Thompson L D, McElhinney D B, Jue K L, Hodge D
Division of Cardiothoracic Surgery, Valley Children's Hospital, Fresno, CA, USA.
J Pediatr Surg. 1999 Sep;34(9):1359-63. doi: 10.1016/s0022-3468(99)90011-8.
Gastroesophageal reflux and dysmotility are common in children with trisomy 21. Children with trisomy 21 and congenital heart disease are at increased risk for complications of gastroesophageal reflux even after repair of their cardiac abnormalities. The optimal management of reflux in these patients is not known.
The authors studied 24 consecutive infants (5.3+/-3.1 months) with trisomy 21 and atrioventricular septal defect who had symptoms or signs of gastroesophageal reflux and a positive esophageal pH study finding early after repair of their cardiac anomaly. Ten patients were given standardized medical therapy with upright positioning during and after feedings, thickening of feedings, metoclopramide, and an H2-receptor antagonist. The other 14 underwent primary surgical management consisting of Nissen fundoplication through a minilaparotomy.
All 10 medically treated patients required readmission within 2 weeks for complications related to reflux, including aspiration or pneumonia (n = 6), persistent failure to thrive (n = 2), and frequent apneic episodes (n = 2). No surgically treated patients had reflux-related complications requiring readmission. The total duration of hospitalization in the medically treated patients, including the initial hospitalization and the rehospitalization, was significantly longer than in patients who underwent fundoplication (35.8+/-9.8 v. 10.4+/-2.2 days, P<.001). At follow-up (24 to 56 months), all patients were alive except for 1 medically treated patient who died of aspiration pneumonia 28 days after readmission. Two medically treated patients required a Nissen, and 3 patients in the surgical group underwent redo fundoplication, all within 1 year. Three other patients in the medically treated group required a total of 8 hospitalizations for complications of reflux. No patient in either group required placement of a gastrostomy tube. Weight percentile for age was higher in surgical than medical patients.
Infants with trisomy 21 and atrioventricular septal defect who undergo fundoplication are less likely to experience major complications of reflux early after cardiac surgery than those treated with a medical regimen of upright posture, thickened feedings, metoclopramide, and H2-receptor blockade.
胃食管反流和动力障碍在21三体综合征患儿中很常见。患有21三体综合征和先天性心脏病的患儿，即使在心脏异常修复后，发生胃食管反流并发症的风险也会增加。这些患者反流的最佳治疗方法尚不清楚。
作者研究了24例连续的婴儿（5.3±3.1个月），他们患有21三体综合征和房室间隔缺损，在心脏畸形修复后早期有胃食管反流的症状或体征，且食管pH值研究结果呈阳性。10例患者接受了标准化药物治疗，包括喂食期间和之后保持直立姿势、喂食增稠、使用甲氧氯普胺和一种H2受体拮抗剂。另外14例接受了主要手术治疗，即通过小切口剖腹术进行nissen胃底折叠术。
所有10例接受药物治疗的患者在2周内均因与反流相关的并发症再次入院，包括误吸或肺炎（6例）、持续生长发育不良（2例）和频繁呼吸暂停发作（2例）。没有接受手术治疗的患者因反流相关并发症需要再次入院。接受药物治疗的患者的总住院时间，包括初次住院和再次住院，明显长于接受胃底折叠术的患者（35.8±9.8天对10.4±2.2天，P<0.001）。在随访（24至56个月）时，除1例接受药物治疗的患者在再次入院28天后死于误吸性肺炎外，所有患者均存活。2例接受药物治疗的患者需要进行nissen手术，手术组有3例患者在1年内进行了再次胃底折叠术。药物治疗组的另外3例患者因反流并发症共住院8次。两组均无患者需要放置胃造瘘管。手术患者的年龄体重百分位数高于药物治疗患者。
与采用直立姿势、喂食增稠、甲氧氯普胺和H2受体阻滞剂的药物治疗方案相比，接受胃底折叠术治疗的患有21三体综合征和房室间隔缺损的婴儿在心脏手术后早期发生反流主要并发症的可能性较小。
