Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center.

Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.

Total gastric transposition is better than partial gastric tube esophagoplasty for esophageal replacement in children.

Whenever the surgeon uses the stomach as an esophageal substitute, either one of two techniques is generally performed: total gastric transposition or gastric tube esophagoplasty. No existing reports compare the complications associated with these two surgical procedures. The purpose of this study is to review the authors' experience with total gastric transposition and verify whether this technique is superior to gastric tube esophagoplasty in children by comparing the main complications with those reported in the publications of gastric tubes esophagoplasties in the English language literature published in the last 38 years. A total of 35 children underwent total gastric transposition according to the classical technique. Most of these patients (27, or 77.1%) had long gap esophageal atresia. The most frequently observed complications were compared to those reported in nine studies of gastric tube esophagoplasty comprising 184 patients. Mortality and graft failure rates were also compared. Seven patients (20.0%) presented with leaks, all of which closed spontaneously. Six children were reoperated, three experienced gastric outlet obstruction secondary to axial torsion of the stomach placed in the retrosternal space and the other three experienced delayed gastric emptying that required revision of the piloroplasty. There were two deaths (5.7%) and no graft failure. Strictures were observed in five patients (14.2%) and all of these were resolved with endoscopic dilatations. Six patients had diarrhea that spontaneously resolved. In the late follow-up period, all patients were on full feed and thriving well. The comparisons with gastric tube patients demonstrated that the total gastric transposition group presented with significantly less leaks and strictures (P = 0.0001 and 0.001, respectively). The incidence of death and graft failure was not statistically different. In conclusion, gastric transposition is as a simple technical procedure for esophageal replacement in children with satisfactory results, and is superior to gastric tube esophagoplasty.

Compressöes do esôfago e da traquéia por anomalias do arco aórtico na infância / Compression of esophagus and trachea by aortic arch anomalies in childhood

De fevereiro de 1985 a novembro de 1992, 14 crianças portadoras de malformaçöes do arco aórtico foram atendias no Serviço de Cirurgia Pediátrica do Instituto da Criança da Faculdade de Medicina da Universidade de Säo Paulo, compreendendo sete pacientes portadores de artéria subclávia direita anômala, quatro portadores de duplo arco aórtico e três portadores de arco aórtico à direita com presença de ligamento arterioso O diagnóstico preciso da malformaçäo foi feito apenas através de esofagograma e traqueobroncoscopia. O tratamento cirúrgico foi realizado através de toracotomia póstero-lateral esquerda em todos os casos, a qual proporcionou uma excelente exposiçäo das anomalias. Näo houve óbito intra-operatório. Ocorreram três óbitos no pós-operatório tardio, decorrentes de lesöes pulmonares crônicas (2) e traqueomalácia grave (1), que se tornou sintomática apenas após a correçäo cirúrgica da anomalia. As principais complicaçöes ocorridas estäo diretamente relacionadas à demora no diagnóstico das malformaçöes. Os autores concluem que a existência dessa anomalias deve ser sempre suspeitada em crianças com sintomas respiratórios de origem indeterminada, sendo o diagnóstico feito de forma simples, basicamente através do esofagograma e da traqueoscopia