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Gastro-oesophageal Reflux Disease 315

those that have been shown to have delayed gastric emptying. Brown
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et al. have demonstrated that a gastric outlet operation is not needed
in most cases of fundoplication because almost 90% of patients have
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normalised gastric emptying after surgery. Also, Pacilli et al. have
demonstrated that gastric emptying, measured by using an isotope milk
scan, increased following Nissen fundoplication without pyloroplasty.
Therefore, a policy of fundoplication without pyloroplasty seems
justifiable, leaving this option as a later addition in those that have
continuing problems.
14. Pyloroplasty is performed by making a longitudinal incision along
the pylorus through all layers. This is then closed transversely using
interrupted sutures.
A laparoscopic approach to Nissen fundoplication is justifiable
in surgeons with the expertise, with comparable outcomes compared
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to open surgery in randomised studies (in adults). In a randomised
trial, laparoscopic Nissen fundoplication in children was shown to
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preserve immune function in the postoperative period. Laparoscopic Figure 49.5: Contrast study after a Nissen fundoplication with recurrence
antireflux surgery has now largely become the preferred approach in of symptoms, demonstrating a sliding hernia. Note the indentation of the
children where expertise exists (including our own institution). Day oesophagus, indicating the wrap is intact.
case laparoscopic Nissen fundoplication in South Africa has also been
described, and is a testament to the advances in recovery that can be complications are treatable by conservative measures. Leakage from
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achieved with the laparoscopic approach. the stoma site is best addressed first by changing to a shorter button
The other more common operations used to treat GORD include: to achieve a better fit. Occasionally downsizing to a smaller gauge, to
• Thal fundoplication (anterior 180° wrap). allow the stoma to shrink, then replacing with the original size is helpful.
Granulomas can be treated with repeated silver nitrate cautery, which is
• Toupet fundoplication (posterior 270° wrap). effective in most cases. Occasionally, excision is required. Infections are
• Boix-Ochoa fundoplication; additional steps after closing the hia- treated with appropriate topical or systemic antibiotics, depending on
tus involves stitching the fundus to the right crus of the diaphragm prevalence and culture results. Parents and caregivers should always be
to restore the angle of His. The fundus is then plicated over the warned of tubes falling out and advised of the action to take to maintain
intraabdominal oesophagus as a partial anterior wrap up to the hia- stoma patency. Occasionally, attempts at replacing the tube can lead to
tus. The fundus of the stomach is then sutured to the undersurface separation of the stomach from the abdominal wall, with peritonitis if
of the diaphragm by using three sutures that suspend the fundus. feeds are then instilled into the abdominal cavity. This can be fatal if not
Many other versions and variations of antireflux surgery exist, with recognised or if recognised too late.
slight variations of the steps for Nissen fundoplication. There is little Dysphagia is present in 5–10% of patients in the postoperative period. Most
evidence that any one operation is superior to any other in terms of tend to resolve with time. A portion of patients continue to have significant
efficacy and outcome, and the choice of operation is usually up to the problems and need dilatation; an even smaller portion need redo surgery.
surgeon’s choice and experience. Intestinal obstruction caused by adhesions can occur. This complication
can be treated operatively or initially conservatively depending on clinical
Total Oesophagograstric Dissociation
presentation. The incidence of adhesions may be lower after laparoscopic
Total oesophagogastric dissociation (Roux-en-Y oesophagojejunal
approach compared to open surgery.
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anastomosis and jejunojejunostomy with gastrostomy feeding tube)
Retching after fundoplication occurs predominantly in the
was initially proposed as a salvage operation for patients who have mul-
neurologically impaired group. This can resolve with changes in the
tiple failed fundoplications 44,45 (predominantly neurologically impaired
feeding regimen and type of milk. In some patients, it persists, and a
children). It has now been proposed to include total oesophagogastric
trial of alimemazine, an antihistaminic that has shown to improve this
dissociation as a primary procedure in the severely neurologically
symptom, is sometimes effective. Most patients with postoperative
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impaired child or in difficult scenarios. 46,47 The author has no experi-
retching settle with conservative management. In the remainder,
ence with this operation and further details are therefore not given here.
alimemazine has variable success. Gas bloat is also common due to
Complications the inability to burp up ingested air. Patients with gastrostomies can be
Bleeding from trauma to the liver or spleen can occur intraoperatively and vented regularly to avoid bloating.
should be anticipated with cross-matched blood. Rarely, splenectomy is Recurrence is seen in 5–25% of patients, depending on the series
required due to uncontrollable bleeding. quoted. 27,31,50,51 The incidence is higher in patients with neurological
Perforation of the oesophagus during mobilisation is avoidable if impairment (20–40%) compared to neurologically normal children
careful dissection is performed. Occasionally, difficult dissection due to (5–10%). 31,51,52 The incidence is also higher in patients with congenital
severe inflammation may make this complication more likely. anomalies. If further surgical intervention is being considered, an upper
Respiratory complications, including pneumonia and atelectasis, occur gastrointestinal contrast study is performed to assess the integrity and
mainly in the neurologically impaired or in those with neuromuscular disease. position of the wrap. In most series, the cause of the recurrence is
Pneumothorax may be caused during the dissection around the oesophageal equally shared by wrap failure and wrap migration (into the chest).
hiatus if the pleura is accidentally incised. The consequence is usually mild, Figure 49.5 shows two contrast studies demonstrating intact wraps that
and the operation can be continued without intervention. Occasionally, a have migrated into the chest. Recurrent herniations are best treated by
chest tube may be needed intraoperatively. If suspected and demonstrated on redo surgery (redo of the wrap itself is not mandatory, however, if it
a postoperative x-ray, treatment should be on clinical grounds. appears sufficient at operation).
Gastrostomy-related complications include leakage, granuloma Barrett’s oesophagus can occur despite surgical or medical treatment.
formation, infection, and tube dislodgement. Most gastrostomy In adults, it seems to be between 4 and 8 per 1,000 patient years, with no