Esposito Ciro, Langer Jacob C, Schaarschmidt Klaus, Mattioli Girolamo, Sauer Carolien, Centonze Antonella, Cigliano Bruno, Settimi Alessandro, Jasonni Vincenzo
Paediatric Surgery, "Magna Graecia" University, Catanzaro, Italy.
J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):349-51. doi: 10.1097/01.mpg.0000151761.43664.b2.
The validity of open fundoplication after esophageal atresia (EA) repair is still disputed. The authors have retrospectively evaluated the results achieved in their centers using laparoscopic antireflux procedures (LARP) in children operated for EA at birth.
From 1998 to 2002, 350 children underwent LARP. Of these, 21 (6%) underwent EA repair at birth. Our study focused only on the management of these 21 patients; 5 of them (23.8%) were neurologically impaired children (NIC). All underwent LARP, 9 patients according to Nissen, 9 according to Thal, and 3 according to Toupet. The 5 NIC with feeding problems underwent concomitant g-tube placement during the same procedure.
All the procedures were completed in laparoscopy, without intraoperative complications. The mean operative time was 65 minutes (range 45-140). We had no mortality in our series. Hospital stay varied from 2 to 9 days (median 3 days). At a maximum follow-up of 6 years, all patients were evaluated with a 24-hours pH-metry and barium swallow. The 16 neurologically normal children were free of symptoms at the last follow-up; five of them (31.2%) had mild dysphagia, which disappeared spontaneously within 3-6 months. One girl experienced an important episode of aspiration 2 years after the LARP, although there was no evidence of reflux at the follow-up examinations. As for the 5 NIC, one patient eats only through a g-tube, the other 4 undergo mixed feeding (g-tube and mouth); none have signs of GER, but two of them still present respiratory symptoms, and one has delayed gastric emptying.
In our experience laparoscopic antireflux surgery is an appropriate treatment of GER in children operated for EA at birth, independently of the antireflux mechanism adopted; the 31.2% rate of short-term dysphagia presenting as residual respiratory symptoms may be due to a primary dysmotility of the esophagus consequent to the esophageal atresia.
食管闭锁（EA）修复术后开放型胃底折叠术的有效性仍存在争议。作者回顾性评估了他们中心对出生时接受EA手术的儿童采用腹腔镜抗反流手术（LARP）所取得的结果。
1998年至2002年，350名儿童接受了LARP。其中，21名（6%）在出生时接受了EA修复术。我们的研究仅聚焦于这21例患者的治疗；其中5名（23.8%）为神经功能受损儿童（NIC）。所有患者均接受了LARP，9例采用Nissen术式，9例采用Thal术式，3例采用Toupet术式。5名有喂养问题的NIC在同一手术过程中同时进行了胃造瘘管置入。
所有手术均在腹腔镜下完成，无术中并发症。平均手术时间为65分钟（范围45 - 140分钟）。我们的系列研究中无死亡病例。住院时间为2至9天（中位数3天）。在最长6年的随访中，所有患者均接受了24小时食管pH值监测和吞钡检查。16名神经功能正常的儿童在最后一次随访时无症状；其中5名（31.2%）有轻度吞咽困难，在3 - 6个月内自行消失。一名女孩在LARP术后2年发生了一次严重的误吸事件，尽管在随访检查中没有反流的证据。至于5名NIC，1例仅通过胃造瘘管进食，另外4例采用混合喂养（胃造瘘管和经口）；均无胃食管反流（GER）迹象，但其中2例仍有呼吸道症状，1例有胃排空延迟。
根据我们的经验，腹腔镜抗反流手术是出生时接受EA手术的儿童GER的合适治疗方法，与所采用的抗反流机制无关；作为残留呼吸道症状出现的31.2%的短期吞咽困难发生率可能是由于食管闭锁导致的原发性食管运动障碍。
