gerd - peds surg lecture

7/25/2019 GERD - Peds Surg Lecture

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Gastroesophageal RefuxDisease

Pediatric Surgery


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Background Esophagus: conveys ood rom

pharynx to stomach Gastroesophageal refux: Descri!es

the "usually# undetected !ackfo$ ogastric contents into the esophagus

Physiologic phenomenon and occurs inother$ise normal people several timesdaily% especially postprandial $ith oodssuch as soup& tea& co'ee& milk& etc


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Background (echanisms to $ard o' negative

e'ects o refux: Rapid clearance o refuxed material !y

propulsive peristalsis Bu'ering o refuxate !y s$allo$ed

saliva

Resistance o esophageal s)uamouslayer to refuxed contents


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GERD *s a pathologic refux + refux $hich causes

ma,or symptoms or complications: -ailure to thrive Distur!ance o sleep Recurrent aspiration in young in ants Epigastric or retrosternal pain .eart!urn Esophagitis Stenosis

/01 o $estern $orld is a'ected


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Esophagogastric 2unction Separates higher pressure a!dominal

compartment rom lo$er pressurethoracic compartment

3onsists o : 3rura o diaphragmatic hiatus 4ngle o .is 5ES "5o$er esophageal sphincter#


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5ES structures 3rural Diaphgram 6 orms an o!li)ue slit

encircling the esophagus $hich constitutesan external pinchcock mechanism

4ngle o .is: 4cute angle created !et$eencardia at entrance o stomach andesophagus

-orms valve preventing refux% angle created !y

the collar sling 7!res and circular muscles aroundGE ,unction 8nderdeveloped in in ancy% esophagus makes a

vertical ,unction $ith stomach + so refux morelikely


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5ES 5ies $ithin diaphgragmatic hiatus& $hich orms

a 7rm tunnel in $hich esophagus is secured !yphren6esophageal mem!rane

(aintains !asic tonus& !ut relaxes $ithongoing propulsive peristaltic $ave o s$allo$ 9ransient lo$er esophageal sphincter

relaxations "95ESRs# o 6;0 seconds occur

even in a!sence o any other esophagealperistalsis Remain unrecogni


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95ESR 95ESR is primary pathophysiologic mechanism

in all individuals $ith GERD Relaxation triggered !y gastric mechanoreceptors

that signal distension to hind!rain + generatesmotor signals to 5ES=esophagus via vagus n

Ba!ies $ith pathologic refux experience moreprolonged 95ESR

*ndigested fuid triggers 95ESR !y gastricdistension% so largely li)uid ood "milk# given toin ants is another actor that may cause more

re)uent 95ESR


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95ESR Delayed gastric emptying $ith pathologic

95ESR is o!served in children $ithneurologic disorders + may increase the

incidence o refux episodes

Pathologic refux may !e regarded as signo delayed maturation or distur!edcoordination o control centers in thehind!rain& disrupting unction o esophagealperistalsis& 5ES& and gastric motility


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Symptoms (ild regurg or occasional vomiting as

a sign o GER + may !e seen in > allne$!orns=young in ants ed milkSymptoms less re)uent a ter ?6@ moo li e

Pathologic refux + re)uent regurgepisodes& restless sleep $ith suddenunexplained $ake6up and excessivecrying episodes and even

malnutrition and ailure to thrive


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Symptoms Beyond in ancy& recurrent

regurgitation o acid gastric ,uice&nighttime symptoms during sleep%can develop recurrent respiratorytract disease due to micro6aspirationo refux

3hronic infammation o mucosa maylead to microscopic !leeding andchronic anemia% may eventually

cause stenosis due to scarring


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Symptoms (icro6aspiration may lead to

laryngitis& laryngeal pseudopolypsand $hee


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Diagnostic *nvestigations UGI Series : eval o peristaltic xn o esophagus&

visuali


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Diagnostic *nvestigations (anometric

*nvestigations +demonstratemotor xn and

peristalsis oesophagus

(anometric sign

o a 95ESR is the3PP "commoncavityphenomenon#


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Diagnostic *nvestigations Endoscopy & Histology: *nvasive !ut essential

part o dx $orkup o GERD Reddening& ulceration or pseudopolyps on the

vocal cords are typical signs o laryngeal refux Bx specimen rom duodenum and antrum o

stomach are tested or . Pylori Essential to take several !x specimens proximal

to C6line% hyperplasia o !asal cell layer andelongation o papillae are signs o increasedturnover due to refux associated acid exposure


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3onservative 9herapy *n in ants& GERD resolves spontaneously in

01% so conservative therapy is tx o choice Supine position $ith elevation o head o the !ed

or le t sided position during sleep are pre erred -re)uent small6volume meals and thickening o

ood $ith rice gruel lder children& no evidence o any speci7c

change in ood to reduce refux !esity& large6volume meals& and late eating have

!een associated $ith symptoms o GERD


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(edical 9herapy ./ receptor antagonists have !een used

since F0s to provide symptomatic relie 9oday PP*s are tx o choice

3hildren on long6term PP* or GERD havehigher risk o acute gastroenteritis andcommunity ac)uired pneumonia

e$ promising therapy option + inhi!itiono 95ESR !y G4B4 B agonists "ex:!aclo en#

.as sho$n signi7cant reduction in 95ESR andrefux in !oth adults and children


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Surgical 9herapy 5ap undoplication is tx o choice (ost commonly used procedure is

issen techni)ue $ith ;@0degree$rap

Essential element is to mo!ili


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5aparoscopic issen


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Results o surgery H# 95ESR reduced to 01 o

preoperative state /# Rate o 95ESR accompanied !y

refux reduced rom ?F1 to HF1 ;# (ean residual pressure at GE ,xn

during s$allo$ing6induced relaxationincreased rom 0 F mm .g to @ mm.g $hile !asal 5ES Pressure nota'ected


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Results -undoplication $ith a foppy $rap is a po$er ul

means o controlling refux in appropriatelyselected children in $hom medical treatment ails&or in symptomatic refuxers $ith speci7ccomor!idities

5ap vs open: R39s in adult patients have sho$nsigni7cantly lo$er operative mor!idity& shorterpostop stay& and less prolonged sick leave ollo$ing

laparoscopic approach Randomi


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3omplications (ost common: $rap herniation

"H ;1# Reoperation rate / F1 (ortality rate 0 0I1 Persistent dysphagia is related to

tightness o $rap *n childhood& recurrent GERD is most

common pro!lem a terundoplication

gerd - peds surg lecture

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