Postfundoplication Complications in Children

The optimal "treatment" of postfundoplication complications is preoperative prevention of them. Nonreflux causes of the symptom prompting surgery should be carefully eliminated preoperatively. Failure to respond to optimal powerful antireflux pharmacotherapy suggests that GERD was not the cause of symptoms. Neurologic or respiratory disease, delayed gastric emptying or retching, short esophagus, and esophageal dysmotility may predispose patients to complications, and may require careful tailoring of the fundoplication. The optimal antireflux surgery, with a wrap neither too loose nor too tight, may require a nadir lower esophageal sphincter pressure of more than 5 mm Hg to prevent reflux, but less than some value to prevent dysphagia. This latter value may be approximately 10 mm Hg, but depends on swallowing parameters such as peristaltic pressure, lower esophageal sphincter opening diameter, swallowed bolus diameter, and other considerations. Infants may require a gastrostomy tube for venting because of their lower gastric compliance to deal with swallowed air. Children with delayed gastric emptying may benefit from pyloroplasty, but this is debated. When complications occur, re-evaluate the diagnosis and the competence of the fundoplication with barium fluoroscopy, endoscopy with histology, pH probe, and other modalities as indicated. Initially try conservative management of the patient's complications, including dietary and feeding modifications. Give a trial of antireflux pharmacotherapy for recurrent reflux or pharmacotherapy directed at the specific side-effect of the fundoplication if one is present. Consider endoscopically dilating a persistently tight wrap or surgically revising the fundoplication if it is suggested by the evaluation.