Gastroesophageal reflux in childhood. The dilemma of surgical success.

Successful surgical correction of gastroesophageal reflux has prompted frequent and early referral of children for antireflux surgery. This report describes the results and defines the complications in a series of children treated surgically for gastroesophageal reflux. Methods are suggested to reduce the occurrence of these postoperative complications. In five years (1977-1981), 117 children, 3 weeks to 16 years old, were operated on for gastroesophageal reflux at The Oklahoma Childrens Memorial Hospital. Nissen fundoplication was performed on 111 of them. Patients have been followed for 3 months to five years. At most recent examination, clinical success (remission of symptoms) has been accomplished in 81 of 92 patients (90%). In 86 patients evaluated radiographically, gastroesophageal reflux was absent in 83 and persistent in 3. There were no operative deaths. Twenty-three major complications occurred in 21 patients, 13 of whom required reoperation. These major complications were paraesophageal hiatal hernia (ten patients), small bowel obstruction (eight patients), and wrap malalignment (5 patients). Observations of and reoperation on these children suggests the following necessary steps for avoidance of complications in children: (1) Nissen fundoplication in childhood should be accompanied by an accurate multi-suture crural repair and by suture fixation of the fundal wrap to the crura and to the abdominal surface of the diaphragm; (2) appropriate alignment of the fundal wrap and of the crural repair is best accomplished with a large indwelling esophageal bougie of sufficient size to efface and blanche the esophageal musculature; and (3) appropriate care in avoiding small bowel obstruction mandates meticulous avoidance of trauma to the liver capsule and small bowel serosa.