Gastroesophageal Reflux and Antireflux Surgery

What is gastroesophageal reflux and antireflux surgery?

Gastroesophageal reflux, also called acid reflux or heartburn occurs when stomach contents (acidic stomach juices, foods or fluids) return from the stomach into the esophagus (the tube between the mouth and the stomach). Reflux is very common in infants and toddler up to 2 years of age; it is the most common cause of vomiting or “spitting up” during infancy. Reflux occurs because the muscle group at the bottom of the esophagus relaxes too frequently, allowing stomach contents to re-enter the esophagus. In most babies. the problem will go away on its own. If it does not go away or causes repeated problems in your child, the word “disease” is added and the process is referred to as gastroesophageal reflux disease or GERD.

The most common symptoms of GERD may include: belching, heartburn, refusal to eat, vomiting or regurgitation, hiccups, gagging and chronic cough. Less commonly, GERD can cause wheezing, sore throat, hoarseness, recurrent aspiration pneumonia, exacerbation of asthma and esophageal stricture. In young infants severe reflux can trigger a nerve pathway that causes breath holding, slows the heart rate; events that require immediate medical attention.

How is GERD treated?

Treatments vary based on your child's age, health, and medical history, the extent of your child's disease, his or her tolerance for specific medications, procedures, and therapies. Medical therapies to treat reflux in infants in children may include altering feeding habits, or using medications that help speed the emptying of the stomach contents into the intestine or that reduce stomach acid. Sometimes GERD may be managed with medications such as Zantac, Prilosec, and Prevacid, which decrease the amount of acid in the stomach. These medications will reduce the heartburn associated with GERD. Reglan is another medication that may be prescribed for GERD. It is usually taken before meals and at bedtime to help the stomach empty faster, which in turn may decreases symptoms associated with GERD. Many times, these two types of medications are given in combination. Over 90% of GERD can be managed with these techniques alone.

The failure of medical therapies or a life-threatening event due to reflux are both indications for surgery. There are many different tests which may be used to assess GERD, to ensure that surgery is right for your child. The sequence of and exact studies ordered will vary from child to child and physician to physician but may include:
  1. A chest x-ray may be done to look for evidence of aspiration or pneumonia. 
  2. An upper gastrointestinal series is another test that may be done. Your child will swallow a chalky fluid, called barium which is used to coat the insides of the esophagus, stomach, and the first section of the small intestine so that they can be seen in an x-ray. This test shows will demonstrate how well the esophagus and stomach empty and also shows us if there is any blockage of the esophagus, stomach or intestines that could be causing food to be regurgitated. 
  3. An endoscopy may also be done to assess GERD. This test uses a small, flexible tube with a light and a camera at the end to examine the inside of the digestive tract and look for evidence of acid injury to the esophagus. 
  4. Ph testing may also be done. During this, a small tube is passed into the esophagus to measure the pH, or acid level over 12 to 24 hours. 
  5. Intraluminal impedance monitoring may be performed to detect and record the amount of stomach contents coming back up into the esophagus when a child cries, arches, coughs, gags or vomits. It also determines if the gastric contents are acidic or not, how long they stay in the esophagus as well as how often it occurs. A thin wire with sensors on it is inserted through the nose into the lower part of the esophagus. It is usually used in combination with pH monitoring so that episodes of acid reflux may be distinguished from non-acid reflux. 
  6. Gastric emptying studies may also be done. This study measures that speed at which food empties from the stomach. The study uses a special camera to take pictures of your child’s stomach and throat while they drink or eat. It checks to see if the stomach is emptying as it should and if any food is going back up (refluxing) into the throat. It is often referred to as a gastroesophageal reflux study. 
  7. Esophageal manometry studies may be done to assess peristalsis and lower esophageal sphincter function. A small, flexible high resolution manometry tube is passed through your child’s nose, down their esophagus and into their stomach. The end of the tube exiting your child’s nose is connected to a machine that records the pressure exerted on the tube. Sensors at various locations on the tubing sense the strength of the lower esophageal sphincter and muscles of the esophagus. During the test, your child may swallow a small amount of water to evaluate how well the sphincter and muscles are working. The sensors also measure the strength and coordination of the contractions in the esophagus while your child swallows. (The test lasts 10 to 15 minutes)
The most common type of anti-reflux surgery is called fundoplication. The goal of a fundoplication is to increase is to increase the pressure the lower esophagus to prevent reflux but still permit food to move down the esophagus into the stomach. This operation is accomplished by wrapping the upper portion of the stomach around the lower portion of the esophagus, tightening the outlet of the esophagus as it empties into the stomach. After a fundoplication, food and fluids can pass into the stomach but are prevented from returning to the esophagus and causing symptoms of esophageal reflux.

What will happen in the hospital?

This surgery usually takes 2 to 3 hours. Your child will be give general anesthesia before the surgery. That means the child will be asleep and unable to feel pain during the procedure. The surgeon will use stitches to wrap the upper part of your child’s stomach around the end of the esophagus. This surgery may be done open or laparoscopically. In the open repair, the surgeon will make a cut in the child’s abdomen. In the laparoscopic repair the surgeon will make 3 to 5 small cuts (5mm or ¼ inch) in the abdomen. A thin, hollow tube with a tiny camera on the end (a laparoscope) is placed through one of these cuts. The choice of surgical procedure performed will depend upon your child’s anatomy and medical/surgical history; however, the vast majority may be done laparoscopically. After surgery your child will be brought to the pediatric recovery room. Once your child is fully awake he or she will be transferred to the Pediatric Surgical Unit for further post-operative management. Pain will be well controlled with intravenous pain medications at first and prior to discharge your child will transition to pain medications by mouth. Your child can start eating again about 1 to 2 days after surgery. Prior to this your child will receive intravenous fluids. When bowel sounds return and your child begins to pass gas, his or her diet will gradually be advanced. Liquids are usually given first and then are slowly advanced to soft foods.

When will my child be discharged?

How long your child stays in the hospital depends on how the surgery was done. Children who have laparoscopic anti-reflux surgery usually stay in the hospital for 2 to 3 days. Children who have open surgery may spend 2 to 6 days in the hospital. Your child will be able to go home once they are drinking full liquids and have adequate pain control with oral medication. Pain control rarely requires more than over the counter pain relievers such as Children’s Tylenol or Advil.

What will be my child's recovery?

After your child has started eating again, his or her pain is well controlled; he or she will be discharged from the hospital. Your child’s abdomen may be generally sore for up to one week after surgery. Initially some patients report difficulty burping. During the recovery period your child will be eating a soft diet. Your child should eat smaller meals during the recovery period and then gradually increased meal sizes.

Most often over-the-counter pain relievers such as Children's Tylenol or Children's Advil are adequate for pain control. The steri-strips should remain in place for at least ten days after the surgery. Your child may shower but should not tub bathe or swim for two weeks until incisions have healed. Your child should avoid vigorous physical activity for 2 weeks. We will see you in the pediatric surgery clinic 2 weeks after the operation for a postoperative visit.

What should I be looking out for after the operation?

In the first two weeks after surgery it is important to monitor for signs or symptoms of infection such as redness, swelling around the surgical site or fever. As with all operative procedures, the most common complication is potential for infection of the surgical site. Heartburn and related symptoms should improve after anti-reflux surgery; however, your child may still need to take medications for heartburn after surgery. To help prevent gas bloat and feeling of fullness your child’s food should be eaten slowly and chewed well prior to swallowing. Most children see an improvement in symptoms, especially after the fundoplication operation, although some long-term effects may continue to be troublesome. Regular review during outpatient appointments is needed for most children.