Fundoplication is a surgical procedure commonly performed in pediatric patients to treat severe
gastroesophageal reflux disease (GERD). GERD occurs when stomach acid frequently flows back into the esophagus, causing irritation and symptoms like heartburn, vomiting, and difficulty swallowing. Fundoplication involves wrapping the top part of the stomach around the lower esophagus to strengthen the valve between the esophagus and stomach, thereby preventing reflux.
Fundoplication is generally recommended for children who have not responded to medical treatments such as
proton pump inhibitors or H2 blockers, and who experience complications from GERD such as:
- Recurrent pneumonia: Due to aspiration of stomach contents.
- Failure to thrive: Inability to gain weight due to chronic vomiting.
- Severe esophagitis: Inflammation and damage to the esophagus.
- Barrett’s esophagus: A precancerous condition.
- Apnea or respiratory issues: Related to reflux.
Types of Fundoplication
The most common type of fundoplication performed in children is the
Nissen fundoplication, where the stomach is wrapped 360 degrees around the esophagus. Other variations include:
- Toupet fundoplication: A partial wrap (270 degrees) which is less tight.
- Dor fundoplication: An anterior 180-200 degree wrap.
These variations are chosen based on the specific needs and conditions of the patient.
Preoperative Evaluation
Before performing a fundoplication, several diagnostic tests are usually conducted to confirm the diagnosis of GERD and assess the anatomy and function of the esophagus and stomach. These tests include:
- Upper gastrointestinal series (UGI)
- Esophageal pH monitoring
- Esophageal manometry
- Endoscopy
Additionally, a thorough medical history and physical examination are essential to rule out other possible causes of the symptoms.
Surgical Procedure
Fundoplication can be performed as an open surgery or using a
laparoscopic approach. The laparoscopic approach is preferred due to its minimally invasive nature, which leads to faster recovery and less postoperative pain.
- Anesthesia: General anesthesia is administered.
- Incision: Small incisions are made for laparoscopic instruments.
- Wrapping: The upper part of the stomach (fundus) is wrapped around the lower esophagus.
- Securing: The wrap is secured with sutures to maintain its position.
The entire procedure typically takes 1-2 hours.
Postoperative Care
After surgery, children are usually monitored in the hospital for a few days to ensure there are no complications. Key aspects of postoperative care include:
- Pain management: Medications are given to manage pain.
- Feeding: Initially, children may be given clear liquids, gradually advancing to solid foods as tolerated.
- Monitoring for complications: Watch for signs of infection, difficulty swallowing, or gas-bloat syndrome.
Follow-up appointments are crucial to assess recovery and ensure the effectiveness of the surgery.
Potential Complications
While fundoplication is generally safe, it can have complications, including:
- Dysphagia: Difficulty swallowing due to a tight wrap.
- Gas-bloat syndrome: Inability to burp, leading to bloating and discomfort.
- Wrap slippage: The wrap may become loose over time.
- Esophageal perforation: A rare but serious complication.
Most complications can be managed with medical or surgical interventions.
Outcomes and Prognosis
The majority of children who undergo fundoplication experience significant improvement in GERD symptoms and quality of life. Long-term outcomes are generally favorable, with many children being able to reduce or discontinue their GERD medications. However, some children may require additional treatments or surgeries if complications arise or symptoms recur.
Conclusion
Fundoplication is a valuable surgical option for pediatric patients with severe GERD unresponsive to medical therapy. With careful preoperative evaluation, skilled surgical technique, and diligent postoperative care, most children achieve excellent outcomes and relief from their symptoms. As always, a multidisciplinary approach involving pediatricians, gastroenterologists, and surgeons is essential for optimal patient care.
