Gastroesophageal reflux in children.

Whereas all of these surgical modifications and new approaches are somewhat preliminary and have yet to achieve widespread clinical application, they illustrate an awareness of shortcomings in the present operative management of reflux as well as a gradual disenchantment with complications seen in many children, especially the neurologically impaired. However, the final analysis of surgical treatment for these children should not be viewed in an overly pessimistic light. Strategies for management of gastroesophageal reflux remain multifaceted, and operative intervention has a laudable role in the relief of symptoms for many afflicted children. However, the child's presentation and symptomatology should be predominant in planning therapy, operative or otherwise. It is the goal of this review to point out several points in this respect: 1. The diagnosis of gastroesophageal reflux may be difficult to pinpoint. 2. Multiple tests for reflux may offer conflicting results. 3. Clinical presentations associated with reflux do respond to treatment, which may include operative intervention. 4. The risks of anti-reflux procedures are greater than have been previously recognized, especially in the chronically ill and neurologically impaired child. 5. New approaches offer some promise to lower the risks of complications inherent in operative treatment of pathologic gastroesophageal reflux. 6. The best management plan for surgical treatment of reflux in children is evolving with less of a conviction for "prophylactic" fundoplication procedures, especially in the neurologically impaired child, and there is a recognition that underlying motility disorders may require modification of the operative approach or even the decision to operate. It is only through an awareness of the significant benefits as well as the considerable risks of operative treatment that the contemporary surgeon can best serve the interests of a child with gastroesophageal reflux. It is hoped that these guidelines will be helpful in this regard.