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Anti-reflux surgery - children

Fundoplication - children; Nissen fundoplication - children; Belsey (Mark IV) fundoplication - children; Toupet fundoplication - children; Thal fundoplication - children; Hiatal hernia repair - children; Endoluminal fundoplication - children

Anti-reflux surgery is surgery to tighten the muscles at the bottom of the esophagus (the tube that carries food from the mouth to the stomach). Problems with these muscles can lead to gastroesophageal reflux disease (GERD).

This surgery can also be done during a hiatal hernia repair.

This article discusses anti-reflux surgery repair in children.

Description

The most common type of anti-reflux surgery is called fundoplication. This surgery most often takes 2 to 3 hours.

Your child will be given general anesthesia before the surgery. That means the child will be asleep and unable to feel pain during the procedure.

The surgeon will use stitches to wrap the upper part of your child's stomach around the end of the esophagus. This helps prevent stomach acid and food from flowing back up.

A gastrostomy tube (g-tube) may be put in place if your child has had swallowing or feeding problems. This tube helps with feeding and releases air from your child's stomach.

Another surgery, called pyloroplasty may also be done. This surgery widens the opening between the stomach and small intestine so the stomach can empty faster.

This surgery may be done several ways, including:

  • Open repair: The surgeon will make a large cut in the child's belly area (abdomen).
  • Laparoscopic repair: The surgeon will make 3 to 5 small cuts in the belly. A thin, hollow tube with a tiny camera on the end (a laparoscope) is placed through one of these cuts. Other tools are passed through the other surgical cuts.

The surgeon may need to switch to an open procedure if there is bleeding, a lot of scar tissue from earlier surgeries, or if the child is very overweight.

Endoluminal fundoplication is similar to a laparoscopic repair, but the surgeon reaches the stomach by going through the mouth. Small clips are used to tighten the connection between the stomach and esophagus.

Why the Procedure Is Performed

Anti-reflux surgery is usually done to treat GERD in children only after medicines have not worked or complications develop. Your child's health care provider may suggest anti-reflux surgery when:

  • Your child has symptoms of heartburn that get better with medicines, but you do not want your child to continue taking these medicines.
  • Symptoms of heartburn are burning in their stomach, throat, or chest, burping or gas bubbles, or problems swallowing food or fluids.
  • Part of your child's stomach is getting stuck in the chest or is twisting around itself.
  • Your child has a narrowing of the esophagus (called stricture) or bleeding in the esophagus
  • Your child is not growing well or is failing to thrive.
  • Your child has a lung infection caused by breathing contents of the stomach into the lungs (called aspiration pneumonia)
  • GERD causes a chronic cough or hoarseness in your child.

Risks

Risks for any surgery include:

  • Bleeding
  • Infection

Risks for anesthesia include:

Anti-reflux surgery risks include:

  • Damage to the stomach, esophagus, liver, or small intestine. This is very rare.
  • Gas and bloating that makes it hard to burp or throw up. Most of the time, these symptoms slowly get better.
  • Gagging.
  • Painful, difficult swallowing, called dysphagia. For most children, this goes away in the first 3 months after surgery.
  • Rarely, breathing or lung problems, such as a collapsed lung.

Before the Procedure

Always make sure your child's health care team knows about all the medicines and supplements your child is taking, including those you bought without a prescription.

A week before surgery, you may be asked to stop giving your child products that affect blood clotting. This may include aspirin, ibuprofen (Advil, Motrin), vitamin E, and warfarin (Coumadin).

You will be told when to arrive at the hospital.

  • The child should not eat or drink anything after midnight before surgery.
  • You child may take a bath or shower the night before or the morning of surgery.
  • On the day of surgery, the child should take any medicine that the provider said to take with a small sip of water.

After the Procedure

How long your child stays in the hospital depends on how the surgery was done.

  • Children who have laparoscopic anti-reflux surgery usually stay in the hospital for 2 to 3 days.
  • Children who have open surgery may spend 2 to 6 days in the hospital.

Your child can start eating again about 1 to 2 days after surgery. Liquids are usually given first.

Some children have a g-tube placed during surgery. This tube can be used for liquid feedings, or to release gas from the stomach.

If your child did not have a g-tube placed, a tube may be inserted through the nose to the stomach to help release gas. This tube is removed once your child starts eating again.

Your child will be able to go home once they are eating food, have had a bowel movement and are feeling better.

Outlook (Prognosis)

Heartburn and related symptoms should improve after anti-reflux surgery. However, your child may still need to take medicines for heartburn after surgery.

Some children will need another operation in the future to treat new reflux symptoms or swallowing problems. This may happen if the stomach was wrapped around the esophagus too tightly or it loosens.

The surgery may not be successful if the repair was too loose.

References

Kane TD1, Brown MF, Chen MK; Members of the APSA New Technology Committee.Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association. J Pediatr Surg. 2009 May;44(5):1034-40. PMID: 19433194 www.ncbi.nlm.nih.gov/pubmed/19433194.

Khan S, Orenstein S. Gastroesophageal reflux disease. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 315.

Petersen RP, Pellegrini CA Oelschlager BK.. Hiatal Hernia and Gastroesophageal Reflux Disease. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 44.

    • Prepare for your child's hernia surgery

      Animation

    •  

      Prepare for your child's hernia surgery - Animation

      Whenever your child is going in for surgery, it's a big deal for parents and for the child also. I'm Dr. Alan Greene and I'd like to discuss with you how to prepare your child, how to get ready for hernia surgery. The good news is that when the surgery is done you get instant results. Right away the problem's been fixed. And there are just a few steps to take to make the process go as smoothly as possible. Perhaps the first thing is preparing yourself because if you're feeling confident and good about the surgery, then everything will go much easier for you and for your child. And that means getting your questions answered beforehand. And in particular, the question I hear the most from parents is concern about the anesthesia. And that comes often from anesthesia risks that happened back when we were children. Anesthesia was much more dangerous than it is today. The problem was there weren't ways to monitor whether kids were getting enough oxygen to the brain or not. But since those monitors were developed about 20 years or so ago now, anesthesia has become incredibly safe - in fact, often safer than driving to the hospital. Now there other things that are important to do to prepare. First is to remember to take notice if your doctor has ordered any lab tests before the surgery. Perhaps blood tests, perhaps urine tests, maybe nothing was needed. But if it was, you want to make sure you've gotten it done before you end up going to the hospital. The second thing are instructions should've been given to you about when is the last time your child could eat or drink before heading to the hospital. Often it'll be midnight the night before, but whatever you were told be sure to take note of that and really don't cheat on this one. Nothing after what they say. And that leads to point number 3. Whatever medications that your child is taking, prescribed medicines, over-the-counter medicines, need to be taken into account. So, make sure you discuss with your physician, your anesthesiologist or the surgeon beforehand whatever medicines your child is taking and whether they should be taken or skipped after that deadline for food and drink. Next thing that's important, number 4, is to help your child select a favorite toy or stuffed animal, action figure to bring with them to the hospital. This little dog here or something that's comforting for them to have with them along the way. And it's a great idea before the whole thing depending on the age and temperament of your child to act out the whole scenario using their favorite toy. So, for instance, this little dog is not feeling well, hasn't been feeling well for awhile, has to take lots of medications, but the doctors are going to be able to fix it. Can't eat or drink anything after midnight - every step of it you go through. They're a little bit scared and they find out everything is fine and it worked out great and they get some ice cream afterwards and the problem is all gone. But to work it through with them so they get the story and it also helps you feel more prepared. I also suggest giving children something specific and fun to look forward to shortly after the surgery. It might be something as simple as a trip to the movies together or a trip to get ice cream but something that they can focus on. Take the focus a little bit off the surgery itself. Not a bad thing for you too. Then a couple of practical things. I do suggest that before going in you take off any jewelry that the child has, you bathe them, you get rid of even earrings that may stay in all the time or hair clips that may, you don't really want those at the hospital. And it's good to choose comfortable clothes when you go to the hospital, things that are easy on, easy off. It's not a fashion show. Although you may want some pictures of this cause it is a kind of historic moment. And lastly, if your child does develop any kind of fever or rash or cold beforehand, make sure to give them a call and let the folks know what's going on cause it may mean the surgery should be postponed. But the good news is that this kind of minor surgery today in children is extraordinarily safe and when it's done for the right child at the right time really helps move them ahead, move the family ahead. Most parents are really glad afterwards that the surgery has been done.

    • Prepare for your child's hernia surgery

      Animation

    •  

      Prepare for your child's hernia surgery - Animation

      Whenever your child is going in for surgery, it's a big deal for parents and for the child also. I'm Dr. Alan Greene and I'd like to discuss with you how to prepare your child, how to get ready for hernia surgery. The good news is that when the surgery is done you get instant results. Right away the problem's been fixed. And there are just a few steps to take to make the process go as smoothly as possible. Perhaps the first thing is preparing yourself because if you're feeling confident and good about the surgery, then everything will go much easier for you and for your child. And that means getting your questions answered beforehand. And in particular, the question I hear the most from parents is concern about the anesthesia. And that comes often from anesthesia risks that happened back when we were children. Anesthesia was much more dangerous than it is today. The problem was there weren't ways to monitor whether kids were getting enough oxygen to the brain or not. But since those monitors were developed about 20 years or so ago now, anesthesia has become incredibly safe - in fact, often safer than driving to the hospital. Now there other things that are important to do to prepare. First is to remember to take notice if your doctor has ordered any lab tests before the surgery. Perhaps blood tests, perhaps urine tests, maybe nothing was needed. But if it was, you want to make sure you've gotten it done before you end up going to the hospital. The second thing are instructions should've been given to you about when is the last time your child could eat or drink before heading to the hospital. Often it'll be midnight the night before, but whatever you were told be sure to take note of that and really don't cheat on this one. Nothing after what they say. And that leads to point number 3. Whatever medications that your child is taking, prescribed medicines, over-the-counter medicines, need to be taken into account. So, make sure you discuss with your physician, your anesthesiologist or the surgeon beforehand whatever medicines your child is taking and whether they should be taken or skipped after that deadline for food and drink. Next thing that's important, number 4, is to help your child select a favorite toy or stuffed animal, action figure to bring with them to the hospital. This little dog here or something that's comforting for them to have with them along the way. And it's a great idea before the whole thing depending on the age and temperament of your child to act out the whole scenario using their favorite toy. So, for instance, this little dog is not feeling well, hasn't been feeling well for awhile, has to take lots of medications, but the doctors are going to be able to fix it. Can't eat or drink anything after midnight - every step of it you go through. They're a little bit scared and they find out everything is fine and it worked out great and they get some ice cream afterwards and the problem is all gone. But to work it through with them so they get the story and it also helps you feel more prepared. I also suggest giving children something specific and fun to look forward to shortly after the surgery. It might be something as simple as a trip to the movies together or a trip to get ice cream but something that they can focus on. Take the focus a little bit off the surgery itself. Not a bad thing for you too. Then a couple of practical things. I do suggest that before going in you take off any jewelry that the child has, you bathe them, you get rid of even earrings that may stay in all the time or hair clips that may, you don't really want those at the hospital. And it's good to choose comfortable clothes when you go to the hospital, things that are easy on, easy off. It's not a fashion show. Although you may want some pictures of this cause it is a kind of historic moment. And lastly, if your child does develop any kind of fever or rash or cold beforehand, make sure to give them a call and let the folks know what's going on cause it may mean the surgery should be postponed. But the good news is that this kind of minor surgery today in children is extraordinarily safe and when it's done for the right child at the right time really helps move them ahead, move the family ahead. Most parents are really glad afterwards that the surgery has been done.

      A Closer Look

       

      Review Date: 2/5/2015

      Reviewed By: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of pediatrics, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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