Does retching matter? Reviewing the evidence-Physiology and forces

Area of Science:

• Pediatric Surgery
• Gastroenterology
• Biomechanical Analysis

Background:

• Antireflux surgery failure is common in children with neurodisability, often presenting as persistent retching.
• Anatomical disruption of the fundoplication wrap is a frequent cause of failure.
• Previous theories attributed wrap failure to reduced gastric capacity or compliance.

Purpose of the Study:

• To review and analyze the forces acting on the fundoplication wrap during potential stressing episodes.
• To determine the primary biomechanical cause of wrap disruption in pediatric antireflux surgery.

Main Methods:

• Review of biomechanical forces generated during common events in children with neurodisability.
• Analysis of historical and current clinical evidence linking specific forces to wrap failure.
• Evaluation of the efficacy of gastric emptying procedures in preventing wrap disruption.

Main Results:

• Postoperative pressure changes from reduced gastric capacity are insufficient to cause wrap disruption.
• Diaphragmatic stressor events are associated with wrap breakdown, but are not the primary cause.
• The greatest forces causing fundoplication wrap failure are generated during retching and vomiting.

Conclusions:

• Retching and vomiting produce forces sufficient to cause wrap herniation and separation.
• Addressing retching and vomiting is essential for reducing antireflux surgery failure rates in neurodisabled children.
• Gastric emptying procedures lack evidence of benefit and do not address the primary cause of wrap failure.