surgery for their GORD. In one through the pylorus at the time of surgery and confirmed to be in the
study in Cape Town, only 6 out of 31 patients with strictures secondary jejunum on x-ray. This tube also has the advantage of having access
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to GORD did not require antireflux surgery. Overall, the approach of ports in the stomach to allow gastric feeding or decompression.
dilatation followed by antireflux surgery cures 75% of strictures. The Placement of a jejunostomy tube directly into the jejunum is
remainder of patients may require further dilatations or resection of the occasionally used. This is usually a tunnelled type (although a Roux-
strictured segment of oesophagus. en-Y configuration is possible). Through a mini-laparotomy incision,
Barrett’s oesophagus can also be considered a relative indication a loop of jejunum, preferably 15 cm from the DJ flexure, is isolated
for antireflux surgery. There is a small incidence of adenocarcinoma as the insertion site. The silk jejunostomy tube is then tunnelled
secondary to Barrett’s metaplasia. The evidence that surgical treatment along the jejunum by imbricating the serosa around the tube by
is more effective than medical management in preventing progression using sutures. The tube is then inserted into a stab incision in the
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to cancer has not been proven, however. Laser ablation therapy has jejunum and secured with a double purse string suture in a Stamm
been shown in adult studies to be highly effective in curing Barrett’s gastrostomy fashion. The jejunum, from the apex to the insertion site,
metaplasia 34;35 alongside medical or surgical management of the is then sutured to the abdominal wall to complete the tunnel. The
GORD. No data of its use in children have been published. disadvantage of a jejunostomy is the difficulty in re-establishing the
Surgery for GORD can be divided into either supportive/temporary tube should it be pulled out. Displacement is possible, and caregivers
or definitive (see Figure 49.1). should be aware of what should be done in the event of this occurrence.
Supportive or Temporary Surgery Jejunostomies are associated with higher complication rates compared
Gastrostomy for treatment of GORD is occasionally used as a means of to gastrojejunostomies (e.g., infections, leakage, feeding difficulties).
establishing feeds and allowing the infant or child to thrive temporarily The options outlined above provide temporary treatment of GOR by
while maintaining minimal oral intake if possible. There is still some allowing enteral intake and growth to be established before embarking
debate in the literature as to whether gastrostomy placement worsens on more major surgery. The infant/child can be tried on increasing oral
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reflux. Some surgeons argue that a gastrostomy placed in the lesser intake while tube-feeding continues. Tube-feeding can then be stopped
curvature of the stomach is associated with less reflux, and may even if full oral intake is achieved. These devices can then be removed on
improve symptoms. 37,38 Nevertheless, worsening of reflux is a pos- an outpatient basis without the need for surgery. Occasionally, a minor
sibility and should be taken into account; this possibility should be operation is needed if the stoma does not close.
mentioned when obtaining consent for surgery. Gastrostomy placement Definitive Surgery
may also be required in patients with severe strictures that need dilata- Definitive surgery (fundoplication) for GORD aims to address or aug-
tion, both as a means of establishing feeds and a means of accessing the ment the main contributing factors preventing reflux and to reverse
oesophagus for string-guided dilatations. 32 any pathology present. Table 49.2 shows the key features of definitive
Gastrojejunostomy is one step further along in the management of surgery to correct GORD as it relates to the antireflux mechanism and
GORD in children. It offers advantages over gastrostomy in allowing pathology discussed earlier.
feeding beyond the pylorus, thus significantly reducing reflux. It Nissen Fundoplication to Treat GORD
has the disadvantages of needing more time-consuming feeding The operative details of Nissen fundoplication (360° wrap) are pre-
regimens due to the inability to bolus feed. There are various methods sented here because it is the author’s operation of choice. Salient points
of achieving gastrojejunostomy tube feeds. A feeding tube can be on other operations are briefly presented in the next section.
placed through an existing gastrostomy and confirmed by radiological
imaging. Alternatively, custom-made devices, such as the percutaneous 1. A subcostal incision is appropriate in most cases. (Other options
endoscopic gastrostomy–jejunostomy (PEG-J) tube, can be used. include rooftop, transverse supraumbilical or midline incisions,