ABSTRACT
La reaparición de síntomas de reflujo gastroesofágico (RGE) después de realizarse una funduplicatura es un grave problema, ya que la sintomatología es refractaria al tratamiento médico y es necesario efectuar una segunda operación antirreflujo en condiciones técnicas más difíciles. Se han identificado diferentes factores que contribuyen al fallo de este tipo de intervenciones en el niño. Presentamos ocho pacientes en los cuales realizarnos una segunda técnica antirreflujo después del fallo de la técnica inicial, sobre una serie total de 96 pacientes intervenidos por reflujo gastroesofágico. En cuatro casos la primera intervención fue realizada en nuestro servicio. Seis pacientes tenían lesiones o déficit neurológico, seis padecían patología respiratoria crónica y dos casos presentaban atresia de esófago. Los síntomas principales fueron recurrencia del vómito (n = 8) y aspiración (n = 4). La reaparición del reflujo se confirmó mediante esofagograma y endoscopia. Los hallazgos operatorios fueron: rotura del manguito de la funduplicatura en dos casos, rotura del manguito asociado a hernia hiatal en cinco casos, rotura del manguito asociado a hernia paraesofágica en dos casos y hernia paraesofágica con manguito normal en uno. Se efectuó una segunda funduplicatura de Nissen en cinco pacientes, y en tres niños en los que se consideró que tenían un 'esófago corto', realizamos una gastroplastia de Collis-Nissen. En seis casos la evolución clínica ha sido satisfactoria; un paciente presenta una disfagia severa y otro recurrencia de los vómitos. En nuestra experiencia, los pacientes con enfermedad por reflujo gastroesofágico recurrente, precisan una técnica antirreflujo adaptada de forma específica a sus alteraciones anatómicas o funcionales (AU)
Subject(s)
Child , Child, Preschool , Male , Infant , Female , Humans , Treatment Failure , Reoperation , Gastroesophageal RefluxABSTRACT
Recurrent gastroesophageal reflux following fundoplication is a challenging problem, because it is usually refractory to medical treatment and a second, technically difficult, antireflux operation is required. Different factors that may contribute to surgery failure have been identified in children. We present 8 cases who underwent redofundoplication after failed procedures, from a total number of 96 patients operated on due to gastroesophageal reflux. Four patient's had their initial fundoplication performed at our institution. Six patients were neurologically impaired, six had chronic pulmonary disease, and two had esophageal atresia. The main presenting symptoms were recurrent vomiting (n = 8) and aspiration (n = 4). Gastroesophageal reflux was confirmed by barium swallow and endoscopy. Operative findings showed wrap breakdown in two cases, warp breakdown associated with hiatal hernia in five, wrap breakdown associated with paraesophageal hernia in two cases, and paraesophageal hernia with normal wrap in one. A second Nissen procedure were performed in five cases, whereas a Collis-Nissen gastroplasty was realized in three with a short esophagus. Six patients had a successful outcome remaining symptom free, one has severe disphagia, and one has recurrent vomiting. In our experience, patients with recurrent gastroesophageal reflux disease should undergo an antireflux procedure tailored to specific anatomic or functional abnormalities.
Subject(s)
Gastroesophageal Reflux/surgery , Child , Child, Preschool , Female , Humans , Infant , Male , Reoperation , Treatment FailureABSTRACT
Incidence of pediatric laryngeal stenosis has increased due to better Intensive Care Units. The medical records of the patients with laryngeal stenosis treated in the hospital between 1990 and 1995 were reviewed, analyzing the type of lesion, ethiologic factors, surgical technique employed and post-op result. The surgical technique was chosen conditioned by the age, weight of the patient, grade of the stenosis according to Cotton's classification and presence or absence of respiratory distress. 48 patients had laryngeal stenosis. 2 of them had acute glottic edema (4%) and 45 subglottic stenosis (96%), most of them after long term endotracheal intubation, 34 cases (75.5%). 19 of these occurred in the neonatal period. 7 cases (15.5%) were congenital stenosis (2 subglottic membranes, 1 subglottic cyst and 4 true congenital subglottic stenosis). 5 cases were a miscelanea. We found 13 grade I cases (29%), grade II 16 cases (35%) and grade III 12 (27%). No grade IV were seen. 8 patients (18%) had gastro-esophageal reflux, 5 of them required Nissen's funduplication before airway surgery. 12 patients followed medical treatment (27%), all of them grades I and II, with good results. Endoscopic treatment was done in 6 patients (13%), with good results in all but one that required a surgical approach. The anterior cricothiroid split was done in 7 patients (15%), all of them under 5 months of age. Good results were obtained in 71.4 percent of the patients. 9 cases (20%) underwent an anterior largingotracheoplasty with costal cartilage graft with good results in 88.9 percent of the patients. Anterior and posterior cartilage graft after double laringotracheoplasty was done to 8 patients (18%). One of them developed a subglottic sinequiae which was solved endoscopically, and another patient evolved to restenosis. 20 patients had a tracheostomy. All but four were decanulated in 11.7 +/- 12.3 (4-54) weeks. Mortality rate associated with the surgical technique has been zero, with excellent results in 82.5 percent of the series. The new surgical techniques developed in recent years for laringotracheal stenosis in childhood have made unnecessary the use of permanent tracheostomies in these children which have obvious inconvenient and potentially lethal complications.
