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Gastro-oesophageal reflux and intestinal malrotation in children
D Kumar1, R J Brereton, L Spitz
1Department of Surgery, Hospital for Sick Children, London, UK.
Insights
A high incidence of intestinal malrotation was found in children undergoing Nissen fundoplication for gastro-oesophageal reflux. This association requires awareness for accurate pre-operative diagnosis and treatment, often needing combined surgical procedures.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Congenital Abnormalities
Background:
- Persistent gastro-oesophageal reflux in children often requires surgical intervention, such as Nissen fundoplication.
- Intestinal malrotation is a congenital condition that can present with various gastrointestinal symptoms.
- The co-occurrence of gastro-oesophageal reflux and intestinal malrotation in pediatric patients is not widely emphasized.
Purpose of the Study:
- To investigate the incidence of intestinal malrotation in children undergoing Nissen fundoplication for refractory gastro-oesophageal reflux.
- To highlight the importance of recognizing the association between these two conditions for improved clinical management.
- To evaluate the diagnostic utility of barium radiology in detecting intestinal malrotation pre-operatively.
Main Methods:
- Retrospective analysis of 74 children who underwent Nissen fundoplication for persistent gastro-oesophageal reflux.
- Review of pre-operative diagnostic methods, focusing on barium radiology for intestinal malrotation detection.
- Categorization of patients into those with reflux secondary to congenital abnormalities and those with 'idiopathic' reflux.
Main Results:
- A significant incidence of 54% (n=40) for intestinal malrotation was observed in the study cohort.
- Intestinal malrotation was present in 48% of children with reflux due to congenital abnormalities and 57% with 'idiopathic' reflux.
- Barium radiology was identified as a crucial pre-operative diagnostic tool for intestinal malrotation.
Conclusions:
- There is a high, often unexpected, incidence of intestinal malrotation in children with persistent gastro-oesophageal reflux requiring Nissen fundoplication.
- Clinicians must maintain a high index of suspicion for intestinal malrotation in these patients and utilize careful barium radiology.
- In children over 3 months with both conditions, combined surgical procedures (antireflux operation and Ladd's procedure) may be necessary for effective treatment.
Abstract:
In a series of 74 children undergoing Nissen fundoplication for persistent gastro-oesophageal reflux unresponsive to intensive medical treatment, there was an unexpectedly high incidence (54 per cent, n = 40) of intestinal malrotation. The series was not homogeneous, 25 of the children having reflux as a complication of a serious congenital abnormality (48 per cent incidence of intestinal malrotation), and 49 presenting with 'idiopathic' reflux (57 per cent incidence of intestinal malrotation). Intestinal malrotation is best detected pre-operatively by careful barium radiology, requiring clinicians to be aware of the association. In our experience, in children over the age of 3 months, both an antireflux operation and Ladd's procedure are often necessary to stop gastro-oesophageal reflux when an intestinal malrotation is present.