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316 Gastro-oesophageal Reflux Disease

significant difference between those treated medically and those treated The main adverse determinants of outcome seem to be the presence
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surgically. The incidence in children is difficult to establish. of neurological impairment, the presence of associated congenital
A mortality risk exists for children having Nissen fundoplication. Most anomalies, and stricture.
of the mortality is late and due to associated conditions. Bradnock et al., Barrett’s oesophagus is a precursor to malignant adenocarcinoma of
in their series of 85 patients, found a late mortality of 7% in children who the oesophagus. Endoscopic surveillance is advocated in older children
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underwent laparoscopic fundoplication. A similar rate of mortality was into adulthood. The incidence of carcinoma in those diagnosed in
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reported by Tovar et al in their series of 252 children who had either childhood is not well established.
open or laparoscopic fundoplication. In that series, 17 deaths (6.7%) Prevention
occurred; 3 in the first postoperative month, with only 1 (0.4%) related
to the operation. There are no known preventive measures.
Prognosis and Outcomes Evidence-Based Research
Tables 49.3 and 49.4 present trial studies on thickened-feed interventions
In patients with mild disease that resolves on conservative management or
in infants and a comparison of laparoscopic and open fundoplication in
with pharmacotherapy with no recurrence, the outcome is good. Resolution
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in infants usually takes 3 to 6 months. Those with more severe symptoms children, respectively.
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may have ongoing disease even if improvement is noted.
Table 49.3: Evidence-based research. Table 49.4: Evidence-based research.
Title The effect of thickened-feed interventions on Title Clinical outcome after open and laparoscopic Nissen
gastroesophageal reflux in infants: systematic review and fundoplication in children: randomised controlled trial
meta-analysis of randomised, controlled trials
Authors McHoney M, Eaton S, Drake DP, Kiely EM, Curry J, Spitz L,
Authors Horvath A, Dziechciarz P, Szajewska H Pierro A
Institution Department of Paediatrics, Medical University of Warsaw, Institution Great Ormond Street Hospital for Children, London, UK
Warsaw, Poland
Reference Abstract Canadian Association of Pediatric Surgery
Reference Pediatrics 2008; 122:e1268–e1277 Conference, October 2004
Problem Currently, thickened feeds are increasingly being used to Problem There have been no randomised controlled studies comparing
treat infants with gastro-oesophageal reflux, driven in large the outcome between open and laparoscopic fundoplication
part by the baby food industry. Previous meta-analyses in children. The aim of this study was to compare the clinical
have shown that although thickened formulas do not seem outcome in children undergoing Nissen fundoplication who
to reduce measurable reflux, they may reduce vomiting. were randomised to open surgery or laparoscopy.
However, because data are limited, there is still uncertainty
regarding the use of thickening agents. Intervention Randomised to open and laparoscopic Nissen fundoplication.
Comparison/ Randomised control trial.
Intervention Meta-analysis of randomised controlled trials.
control
Comparison/ The Cochrane Library, Medline, Embase, and CINAHL (quality of
control databases and proceedings of the European and North evidence)
(quality of American paediatric gastroenterology conferences (from
2000) were searched in May 2008; additional references
evidence) Outcome Twenty patients in the open and 19 patients in the
were obtained from reviewed articles. Only randomised, effect laparoscopic group. Median time to establish full feeds was
controlled trials that evaluated thickened feeds used in 2 days in both groups. Median hospital stay was 4.5 days
infants for at least several days for the treatment of gastro- in the open group versus 5 days in the laparoscopic group,
oesophageal reflux were considered for inclusion. Three with no significant difference between groups. There was
reviewers independently performed data extraction by using no significant difference in morphine requirements, although
standard data-extraction forms. Discrepancies between pain scores fell significantly faster in the laparoscopy group.
reviewers were resolved by discussion among all authors. Incidence of dysphagia, recurrence of reflux, and need for
Only the consensus data were entered. redo fundoplication were not significantly different between
Outcome Fourteen randomised, controlled trials with a parallel or groups. At the time of follow-up, the incidence of retching was
higher after open surgery (56%) versus laparoscopy (6%; p =
effect crossover design, some with methodologic limitations, 0.003).
were included. Use of thickened formulas compared with
standard formula significantly increased the percentage of Historical This randomised trial demonstrated equal efficacy between
infants with no regurgitation, slightly reduced the number of significance/ laparoscopic and open fundoplication in children.
episodes of regurgitation and vomiting per day (assessed comments
jointly or separately), and increased weight gain per day.
It had no effect on the reflux index, number of acid gastro-
oesophageal reflux episodes per hour, or number of reflux
episodes lasting >5 minutes, but significantly reduced
the duration of the longest reflux episode of pH <4. No
definitive data showed that one particular thickening agent
is more effective than another. No serious adverse effects
were noted.
Historical Thickened food is moderately effective in treating gastro-
significance/ oesophageal reflux in healthy infants.
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